Rdz F et al_Avelar AJCS 12-2011

The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 241

ORIGINAL ARTICLE

One Hundred Consecutive Lipoabdominoplasty Procedures: ModiÞ ed Avelar Technique for Full Abdominoplasty Without Panniculus Undermining�Advances, Morbidity, and ComplicationsFiliberto Rodriguez, MD; Marvin A. Borsand, DO, FACOS, FAACS

Introduction: Abdominoplasty can be limited by preexist-ing scars and is associated with postoperative drains, seromas, and deep vein thrombosis (DVT). The Avelar technique has been described as an alternative to extensive ß ap dissection. We adopted this technique in 2007.

Materials and Methods: The lower abdomen is marked for planned resection. Liposuction is performed throughout the entire abdomen below Scarpa�s fascia and superÞ cially in the lower abdomen to thin the redundant pannus. The skin is sharply incised, and the thinned pannus is bluntly avulsed, leaving the subcutaneous fat and vessels intact. The upper abdominal skin can be slid over the deep fascia, preserving the perforating vessels. A narrow tunnel is dissected from the umbilicus to the xiphoid for rectus plication. The umbili-cus is transposed in the usual manner. All patients receive DVT prophylaxis with perioperative heparin, sequential compression devices, and Lovenox. Surgery is ambulatory, and drains are not routinely used.

Results: Between April 2007 and December 2010, 100 consecutive lipoabdominoplasty procedures were performed. There were no DVTs and no deaths. One patient sustained small-bowel injury during liposuction, which was immedi-ately recognized and successfully repaired. Five hematomas (28 ± 28 mL) occurred within the early postoperative period, 2 of which became infected. Four hematomas responded to local drainage, but 1 required surgical evacuation 3 months later. The incidence of late seroma was 0%. Two marginal skin necroses occurred in patients with preexisting Kocher and laparotomy scars, which healed without ill effect.

Conclusions: The incidence of wound dehiscence, seroma, hematoma, and DVT after lipoabdominoplasty is less than that reported for traditional abdominoplasty.

Abdominoplasty is the fourth most frequently performed cosmetic surgical operation in the

United States.1 Over the years, several technical reÞ ne-ments have signiÞ cantly improved the results of abdominoplasty, yet the most common approach for abdominal contouring remains traditional abdomino-plasty with extensive undermining of the abdominal ß ap at the deep fascia up to the costal margin for advancement. This approach, however, signiÞ cantly compromises the blood supply to the abdominal ß ap as the large central perforators are sacriÞ ced during the ß ap elevation, leaving the ß ap dependent on its lateral blood supply. Despite increased awareness and efforts to decrease the morbidity associated with traditional abdominoplasty, the procedure continues to be plagued with several complications, which include seroma formation (the most common, 5�22%), hema-toma (6.9%), infection (12.1%), wound ischemia, skin necrosis of the infraumbilical area, and deep vein thrombosis (DVT) with venothromboembolism (VTE) (0.34�3.4%).2�6

The decreased blood supply to the abdominal ß ap has led to advocacy against any liposuction of the central abdomen (zones 2 and 3) at the time of abdominoplasty in order to minimize the risk of ß ap necrosis.7 The extensive dissection also disrupts the lymphatic drainage, which predisposes abdominoplasty to seroma formation, causing most surgeons to routinely use drains in an attempt to avoid this complication. Although progressive tension sutures without the use of drains, as described by Pollock and Pollack8 has

Received for publication June 21, 2011.From the Body Sculpting Center, Scottsdale, Ariz.Presented in part at the International Symposium of Minimal Invasive

Plastic Surgery and Dermatology, Bangkok, Thailand, April 2011, and the World Academy of Cosmetic Surgery 2nd Annual Meeting, Vienna, Austria, September 2011.

Corresponding author: Filiberto Rodriguez, MD, The Body Sculpting Center, 2255 N Scottsdale Rd, Scottsdale, AZ 85257 (e-mail: [email protected]).

242 The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011

recently been shown to decrease the incidence of seroma after abdominoplasty from 24% to 1.7%,9 this technique has not been universally adopted. Moreover, the fear of hematoma after the extensive dissection for abdominoplasty may prevent surgeons from instituting anticoagulation for DVT prophylaxis, even though excisional contouring surgery of the abdomen remains associated with the highest rate of thromboembolic disease for cosmetic surgery,6 and despite published recommendations from the American Society of Plastic Surgeons based on the guidelines devised by the American College of Surgeons.10,11

Alternative techniques have been described for abdominoplasty that do not entail extensive ß ap eleva-tion and dissection.3,12,13 These techniques involve various adaptations of aggressive liposuction in the deep abdominal subcutaneous tissue to enable forward advancement of the abdominal ß ap after excision of the redundant pannus. Although these techniques have been shown to decrease the incidence of postopertive complications,3,13,14 these methods have idiosyncrasies, such as en bloc excision of the redundant pannus with the umbilicus and the creation of a neoumbilicus,12 excision of small areas of skin the suprapubic region and the upper abdomen along the inframammary folds,3 and disruption of �skin-retaining ligaments,�13 which may preclude wide acceptance.

In 2007, the senior author (M.A.B.) began adapting the principles of the Avelar technique to his mini-abdominoplasty procedures (lower abdominoplasty without translocation of the umbilicus) and has since expanded the technique to all conventional and ß eur-de-lis abdominoplasty procedures. The resulting modiÞ -cations have emerged as a hybrid procedure combining the principles of the Illouz suction abdominoplasty,12 conventional abdominoplasty with diastasis repair and transposition of the umbilicus, and the Avelar tech-nique for aggressive liposuction and blunt avulsion of redundant tissue without undermining of the upper abdominal ß ap.3 The procedure has been simpliÞ ed to eliminate the idiosyncratic aspects of these alternative approaches, and a streamlined, simpliÞ ed technique has emerged. This lipoabdominoplasty procedure has proven safe and convenient when combined with concomitant additional cosmetic procedures, with cir-cumferential liposuction of the ß anks and back in par-ticular. We have also been able to abandon the routine use of postopertive drains and implement an aggressive anticoagulation protocol for DVT prophylaxis with minimal hematoma and seroma complications.

Patients and MethodsOne hundred consecutive patients underwent

lipoabdominoplasty from April 2007, when we Þ rst adopted the procedure into our practice, through December 2010. Of the patients, 99% were women. The average age was 39 years (range, 18 to 62), and the average body mass index (BMI) was 27.3 ± 4.0 (range, 20.7 to 38.9). Of the patients, 87 underwent full abdominoplasty (Figures 1 through 3), 9 underwent a lower abdominoplasty without translocation of the umbilicus (ie, mini tummy tuck), and 4 patients underwent a ß eur-de-lis abdominoplasty (Figure 4). In addition, 65 patients underwent concomitant circum-ferential torso liposuction of the ß anks and back, and 32 patients underwent liposuction of additional areas (eg, thighs, chin, arms). Further, 6 patients had fat transfer for gluteal augmentation, 1 patient underwent fat grafting to the face, and 3 patients had additional body contouring surgery (eg, thigh lift or mid-body lift). Concomitant breast surgery, either implant augmentation alone or with mastopexy, was done in 37 patients; 3 patients underwent intra-abdominal tubal ligation, and 1 patient underwent vaginoplasty. The overall incidence of concomitant additional procedures was 95%, with an average of 1.8 ± 1.0 (mean ± SD) procedures performed per patient.

Surgery was performed in a licensed outpatient surgery center under local anesthesia with intravenous sedation and monitored anesthesia care. The usual length of surgery was 4 hours, and patients were discharged within 2 hours after surgery. All patients received aggressive DVT prophylaxis consisting of 5000 units of heparin subcutaneously at the time of surgery, use of sequential compression devices during surgery, and 10 days of Lovenox (SanoÞ -Aventis, Bridgewater, NJ) 40 mg subcutaneously after surgery.

Operative TechniquePreoperatively, the redundant pannus is marked on

the patient. Circumferential liposuction of the back and ß anks is performed while the patient is in the prone position when indicated using a super-wet tu-mescent technique. The patient is then rotated to the supine position, and liposuction of the entire abdomen is performed in the deep plane below Scarpa�s fascia. This deep liposuction allows the upper abdominal skin and subcutaneous tissue to be slid over the deep fascia while preserving the perforating vessels as multiple pedicles. Additional liposuction is performed in the upper abdomen as needed to optimize its thickness and enhance the Þ nal contour. Liposuction is then


performed aggressively in the superÞ cial plane in the previously marked lower abdominal redundant pannus to thin this tissue to facilitate excision.

After liposuction and before the skin is incised, the patient is ß exed and the skin is tailor-tacked with towel clamps to ensure that successful closure will be possible once the pannus is excised. This is a critical distinction from traditional abdominoplasty as the skin excision is predetermined as opposed to being deter-mined after the ß ap has been elevated and the patient is ß exed. The skin is sharply incised along the preopera-tive markings, the umbilicus is freed circumferentially, and the thinned pannus is bluntly avulsed via the Avelar technique, leaving the underlying subcutaneous fat, connective tissue, and vessels intact. A narrow tunnel is dissected, when indicated, from the umbilicus to the xiphoid, allowing complete diastasis plication from the xiphoid to pubis. The patient is then ß exed, and the abdominal incision is closed under minimal tension, with interrupted deep dermal staples (INSORB, Incisive Surgical, Plymouth, Minn) and a running subcuticular

3-0 polydioxanone Quill suture (Angiotech Pharma-ceuticals, Vancouver, British Columbia). The patient is then ß attened, and the umbilicus is transposed in the usual manner. Drains were placed in 11 patients (11%) depending on the degree of exposed fascia after avulsion of the pannus.

ResultsThere were no deaths or incidents of DVTs. One

patient with a preexisting laparotomy scar required small-bowel repair at the time of abdominoplasty as a result of small-bowel injury from the liposuction cannula. She was admitted to the hospital overnight and recovered without incident. Five hematomas (28 ± 28 mL) occurred within the early postoperative period, 2 of which became infected. Four hematomas responded to local drainage, and 1 required surgical evacuation 3 months later. No seromas occurred beyond the 6-week postoperative period. Fluid collec-tions within the initial 6-week postoperative period

Figure 1. Before-and-after photographs of a 43-year-old woman (weight, 185 lb; body mass index, 34.5; full abdominoplasty with abdominal liposuction, 750 mL; total lipoaspirate, 2100 mL). The postoperative photograph was taken 2 months after surgery.


were managed with periodic tapping in 9 patients (26 ± 25 mL). Four superÞ cial stitch abscesses occurred, which were successfully treated with oral antibiotics. Marginal skin necrosis occurred in 2 patients with preexisting Kocher and full midline laparotomy scars, respectively, which healed without ill effect (Figure 5).

Good abdominal contour was achieved with lipoab-dominoplasty (see Figures 1 through 4), and patient satisfaction was high, as evidenced by our patient referral rate of 68%.

DiscussionOver the past 30 years, increased attention has been

placed on the incidence and avoidance of the compli-cations associated with abdominoplasty, which include seroma formation (the most common, 5�22%), hema-toma (6.9%), infection (12.1%), wound ischemia, skin necrosis of the infraumbilical area, and DVT with VTE (0.34�3.4%).2�6

Various methods for reducing complications are described in the literature. For seroma, recommenda-tions include quilting sutures,2,15 Þ brin glue,16 and progressive tension sutures without the use of drains,8 which has recently been shown to decrease the incidence of seroma after abdominoplasty from 24% to 1.7%.9 To avoid ß ap necrosis, Matarasso empha-sized that liposuction of the central abdomen (zones 2 and 3) should not be performed at the same time as abdominoplasty because of concerns of jeopardizing the tenuous blood supply of the abdominal ß ap following ß ap elevation and dissection.7

For DVT prophylaxis, the American Society of Plastic Surgeons formed a task force on DVT in 1999 that published recommendations based on the guide-lines devised by the American College of Surgeons.10,11 The focus on DVT after abdominoplasty stems from the fact that excisional contouring surgery of the abdomen is associated with the highest rate of throm-boembolic disease in cosmetic surgery.6 Although the

Figure 2. Before-and-after photographs of a 47-year-old woman (weight, 214 lb; body mass index, 40.4; full abdominoplasty with abdominal, ß ank, and back liposuction, 6750 mL; total lipoaspirate, 8700 mL). The postoperative photograph was taken 3 months after surgery.


etiology of DVT after abdominoplasty is beyond the scope of this article, an increase in intra-abdominal pressure after diastasis repair, which may retard venous return, combined with decreased ambulation after the procedure, may contribute. Historically, the incidence of DVT after isolated abdominoplasty was

reported at 1.1% in a 1977 review of 10 490 cases, with pulmonary embolus (PE) in 0.8% and death from PE in 0.1% of patients.17 A more recent report from 2010 found the incidence of VTE to be 0.34% after abdminoplasty alone, 0.67% after abdminoplasty with concomitant additional cosmetic procedures, 2.17%

Figure 3. Before-and-after photographs of a 41-year-old woman (weight, 182 lb; body mass index, 34.3; full abdominoplasty with abdominal, ß ank, and back liposuction, 2050 mL; total lipoaspirate, 2500 mL). The postoperative photograph was taken 4 months after surgery.


after abdominoplasty with intra-abdominal procedures, and 3.4% after cirumferential abdominoplasty.6 Despite these staggering statistics, perioperative anticoagulation is not routinely instituted by plastic surgeons (oral communication, University of California, Los Angeles Department of Plastic and Reconstructive Surgery, 2008�2009), perhaps because plastic surgeons remain more concerned about hematoma after the extensive ß ap dissection and choose to not apply the American College of Surgeons DVT prophylaxis guidelines, which did not speciÞ cally include plastic surgery patients.6,11 A recent report discussing preventive measures to reduce thromboembolism after cosmetic surgery, how-ever, reveals that abdominoplasty patients fall into moderate to high risk for DVT and warrant periopera-tive chemoprophylaxis against DVT with Lovenox, in addition to early ambulation and use of sequential compression devices during surgery.18 Hence, sur-geons performing abdominoplasty should aggressively seek to minimize the risk of DVT for their patients.

Figure 4. Before-and-after photographs of a 46-year-old woman (weight, 116 lb; body mass index, 22.3; ß eur-de-lis abdomi-noplasty with abdominal liposuction, 400 mL; total lipoaspirate, 1100 mL). The postoperative photograph was taken 3 months after surgery.

An alternative approach for abdominoplasty may help address and minimize these complications. In 1992, Illouz12 introduced the concept of the suction abdominoplasty. Instead of extensive undermining of the abdominal ß ap at the deep fascia up to the costal margin, Illouz described liposuction of the upper abdomen to loosen the supraumbilical subcutaneous tissue sufÞ ciently to allow downward advancement. The redundant lower abdominal tissue was then excised en bloc with the umbilicus. Undermining of the midline enabled diastasis repair from the xiphoid to the pubis. A neoumbilicus was created after advancement of the upper abdomen and closure. The purported advantages of this method are that it simpli-Þ es the procedure and avoids inherent complications because undermining and subsequent devascularization are avoided.12 Although some surgeons have reported success with this technique19 and variations,13 it has failed to gain wide acceptance.


In 2002, Avelar introduced a fundamentally different approach for abdominoplasty that completely avoids undermining and resection of the panniculus.3 Because of the high incidence of complication rates after conventional abdominoplasy in the 1980s, Avelar abandoned conventional abdominoplasty and abdomi-noplasty combined with liposuction from 1988 to 1998. During that time, Avelar carefully studied the vascularization of the subcutaneous tissue after liposuction.20 From these studies, a method for abdominoplasty was described wherein small areas of skin were excised from the suprapubic region and the upper abdomen along the inframammary folds.3,14 Liposuction was performed throughout the abdomen in the deep layer below Scarpa�s fascia, which allowed the panniculus to be slid easily over the muscular aponeurotic wall while preserving all the perforating vessels. A fundamental element of the skin resection technique was to perform aggressive liposuction of the full thickness of the skin to be resected and then blunt avulsion of this skin, rather than sharp dissection off the fascia, thereby leaving the connective tissue and the arterial, venous, and lymphatic vessels between the muscles below and the thin layer of subdermal structures above.3,14 Umbilical transposition was not necessary, and drains were not used. Only 2 cases of seroma treated with syringe aspiration occurred in Avelar�s series of 97 patients, and there were no cases of hematoma, skin ischemia, or necrosis, although the use of perioperative anticoagulation was not discussed.3

Our modiÞ cations of the Avelar technique for abdominoplasty have resulted in a hybrid procedure combining the principles of the Illouz suction abdom-inoplasty, conventional abdominoplasty with diastasis repair and transposition of the umbilicus, and the Avelar technique for aggressive liposuction and blunt avulsion of redundant tissue without undermining the panniculus. The procedure has been simpliÞ ed to eliminate the idiosyncratic aspects of these alternative approaches,3,12 and a streamlined, simpliÞ ed technique has emerged. This lipoabdominoplasty procedure has proven safe and convenient when combined with concomitant additional cosmetic procedures.

The application of liposuction as a dissection tool throughout the upper abdomen (without ultrasound or laser) causes less vascular trauma to the ß ap and less bleeding than undermining with cautery or scalpel.13 Liposuction selectively disrupts the deep dermal attachments while preserving the ß exible perforators, thereby enhancing ß ap circulation by creating a vascular

Figure 5. Before-and-after photographs of a 44-year-old woman (weight, 213 lb; body mass index, 41.3; full abdominoplasty with abdominal and ß ank liposuction, 2600 mL; total lipoaspirate, 4200 mL). The postoperative photographs were taken 2 weeks and 3 months after surgery, respectively, showing successful wound healing in this patient with large preexisting full midline laparotomy scar.


supporting tissue layer composed of a rich network of blood vessels, lymphatics, connective tissue, and nerves. This supporting tissue layer also provides a deep layer devoid of devascularized fat and ensures even ß ap thickness and deep defatting without surface irregularities.13 Moreover, circumferential liposuction of the ß ank and back not only optimizes the contour correction (see Figure 3) but also facilitates abdominal advancement anteriorly for a tension-free closure.

Our experience shows that circumferential liposuction of the abdomen, ß anks, and back can be safely performed in conjunction with the Avelar abdomino-plasty technique without ß ap necrosis. Even in the presence of extensive preexisting surgical scars, such as a right upper quadrant Kocher scar or a full midline laparotomy, which are known risk factors for lower skin necrosis after abdominoplasty because of the loss of perforating vessels, the Avelar technique allows for full abdominoplasty with minimal wound morbidity. Although a lower midline laparotomy scar from the umbilicus to the pubis does not normally contribute to wound complications, because it is typically excised as part of the abdominoplasty procedure, there is a signiÞ cant difference with a full midline laparotomy (from xiphoid to pubis), as in our patient shown in Figure 5. The upper abdominal skin remains compro-mised by the surrounding scar tissue, and indeed in this patient (Figure 5), the contracted upper component of the midline scar limited the downward traction we were able to place on the abdominal skin, resulting in excess tension, which also contributed to the wound necrosis in this area. Perhaps by performing a ß eur-de-lis abdominoplasty (as shown in Figure 4) rather than a standard tummy tuck, excision and revision of the midline scar could have prevented possible skin necrosis.

The reported incidence of seroma after abdomino-plasty varies widely (5�22%).5 This variation may be attributable to differences in deÞ nition, because seromas are deÞ ned as ß uid collections occurring after drain removal, and the time of drain removal varies widely from patient to patient and author to author.13 Hence, in this report, seromas were deÞ ned as ß uid collection persisting beyond the typical 6-week postopertive interval as deÞ ned by Brauman and Capocci.13 Our incidence of late seroma after lipoabdominoplasty was 0%. Consequently, drains are not routinely used, and periodic tapping is performed for ß uid collections during the early postoperative period as indicated (9%). We note that most ß uid collections tend to occur either in the most dependent aspect along the incision or superiorly in the area of central dissection for

diastasis repair�perhaps of the thermal injury induced by cautery in this area. The decision to place drains (11%) is determined intraoperatively based on the de-gree of fully exposed abdominal fascia after the blunt avulsion of the lower abdominal pannus.

In addition to the decreased incidence of seroma, lipoabdominoplasty has permitted us to implement an aggressive anticoagulation protocol for DVT prophy-laxis with minimal hematoma complications. This aggressive protocol for DVT prophylaxis resulted in a 0% incidence of DVT in this series, despite the high rate of concomitant additional procedures (95%) with 4% of patients undergoing additional intra-abdominal procedures, which would typically be associated with an incidence of 2.17% for DVT in the literature.6 With this aggressive anticoagulation protocol for DVT prophylaxis, our incidence of hematoma remained low (5%) and was less than the recently reported incidence of 6.9% after abdominoplasty by Araco and colleagues in 2009.5 We suspect that our low hematoma rate results from a combination of the tumescent technique for the liposuction, which is fundamental for the Avelar technique; minimal dissection; and the application of pinpoint cautery for hemostasis after blunt avulsion of the lower abdominal pannus.

The Avelar technique for lipoabdominoplasty rep-resents a signiÞ cant technical advance and departure from traditional abdominoplasty, which results in decreased seroma, bleeding, and wound complications. It also allows for safe, aggressive DVT prophylaxis. In particular, the Avelar technique enhances the safety of abdominoplasty even in patients with BMI greater than 30 (Figures 1 through 3). Average BMI in our series was 27.3 ± 4, and it ranged from 20.7 to 38.9. Only 50% of the patients had a BMI less than 30. As is well known, abdominoplasty is not a weight-loss procedure. Hence, once a patient is determined to be a satisfactory candidate for abdominoplasty, BMI is not a factor in the decision whether to use the Avelar technique. Since adopting the Avelar technique for abdominoplasty in April 2007, this has been our exclusive approach for abdominoplasty, and this report reß ects the outcomes of 100 consecutive cases.

However, the Avelar technique does expose patients to the risk of intestinal or organ perforation from the liposuction or tumescent cannula, especially those with preexisting surgical scars as in one of our patients. The risk of intra-abdominal injury during liposuction, although rare, is well known. As discussed in a recent plastic surgery Maintenance of CertiÞ cation article, �Intestinal or organ perforation from the liposuction


cannula, though rare, usually occurs with a preexisting abdominal scar. The abdomen, thorax, retroperitoneum, and major vessels in the subcutaneous space are all potential areas into which a cannula can be misdirected and potentially result in major injury.�21 Because liposuction throughout the abdomen and, especially, aggressive liposuction in the lower abdomen are fundamental components of the Avelar technique, surgeons adopting this technique for abdominoplasty must exercise caution and maintain a high index of suspicion for possible penetration of the fascia during abdominal liposuction, especially in patients with preexisting scars. A high index of suspicion and awareness should prompt a thorough examination of the exposed fascia after avulsion of the lower abdminal pannus. If identiÞ ed, a fascial defect warrants an exploratory laparotomy through the already exposed fascia so that any injuries can be immediately repaired. In our patient, an immediate bowel repair was associ-ated with an excellent cosmetic result and minimal morbidity.

ConclusionWe conclude that lipoabdominoplasty, performed

as a hybrid procedure combining the principles of the Illouz suction abdominoplasty, conventional abdomi-noplasty with diastasis repair and transposition of the umbilicus, and the Avelar technique for aggressive liposuction and blunt avulsion of redundant tissue without undermining of the panniculus, allows for effective treatment of localized adiposity, excess abdominal skin, and diastasis recti. The Avelar tech-nique results in decreased seroma, bleeding, and wound complications compared with published results after standard abdominoplasty. In particular, the Avelar technique enhances the safety of abdominoplasty even in patients with BMI greater than 30. It also allows for aggressive DVT prophylaxis with minimal risk of hematoma. Meticulous technique and a high index of suspicion for possible intra-abdominal injury are critical during the abdominal liposuction, especially in patients with preexisting scars.

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Rdz F et al_Avelar AJCS 12-2011