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LIPOSUCTION 101 Liposuction Textbook

PART V:
Tumescent Liposuction by Area
Chapter 31:
Abdomen

The abdomen is the area of the body treated most often by liposuction. It is a high-priority area for both men and women. In terms of surgical anatomy, cosmetic results, patient comfort during and after liposuction, and potential complications, the abdomen is also one of the most challenging of all the areas treated by tumescent liposuction.

The clinical anatomic definition of abdomen is the body’s lower cavity, from the diaphragm downward, which contains the stomach, bowels, and other organs of nutrition; sometimes this includes the pelvic cavity. Abdomen may also refer to the belly’s outer surface.

Anatomic Considerations

Several ways to categorize abdominal fat are relevant to liposuction. For example, the surface anatomy of the abdominal wall can be subdivided into the following areas:

  1. Upper abdomen, or epigastric area
  2. Lower abdomen
  3. Periumbilical area
  4. Midabdomen, or waist area

The last area includes the periumbilical area and the area lateral to the umbilicus that overlaps the area between the upper and lower abdomen.

The gross anatomy of subcutaneous abdominal fat can be subdivided into volumes of adipose tissue, such as fascia of Camper (Camper’s fascia), sub-Scarpa’s fat, and periumbilical fat. Abdominal fat is either subcutaneous (located deep to skin and superficial to abdominal wall musculature) or visceral (located on the intestines and the omentum).

In very lean individuals the subcutaneous fascia is essentially a layered sheet of fibrous tissue containing minimal amounts of fat. With increasing adiposity, yellow fat begins to appear and accumulate within the lamellar connective tissue sheets of the fascia.

In some persons, visceral or omental fat may be relatively more voluminous than the subcutaneous fat. The proportion of visceral fat relative to subcutaneous fat tends to increase with age. This is an important distinction when evaluating a patient for possible abdominal liposuction. Even with substantial fat liposuctioned from an older woman’s abdomen, she may be dissatisfied with the results if she has a protuberant lower abdomen due to muscle laxity and visceral fat.

On the other hand, a “beer-bellied” male may have much more subcutaneous fat than suspected after an initial cursory examination. A taut abdomen, apparently of omental fat, may reveal significant subcutaneous lower abdominal fat when the patient is examined in a supine position with the back and hips slightly flexed.

The rectus abdominis muscles underlie the midabdominal fat. The anterior portion of the external oblique muscles underlies the lateral abdomen.

Surface Anatomy

As noted, the surface of the abdomen can be subdivided into lower abdomen and upper abdomen (epigastrium). Occasionnally the surgeon must refer to the midabdomen, the area encompassing the breadth of the abdomen and a few centimeters above and below the umbilicus. Some patients who have little fat in the upper epigastrium may require liposuction of only the lower abdomen and midabdomen. Other patients, such as women with previous abdominoplasty, may require liposuction of only the midabdomen and upper abdomen.

The surface anatomy of the lower abdomen is dominated by the rounded abdominal “belly.” In thin females the skin and subcutaneous tissues of the belly generally are soft and supple to the touch. The visible curvature of a lean female abdomen is gently convex or flattened, essentially reflecting the subjacent musculature of the anterior lower abdominal wall.

Waistline Features. In some relatively obese females the upper and lower abdominal areas are separated by the waistline sulcus. This transverse furrow between the upper and the lower abdominal fat pads extends across the abdomen at or just above the umbilical level. Although not usually seen on thin persons, this valley of surfeit is a common superficial anatomic feature of the gourmand (Figures 31-1 and 31-2).

The waistline sulcus coincides with localized increased fibrousness of the adipose tissue. This area of excess fibrousness, present in virtually all patients, is referred to as the waistline fibrosis (Figures 31-3 and 31-4). Congruent with the proximal extent of Scarpa’s fascia, the waistline fibrosis is a dense combination of collagenous septa and fibrous bands adherent superficially to skin and deeply to the linea alba, anterior rectus muscle sheath, and external oblique muscle.

The extent and density of this transverse abdominal area of fibrosis vary from patient to patient. This fibrotic area requires extra effort to achieve an adequate degree of liposuction.

Upper Abdomen. The upper abdominal fat compartment consists of epigastric fat pads as well as the more proximal fat overlying the costal margin, the supracostal abdominal fat pads. In the obese patient the location of specific large creases and rolls of fat is predictable. The supracostal fat and the more distal epigastric fat may appear as two prominent transverse rolls and furrows.

The fibrous septa of the upper abdomen are more numerous, thicker, and more resistant to penetration than septa and collagenous tissue of the lower abdomen. The upper abdomen is uniformly more fibrous and more sensitive to pain than the lower abdomen. It is also more prone to a permanent postliposuction appearance of irregular lumpiness. Smooth results after liposuction of the epigastrium are more easily achieved using microcannulas than larger cannulas.

Rugosity. With resolution of postoperative edema after liposuction of the upper abdomen, the epigastric skin tends to appear rugose, crepelike, or crinkled. In older patients with decreased skin elasticity, this “crepiness” (rugosity) seems to be the predictable consequence of deflating the upper abdominal subcutaneous fat compartment. Interestingly, lower abdominal skin does not seem to be susceptible to this postliposuction rugosity.

This epigastric rugosity may partly result from the different degrees of flexibility in the thoracic and lumbar spines. The greater flexibility of the thoracic spine allows compression of the upper abdominal skin, whereas the relative inflexibility of the lumbar spine inhibits compression of the lower abdominal skin. The elasticity of Scarpa’s fascia might prevent rugosity after liposuction of the lower abdomen.

Pregnancy. Previous pregnancy predisposes to diastasis recti abdominis, a condition in which the muscles of the anterior abdominal wall become stretched. This imparts a greater degree of roundness and protuberance to the lower abdomen.

Pannus. A large abdominal panniculus (pannus) usually retracts greatly after adequate tumescent liposuction. Retraction of an excessively large panniculus, however, may be limited or inadequate. Panniculus adiposus, a term used to designate subcutaneous fat, is the adipose tissue between the skin and the enveloping aponeurosis. A pannus of abdominal fat usually refers to an apron of sagging skin and fat on the lower abdomen.

Treatment Considerations. The traditional surgical approach to eliminating an apron of abdominal fat was abdominoplasty (dermolipectomy). The modern approach is first to treat the area using microcannular tumescent liposuction.

In most instances of abdominal obesity, tumescent liposuction provides acceptable or superior aesthetic results, with fewer risks than the traditional “tummy tuck.” If a subsequent dermolipectomy with rectus muscle sheath plication is required, it can be accomplished several months later as a delayed secondary procedure totally by local anesthesia. The surgical risk, recovery time, and postoperative disability are significantly reduced by dividing one abdominoplasty, often requiring general anesthesia, into two procedures, both accomplished totally by local anesthesia.

Abdominal liposuction is not ideal for every patient. Liposuction may not provide significant cosmetic improvement for a prospective patient whose principal concern is the elimination of abdominal stretch marks. Similarly, liposuction results may be inadequate for a patient with excessive skin laxity and little subcutaneous fat.

Gross Anatomy of Subcutaneous Fat

The depth of subcutaneous abdominal fat is subdivided into three layers in the upper abdomen and four layers in the lower abdomen. As in most areas of the body treated by liposuction, three layers of fat extend over the entire abdominal expanse: the apical layer, the mantle layer, and the deep fat compartment layer (see Chapter 25).

Apical fat is the most superficial layer of fat. Intimately attached to the deep surface of the reticular dermis, the apical layer of dermal fat contains vascular and lymphatic networks important to the skin’s normal appearance and physiologic function. Using a liposuction cannula to rasp the apical fat can cause irreparable injury and inflammation to the subdermal vascular plexus, resulting in erythema ab liporaspiration or dermal necrosis (see Chapter 8).

Mantle fat is a layer of vertically oriented palisading columnar fat pearls that form a blanket of fat attached to the dermis. Dissection or magnetic resonance imaging (MRI) often reveals a thin fibrous sheet of collagenous tissue that separates the mantle layer from the deeper compartment of subcutaneous fat.

An excessively large deep fat compartment layer is responsible for the cosmetically unattractive area of focal fat excesses. This compartment is the site of the greatest accumulation of fat in cosmetic lipodystrophy and in obesity. Most of the fat removed by liposuction is derived from the deep compartment of fat.

Camper’s fascia is formally defined as the superficial layer of the superficial fascia of the abdomen. For the purposes of liposuction, a more useful definition is the subcutaneous abdominal fat having the following boundaries:

  1. The superficial boundary is the apical fat.
  2. The deep boundary in the lower abdomen is Scarpa’s fascia.
  3. The deep boundary in the upper abdomen is the aponeurosis of the abdominal wall muscles.

Camper’s fascia extends over the entire area of the abdomen. In the epigastrium, Camper’s fascia consists of the mantle layer and deep fat compartment layer. In the lower abdomen, however, an additional layer of subcutaneous fat is located deep to Camper’s fascia. This layer is separated from Camper’s fascia by a discrete sheet of fibrous tissue known as Scarpa’s fascia.

Sub-Scarpa’s fat is the deepest layer or compartment of fat in the lower abdomen. Sub-Scarpa’s fat is separated from Camper’s fascia by Scarpa’s fascia (Figure 31-5).

Fasciae. The traditional definitions of the subcutaneous fasciae of the abdomen are imprecise and somewhat confusing. Camper’s fascia contains fibrous tissue septa, all the deep compartment fat of the upper abdomen, and all the deep fat of the lower abdomen that is superficial to Scarpa’s fascia.

Scarpa’s fascia extends over the entire lower abdomen and only exists in the lower abdomen. Thin patients have little if any fat between Scarpa’s fascia and the aponeurosis of the abdominal wall muscles. Obese patients, however, have a significant collection of subcutaneous fat located deep to the plane of Scarpa’s fascia (Figure 31-6).

Anatomically, fascia (Latin fascis, bundle) is used in several different contexts. Subcutaneous fascia designates sheets of fibrous tissue that envelop the body beneath the skin. It includes subcutaneous fat; subcutaneous adipocytes seem to be derived from perivascular fibroblasts of the fascia. Subcutaneous fascia is essentially the layer of subcutaneous adipose tissue (including the collagenous fibrous septa, vasculature, and adipocytes) bounded above by the dermis and below by muscle fascia.

Muscle fascia or deep fascia refers to a visibly discrete layer of collagenous fibrous tissue that encapsulates muscles. Muscle fascia, which generally does not contain a significant amount of fat, is distinct from subcutaneous fascia.

Scarpa’s Fascia

Scarpa’s fascia is a fibrous sheet of dense membranous connective tissue within the deeper portion of the lower abdominal subcutaneous fat and is tangentially parallel to the abdominal muscle wall. Scarpa’s fascia can be identified on MRI as a thin line within the deep subcutaneous fat, extending across the lower abdomen.

The cephalad (proximal) portion of Scarpa’s fascia seems to diverge into the dense fibers of waistline fibrosis just proximal to the umbilicus. The insertion of the proximal extent of Scarpa’s fascia actually coincides with the dense waistline fibrosis. Laterally, Scarpa’s fascia inserts into the iliac crest and the anteroinferior iliac spine.

The distal fate of Scarpa’s fascia has clinical interest for the liposuction surgeon. As Scarpa’s fascia crosses the inguinal ligament and extends distally, it merges with the ligament and the deep fascia of the proximal thigh, where it forms a dense attachment. The insertion of Scarpa’s fascia 1 to 2 cm beyond the inguinal ligament forms a tightly sealed barrier that prevents distal migration of fluid.

Distally and medially, however, Scarpa’s fascia inserts into the deep perineum (Colles’ and Buck’s fasciae), extending over and enveloping the genitalia. A distal midline condensation of a portion of Scarpa’s fascia is said to become the fundiform ligament of the penis.

One purpose of Scarpa’s fascia may be the additional weight-bearing function that this elastic sheet provides in supporting the pregnant uterus.

Edema. The location of the fibrous attachments of Scarpa’s fascia explains the occasional ecchymosis and edema of the labia or the scrotum and proximal penis after abdominal liposuction. Under the influence of gravity, residual blood-tinged anesthetic solution tends to percolate and seep distally from the abdominal fat deep to Scarpa’s fascia, causing more bruising in the midline pubic area than laterally over the anterior thighs.

This bruising is not clinically significant but can be a concern if the patient is not forewarned. To some extent this distal bruising can be prevented by (1) placing several adits or incisions along the inferior margin of the abdominal liposuction area and (2) establishing multiple drainage pathways through liposuction tunnels not closed with sutures.

The extent of Scarpa’s fascia can be identified in the patient with a pelvic fracture and rupture of the membranous urethra. Within hours, leakage of urine into the space deep to Scarpa’s fascia will fill and distend the sub-Scarpa’s fat compartment with extravasated urine. Clinical examination reveals a distended expanse of the lower abdomen extending from the level of the umbilicus into the perineum, with associated scrotal or labial edema.

Pseudolipoma. A thin patient has little or no fat between Scarpa’s fascia and the deeper linea alba, the anterior rectus muscle sheath, and the external oblique muscle fascia. Obese patients always have a layer of fat deep to Scarpa’s fascia. The relative amount of fat in the sub-Scarpa’s fat compartment tends to be greatest medially and gradually diminishes laterally and distally. Abdominal posttraumatic pseudolipomas may result from a traumatic tear in Scarpa’s fascia, with herniation of deeper fat through Scarpa’s layer.1

Penetration. Liposuction surgeons may have difficulty penetrating Scarpa’s fascia with larger cannulas. By squeezing or gripping and tenting the lower abdominal skin and fat with the sensory hand, sub-Scarpa’s fat is easily accessible with a microcannula, which readily penetrates fascia.

Pfannenstiel’s Incision. Scarpa’s fascia does have cosmetic significance. Pfannenstiel’s incision refers to the transverse lower abdominal incision typically used for cesarean sections and abdominal hysterectomies. The surgeon advances the incision down through the external sheath of the recti muscles, then splits or separates the muscles in the direction of the fibers. The peritoneum is opened at the sagittal midline.

A common complication of Pfannenstiel’s incision is a persistent focal transverse bulge of subcutaneous fat proximal to the incision. Although liposuction can repair this annoying but harmless deformity, it might be preventable. The pseudolipoma may result partly from traction on the skin when the incision is made and partly from not approximating and suturing the transverse incision through Scarpa’s fascia when repairing a surgical wound. The elastic recoil of the fascia produces a cephalad migration of subcutaneous fat.

Layered closure of the subcutaneous fat at the level of Scarpa’s fascia may reduce the incidence of this iatrogenic pseudolipoma (Figure 31-7).

Abdominal Blood Vessels

Blood vessels located within abdominal subcutaneous fat may be traumatized by liposuction (Figure 31-8).

The anterosuperior epigastric veins originate near the junction of the respective saphenous and femoral veins and course through the medial lower abdomen. The veins are bilateral, travel in a cephalad and medial direction toward the umbilicus, and are located above Scarpa’s fascia (Figure 31-6, D).

The lateral circumflex veins are also bilateral and originate near the saphenofemoral junction. They travel in a cephalad and lateral direction, extending toward the superior and lateral aspect of the iliac crest. The lateral circumflex vein penetrates Scarpa’s fascia at a point approximately half the distance between the pubis and the anterior iliac crest and terminates in the superficial subcutaneous abdominal fat (Figure 31-6, F).

The other important vascular structures are the paramedian neurovascular bundles that penetrate the rectus muscle of the median abdominal wall near the lateral extent of the linea alba. These arteries supply the skin and fat of a transverse rectus abdominis myocutaneous (TRAM) flap used for breast reconstruction after mastectomy. With the use of microcannulas, these vessels rarely are traumatized by liposuction.

Bleeding and Hematoma. The anterosuperior epigastric or lateral circumflex veins may be either punctured during tumescent infiltration with spinal needles or lacerated by a liposuction cannula. Bleeding from these veins during tumescent liposuction seems to cause no significant problem.

Infiltration with a spinal needle in the region of these veins rarely causes minor bleeding from a cutaneous entrance site. To stem this slight amount of bleeding, the clinician simply infiltrates an additional volume of tumescent anesthetic solution into and around the immediate area.

Similarly, focal bleeding during liposuction may be evidenced by increased redness of the aspirate. If an unusual degree of bleeding occurs during liposuction of a localized area of fat, the surgeon simply ceases further liposuction in that area. Occasionally, brief application of direct pressure might be required. If additional liposuction in the area is needed, it can be accomplished on another day.

Two of my patients had clinical evidence of a hematoma after liposuction. In both the bleeding probably resulted from a cannula-induced injury either to a small artery associated with one of the paramedian neurovascular bundles or to the rectus muscle.

In an obese male with adult-onset, non-insulin-dependent diabetes mellitus, I noticed the bleeding during surgery and terminated the procedure before completion. Preoperatively the patient denied taking aspirin; postoperatively he admitted taking “baby” aspirin. The bleeding stopped with direct pressure. After surgical consultation the patient was monitored overnight. Although not evident immediately, the patient eventually developed a small area of necrosis in the left lower periumbilical area (see Chapter 8).

Case Report 31-1 describes my second bleeding case.

Neither patient required direct surgical intervention for hemostasis. Both were managed conservatively, and surgical consultation was obtained. Bleeding was controlled by direct manual pressure over the apparent site of bleeding for approximately 1 hour. Then, for another 24 to 36 hours, continuous firm pressure was applied to the affected area by absorption-compression pads and abdominal binders.

Preoperative Evaluation

The preoperative evaluation for patients contemplating abdominal liposuction must include an assessment for the following:

  1. Diastasis recti abdominis
  2. Umbilical, periumbilical, and ventral hernias
  3. Prior obesity and subsequent weight loss
  4. Degree of intraabdominal, visceral, or omental fat
  5. Previous abdominal surgeries
  6. Any history of abdominal liposuction
  7. Breast augmentation with prosthesis or by injection of silicone into tissues

The consequences and relevance of these findings must be thoroughly documented and discussed with the patient.

The preoperative physical examination should always document the presence or absence of a periumbilical or ventral hernia. A hernia may increase the risk of inadvertent penetration of the peritoneal cavity during liposuction.

An abdominal hernia may require repair by a general surgeon at least 8 weeks before abdominal liposuction (Figure 31-9). Typically a ventral hernia repair is a simple procedure accomplished under local anesthesia.

The curvature of the abdominal wall musculature largely determines the “flatness” of the abdomen after liposuction. Separation of the abdominal rectus muscles as a result of pregnancy limits the degree of improvement. Nevertheless, the vast majority of patients with diastasis recti abdominis are ultimately very satisfied with results obtained by liposuction alone. Most patients, including those with some diastasis, do not “need” an abdominoplasty to achieve a gratifying cosmetic improvement.

The prospective patient should be questioned about prior abdominal surgery, including laparoscopic procedures. The location and extent of scars from prior surgery should be noted.

Prior abdominal liposuction using inadequate tumescent vasoconstriction and sutured incisions increases postoperative inflammation, causing interstitial fibrosis within the treated fat.2 Subsequent liposuction will be more difficult because of this excessive fibrosis.

Abdominoplasty

Tumescent liposuction with microcannulas has proved to be so effective that abdominoplasty is now rarely indicated. After an abdominal liposuction, very few patients require or desire abdominoplasty, even those who have had 2 L or more of supranatant fat suctioned from the abdomen. In the vast majority of patients who have a pendulous lower abdominal panniculus, tumescent liposuction provides a better and more natural cosmetic result than an abdominoplasty.

Indications for abdominoplasty are subjective. A surgeon might recommend an abdominoplasty for the following three reasons:

  1. Extensive diastasis or spreading of the abdominal rectus muscles as a result of pregnancy
  2. Excessive striae or stretch marks
  3. Surgeon’s unawareness of the excellent results from liposuction without abdominoplasty

Liposuction alone will not always provide complete satisfaction. Ultimately the patient’s opinion of the cosmetic results depends on multiple factors, including (1) the patient’s expectations, (2) the patient’s preoperative cosmetic deficiencies, and (3) the surgeon’s technical skills and technique. Thus the results are never completely predictable.

Two-stage Procedure

When an abdominoplasty is indicated, it is safer to separate the traditional surgery into a two-stage procedure. In many patients a two-stage tumescent abdominoplasty can be accomplished totally by local anesthesia.

The first stage is tumescent liposuction. Several months later the patient is reevaluated. The relative merits of abdominal skin resection and rectus muscle plication are discussed. When indicated, the second stage of abdominoplasty can usually be performed totally by local anesthesia using the tumescent technique. General anesthesia is only necessary for the most challenging cases.

The surprising aspect of using this two-stage approach to abdominoplasty is the high degree of satisfaction that patients find from liposuction alone. The vast majority of patients decide not to pursue the second-stage skin resection.

Abdominoplasty is becoming an anachronism.

Option: Tumescent Technique

“Only a tummy tuck will do justice to a patient with a pendulous apron of abdominal fat.”

This dogma is obsolete. Microcannular tumescent liposuction has largely eliminated the need for routine abdominoplasty. For many patients with a pendulous apron of abdominal fat, tumescent liposuction offers better cosmetic results, a quicker recovery, and fewer risks compared with traditional abdominoplasty under general anesthesia (Figures 31-10 and 31-11).

For patients with moderate abdominal obesity and good abdominal muscle tone, tumescent liposuction is a better choice than abdominoplasty (Figures 31-12 to 31-14).

A thin female may require an abdominoplasty only when rectus muscle laxity is excessive or when stretch marks are the major cosmetic concern. Abdominal liposuction is almost always a better option (Figure 31-15).

Liposuction of the male abdomen yields excellent results. Male patients rarely require an abdominoplasty (Figure 31-16).

Patients should be informed an option now exists to the traditional abdominoplasty that is safer and often yields better cosmetic results. Compared with microcannular tumescent liposuction, tummy tucks are associated with a relatively higher risk of dermal necrosis, fat embolism, pulmonary thromboembolism, and other serious complications of major surgery. A large, unsightly scar is often a consequence of abdominoplasty (Figure 31-17).

Intraoperative Positioning

For patient comfort and ease of access to the targeted abdominal fat, the patient is ideally placed in a reclining position, with the abdomen slightly flexed. In this supine cernuous (bowing downward) position the patient is lying on the back, bent slightly at the hips and knees, in such a way that the torso is slightly inclined forward relative to long axis of the thighs (Figure 31-18).

A flat supine position causes the patient’s lower abdominal skin and subcutaneous fat compartments to become taut, making it difficult to grip the tumescent abdominal fat. When the abdominal fat is firm and taut, it is more difficult to palpate the interface accurately between the abdominal fat and abdominal muscles, decreasing the likelihood of adequate liposuction for the deeper abdominal fat.

On the other hand, if the patient’s abdomen is flexed too much, the position of the thighs will obstruct the cannula’s in-and-out motion. Furthermore, excessive abdominal flexion compresses the subcutaneous fat, making the tissues difficult to grip and impeding accurate assessment of the uniformity of the liposuction process.

I prefer to have the patient’s abdomen slightly flexed during the initial phase of the procedure, when the cannulas are directed transversely or diagonally across the abdomen, using 16-gauge and 14-gauge Capistrano microcannulas.

Toward the end of the procedure, 14-gauge and 12-gauge microcannulas are used. At this stage the patient is placed in a flat supine position to facilitate strokes of the cannula that are parallel with the long axis of the body and to avoid interference from the thighs.

With an alert and fully awake patient, it is advisable to gently restrain the patient’s hands to prevent inadvertent contamination of the surgical field. A preferred method is to drape a towel over each side of the table and then have the patient recline on top of the towels. With the patient’s arms at the side, the towel is brought up over the arms and tucked under the patient’s hips. Patients should not feel too confined because the arms are readily extricated from this position by simply raising the hips and thus loosening the towel.

Anesthetic infiltration

The abdomen can be one of the most difficult areas of the body to infiltrate. The abdomen is sensitive, and awake patients feel more vulnerable and anxious. The periumbilical area especially requires proper infiltration technique, since this tissue tends to be more fibrous and more sensitive. Adequate liposuction demands additional effort, and insufficient anesthesia may lead to inadequate liposuction of the periumbilical area.

It is more difficult to infiltrate the abdomen adequately in a patient who has previously lost considerable weight, such as 25 pounds (11 kg) or more. After significant weight loss, residual fat compartments are potentially more capacious than might be predicted based on present physical size. Compared with a patient whose weight is at a lifetime maximum level, a patient who has lost substantial weight has flabbier skin and can accommodate larger volumes of tumescent anesthetic solution. Nevertheless, adequate anesthesia can usually be obtained without infiltrating to the point of maximum tumescence.

To ensure optimal anesthesia and vasoconstriction, the surgeon should wait at least 30 minutes after completion of tumescent anesthetic infiltration before commencing liposuction of the abdomen.

Surgical Technique

Accurate preoperative topographic contour drawings are an important prerequisite to obtaining a uniformly smooth result after tumescent liposuction (Figure 31-19).

Scarpa’s fascia can be relatively more resistant to penetration by large cannulas. Larger cannulas require greater force and thus produce greater discomfort. Microcannulas can penetrate Scarpa’s fascia without excessive force, resulting in minimal discomfort. Microcannulas thus facilitate more complete liposuction of the relatively inaccessible sub-Scarpa’s fat compartment.

Preferably, liposuction deep to Scarpa’s fascia is initiated with a 16-gauge microcannula to minimize the force necessary to penetrate the fascia. After establishing multiple tunnels through Scarpa’s fascia, larger, 14-gauge and 12-gauge cannulas can be used with greater accuracy and less patient discomfort.

The more fibrous periumbilical fat is more resistant to liposuction than fat located 4 cm or more from the umbilicus. The surgeon must direct extra efforts toward this resistant deposit, or residual fat will result in the appearance of a periumbilical “donut.”

Epigastric fat is especially fibrous, and the overlying skin is less elastic than that of the lower abdomen. To maximize the probability of a smooth result, the surgeon can use microcannulas in crisscrossing radial patterns. The patient, especially an older patient, should be told that a postoperative crepelike or wrinkled appearance is possible.

Incisions should be placed in a somewhat random pattern to avoid the appearance of a regular or symmetric distribution. Placing three to five 2-mm adits along the inferior margin of the abdomen, followed by doing liposuction through these adits, establishes a drainage pathway, helps prevent bruising, and hastens the resolution of postoperative edema.

When incisions are limited to the suprapubic or umbilical area, liposuction of the epigastric area is usually insufficient. I prefer to place several 1.5-mm adits in the upper abdomen to permit transverse and oblique liposuction with 16-gauge (1.2-mm internal diameter [ID]) or 14-gauge (1.8-mm ID) cannulas. This tunneling with microcannulas reduces the resistance of the highly fibrous upper abdominal fat. Subsequently, liposuction with larger cannulas, using 2.0-mm adits in the lower or upper abdomen, is more effective, more complete, and more comfortable.

Care must be taken to avoid a forceful thrust of the cannula through the epigastric fat that is directed toward the costal margin. Otherwise, the momentum from sudden penetration of a resistant fibrous partition might risk penetration of the diaphragm or pleural space. Typically, during the initial stages of epigastric liposuction, the microcannulas are directed transversely or distally, away from the costal margin. Only after the fibrous partitions of the epigastric fat have been sufficiently fenestrated using 16-gauge and 14-gauge microcannulas should a larger, 12-gauge cannula be used in the lower abdomen or the upper abdomen. Rarely, when treating a large abdomen, a 10-gauge Finesse cannula may be used.

Incisions or adits above the umbilicus should be limited in number and should not be so small that cannular friction can cause epidermal burn and eventual postinflammatory dyschromia. In the vast majority of patients the 1.5-mm adits or microincisions for a 14-gauge cannula become virtually invisible.

Although dyschromia at the site of an adit or microincision is uncommon, an occasional patient will experience some long-lasting hyperpigmentation. Factors that increase the risk of dyschromia include racial or genetic predisposition and the effects of trauma-induced inflammation to the incision. For example, a history of abdominal liposuction is associated with increased fibrosis within the targeted fat. This scarring fibrosis of fat necessitates more vigorous liposuction efforts, resulting in more friction trauma to the adit or incisions and predisposing to incision site dyschromia (see Chapter 8).

Upper Abdominal Liposuction

Liposuction of upper abdominal fat is more challenging than that of lower abdominal fat because the upper abdomen is so fibrous. Compared with the easy skin retraction and smooth results routinely achieved for the lower abdomen, liposuction of the upper abdomen is more difficult, and the results may not be as smooth.

Excessive fibrousness often limits the thoroughness and smoothness that can be achieved by liposuction. With traditional liposuction using larger cannulas and only two or three incisions in the lower abdomen, upper abdominal liposuction was often incomplete.

Both weight loss and liposuction of the epigastric fat may produce rugosity or transverse pleats of the upper abdominal skin. This uneven appearance results from the following factors:

  1. The removal of fat that once distended the overlying epigastric skin, along with incomplete dermal elastic contraction, results in fine wrinkles or dimpling.
  2. The relative fibrousness of the upper abdominal fat is a result of a dense network of fibers and collagenous sheets that tether the skin to the deep muscle fascia. After weight loss or liposuction, these fibrous tethers remain. When the patient is standing upright, gravity stretches the upper abdominal tissue while the fibrous tethers pull the skin in the opposite direction and produce pleats. When the patient is supine, however, and the effects of gravity are mitigated, these folds or plications usually disappear.
  3. Liposuction in the fibrous upper abdomen may predispose to uneven results. The visible effects of uneven liposuction will become more prominent with subsequent weight gain, with focal areas of excess residual fat becoming more noticeable than adjacent areas.

In most patients of average weight, only three to five 1.5-mm adits or microincisions are needed in the upper abdomen to fenestrate the fibrous subcutaneous fat with tunnels created by 16-gauge and 14-gauge microcannulas. Subsequently, most of the upper abdominal liposuction can be accomplished with 14-gauge and 12-gauge microcannulas from very few 2-mm adits.

Another explanation exists for the smoother results of liposuction of the lower abdomen compared with the upper abdomen. As a result of Scarpa’s fascia, direct fibrous connections may not exist between skin and muscle fasciae in the lower abdomen. Thus Scarpa’s fascia may cushion or mitigate the tethering effects of fibrous tissue attachments to the dermis.

End Point for Abdominal Liposuction

The surgeon should avoid overaggressive liposuction of the abdomen; the end point should be somewhat conservative. The goal is to reduce the deep fat compartment of the abdomen, with the residual layer of fat being uniform in thickness. The shape of the abdomen after liposuction should approximate the shape of the underlying abdominal musculature. The best aesthetic results, however, require that a thin layer of intact fat remain attached to the skin.

The goal is to achieve a result that looks and feels normal. An attempt to remove every possible lobule of subcutaneous abdominal fat often results in patient dissatisfaction. Excessive abdominal liposuction can cause full-thickness dermal necrosis, erythema ab liporaspiration, or an incongruous appearance that feels or looks abnormal. Smooth and natural-appearing results are more important to cosmetic surgery than extreme results.

Reston Foam Contraindicated

In the past, some surgeons have applied Reston foam to the skin overlying areas treated by liposuction to reduce postoperative bruising. This open-cell plastic foamlike sponge has an adhesive backing that adheres to the skin. Although Reston foam minimizes the appearance of ecchymoses, it has no long-term benefits.

No studies have investigated the safety of applying Reston foam after liposuction. A risk of focal skin necrosis and prolonged postinflammatory hyperpigmentation is associated with the foam. The manufacturer of Reston foam has advised against its use after liposuction.

Reston foam causes uniform distribution of the pressure from an overlying postoperative compression garment, thereby preventing extravasated subcutaneous blood from percolating to the skin’s surface. Reston foam only prevents the visible manifestation of bruising. It does not reduce the degree of subcutaneous edema or prevent the osmotic pressure gradient resulting from extravasated blood in the subcutaneous space.

Any gentle, uniform compression of the skin will constrict the interstices within the collagen bundles of the dermis and restrict the oozing or trickling of red blood cells through the fine porous openings within the interstitial spaces. Although blood can still flow through dermal capillaries, sufficiently uniform compression of the skin will close the minute apertures between dermal collagen bundles, resulting in a filterlike effect that prevents visible bruising. This mechanism is the basis for scientifically designed, superabsorptive postoperative compression pads that are now recommended for postliposuction care.

The application of Reston foam precludes the patient from taking a shower. Also, when an allergic contact dermatitis occurs under occlusion, bullae or blister formation is likely, which can cause persistent and cosmetically disfiguring postinflammatory hyperpigmentation.

The two most worrisome complications are cellulitis and dermal necrosis. When Reston blisters rupture under occlusion, the risk of infectious cellulitis increases; because the skin is covered and cannot be directly examined, the diagnosis of cellulitis is often delayed. Cutaneous necrosis can occur when the patient sits or bends, causing the skin to fold and the Reston foam to become crimped. After a patient has slept for many hours, with the Reston foam crimping the superficial cutaneous blood supply, the result can be areas of focal avascular skin necrosis.

Postoperative Care

The immediate postoperative course after abdominal liposuction is similar to that after liposuction of other areas.

Because tumescent anesthesia has a long duration, patients do not require analgesics other than acetaminophen. Patients usually experience the most discomfort or soreness 36 to 72 hours after surgery. There is no restriction on gentle postoperative physical activity. Patients are advised not to remain in bed, but rather to walk inside their home or take a short walk outside on the evening of surgery.

The patient is expected to shower at least once or twice daily beginning the morning after surgery. The day after surgery, as a result of open drainage and significant compression, the degree of cosmetic improvement is usually dramatic. Over the next several days, after drainage has ceased and as the inflammatory healing process progresses, there is a gradual onset of swelling. This subcutaneous abdominal swelling can restrict bending forward; for example, tying shoes becomes a minor challenge.

The edema that occurs after liposuction of the abdomen typically takes longer to resolve than edema in other treated areas. A certain degree of lumpiness, detectable by palpation, is normally present for 4 to 12 weeks. Some degree of firm subcutaneous pitting edema usually persists for 3 to 4 months.

Oral nonsteroidal antiinflammatory drugs (NSAIDs) are generally not necessary or routinely recommended. Patients may begin cautiously taking NSAIDs 72 hours after surgery, however, to reduce the degree of tenderness and discomfort. NSAIDs affect leukocyte function and may decrease resistance to infection.

Open Drainage and Bimodal Compression

The degree of postoperative bruising depends on the individual patient as well as surgical technique and postoperative care. Multiple 1.5-mm or 2-mm adits (nonsutured incisions) and appropriate postoperative compression promote rapid resolution of swelling, soreness, tenderness, and bruising. Bruising is the least important of these common postoperative sequelae. Whereas swelling and pain will impede a patient’s rapid return to normal activities, bruising is merely a cosmetic concern.

Open drainage and bimodal compression minimize postoperative bruising, edema, and pain in the treated areas. This scientific approach to postoperative care allows patients to return to normal activities within days of surgery (see Chapter 30).

Both male and female patients use a postoperative tumescent liposuction compression system specifically designed for abdominal liposuction and breast liposuction.* The system consists of (1) superabsorbent compression pads and (2) a postoperative elastic compression garment and binders.

Absorptive Compression Pads

Superabsorbent compression pads (HK Pads) have two purposes. The first function is to absorb the copious postoperative blood-tinged tumescent anesthetic solution associated with open drainage that occurs when adits or incisions are not closed with sutures.

HK Pads are designed and manufactured specifically for liposuction. The pads contain more than twice the amount of absorptive material per unit area than any other absorbent pads. Superabsorbent powder (SAP) is included in the absorptive material. When properly applied using appropriate compression garments, the pads eliminate the inconvenience and messiness of postoperative tumescent drainage.

The second function of the pads is to distribute uniformly the compressive force delivered to the dermis by the overlying elastic garments. As SAP absorbs a large volume of water, it becomes a gelatinous mass that behaves according to the basic law of physics that describes the uniform distribution of pressure in liquids. A small increment of pressure delivered to one portion of a confined liquid is uniformly transmitted throughout the liquid container.

By uniformly distributing the compression of elastic garments, the pads eliminate most postoperative bruising. The pads minimize postoperative bruising similar to Reston foam. As SAP within the pads becomes swollen with absorbed drainage fluid, the force of the elastic compression garment is hydrostatically distributed evenly over the entire subjacent dermal surface. By preventing the upward migration of blood through the compressed interstices within the dermal collagen, the pads prevent bruising.

Unlike Reston foam, however, HK Pads are not fastened to the skin by an adhesive. Thus the pads eliminate the postliposuction risk associated with using Reston foam, which can fold on itself and crimp dermal blood vessels, resulting in cutaneous necrosis.

Elastic Compression Garments

In addition to absorptive compression pads, the postoperative elastic compression system consists of a spandex breast/torso garment and elastic binders that provide bimodal compression.

The garment has a pair of Velcro strips 2.5 cm (1 inch) wide sewn onto the anterolateral portion of the garment, extending from above the breasts down to the lower abdomen. The Velcro fastens to the woven surface of torso binders, which are 15 or 23.5 cm (6 or 9 inches) wide. These are also known as abdominal binders or rib belts. The Velcro attaches directly to the binders and prevents the binders from slipping out of their intended position relative to the treated areas. A large abdomen may require three overlapping belts, whereas a small abdomen requires only two binders.

The actual placement of the pads, garment, and binders can be easily accomplished using elastic tube netting and paper tape (Figure 31-20).

The purpose of the garment is to deliver a compressive force to the subcutaneous interstitial space and expel the residual blood-tinged tumescent anesthetic solution. Removing this solution dramatically reduces postoperative edema and tenderness.

As the patient moves about, the overlying pads and the elastic garments and torso binders enable the patient’s skin to move in an incremental manner that is independent of the pads. Besides providing continuous, evenly distributed compression over the treated areas, this combination of pads, garments, and binders also avoids the risks and inconveniences of adhesive foam.

Abdominal and Thigh Liposuction. A breast/torso garment is specifically designed for postoperative compression of the torso, which includes the abdomen, breast, and back. Such a garment will not provide compression of the thighs.

The use of an “overall”-type garment is indicated when a patient’s abdomen and thighs are suctioned on the same day. This type of garment provides compression to the abdomen, thighs, and knees. Bimodal compression is provided by using two garments simultaneously for compression of the thighs plus binders for the abdomen.

To provide additional compression during continued open drainage, two garments are applied. The first garment put on the patient is a size larger than the second garment; the larger garment is easier to pull on over the bulky absorptive compression pads. The second, smaller garment then is easily donned, sliding over the smooth surface of the first garment.

The additive effects of the two garments provide so much compression that patients need to be warned about decompression-orthostatic dizziness, which can occur when the garments are removed the following morning before showering. About 24 hours after the drainage of blood-tinged anesthetic solution has ceased, only the smaller of the two garments is worn, and the absorptive compression pads are no longer necessary.

Finding that a compression garment provides postoperative comfort and security, patients often continue to wear the garments for many days after all the drainage has stopped.

Pitfalls and Special Considerations

Doing liposuction with another surgical procedure increases the risk of an adverse outcome. Any surgery that requires postoperative bed rest increases the risk of pulmonary thromboembolism and should be avoided with liposuction.

Peritoneoscopy

Abdominal liposuction and intraabdominal surgery should not be performed concomitantly. Also, liposuction is contraindicated when an intraabdominal procedure is performed on the same day. Peritoneoscopy creates a pathway directly into the peritoneal cavity and increases the risk of a liposuction cannula entering the abdominal cavity and injuring intraabdominal viscera3,4 (Case Report 31-2).

A periumbilical hernia also presents an increased risk of an intraabdominal penetration with a liposuction cannula. A periumbilical hernia is a relative contraindication for abdominal liposuction; it can usually be repaired by a general surgeon using local anesthesia.

Abdominal Perforation

With liposuction under general anesthesia, diagnosis of inadvertent penetration of the abdominal cavity with intestinal laceration will probably be delayed. If a liposuction cannula causes a bowel perforation under general anesthesia, it might not be immediately appreciated. When the patient awakes after general anesthesia, any complaint of abdominal pain may be dismissed as the expected consequence of abdominal liposuction. If the delay extends beyond 18 to 24 hours, there is a serious risk of peritonitis, sepsis, or necrotizing fasciitis.

Liposuction totally by local anesthesia eliminates the possibility of missing the proper diagnosis after a traumatic bowel perforation. A high suspicion of an intestinal perforation should be followed immediately with evaluation by a general surgeon. Prompt diagnosis and surgical intervention greatly reduce the risk of life-threatening complications.

Genital Edema and Ecchymosis

An occasional abdominal liposuction patient will experience transient postoperative ecchymosis and edema of the external genitalia. This is simply the effect of gravity on incomplete postoperative drainage of blood-tinged anesthetic solution. The onset is usually on the second or third postoperative day. This gravitational edema is benign and of no clinical consequence; it resolves spontaneously within a few days after onset. No treatment is necessary, and the patient should be cautioned not to apply ice or attempt other maneuvers that could damage tissues.

Informing patients before abdominal liposuction about the possibility of scrotal or labial edema avoids unnecessary worry and anxious telephone calls to the surgeon. The risk of genital edema can be minimized by avoiding excessive volumes of tumescent anesthesia and by placing 2-mm adits along the inferior margin of the abdomen to facilitate open drainage. Placing sutures in abdominal incisions increases the incidence of edema in dependent parts.

Miscellaneous Caveats

Excess Compression. After an abdominal liposuction, excessive postoperative compression can impair breathing by increasing intraabdominal pressure and impeding the excursion of the diaphragm. Reduced ventilation can precipitate respiratory insufficiency. Nonadjustable, high-compression postoperative garments are especially dangerous after systemic anesthesia with administration of respiratory depressant drugs.

Excess Infiltration. Too much tumescent fluid may be infiltrated into the abdominal subcutaneous fat. An excessive volume of anesthetic solution can impinge on the abdominal cavity. This can cause the abdominal viscera to press upward against the diaphragm, impairing ventilation by limiting the respiratory excursion of the lungs.

For a large female abdomen, one usually does not need to infiltrate more than twice the anticipated volume of aspirated supranatant fat. Liposuction of a very large abdomen can be done as staged procedures separated by a month or more.

Fat Distribution. There is proportionately less upper abdominal fat than lower abdominal fat. Consequently, upper abdominal fat is aesthetically less objectionable than lower abdominal fat. Thinner patients are often unaware of or unconcerned about upper abdominal fat. If the upper abdominal fat is not suctioned or inadequately suctioned, however, subsequent weight gain will enlarge the upper abdomen and create a midriff.

In some patients, suctioning only the lower abdomen may result in a disproportionately prominent epigastric fat pad. When the patient stands upright, the weight of residual epigastric fat causes the upper abdominal skin to sag. This “sad-face” result can be avoided by unweighting the upper abdominal skin by extending the liposuction into upper abdominal fat.

An “inverted-smile” appearance can be treated by carefully reducing the gross weight pulling downward on the epigastric skin, using careful liposuction and microcannulas (Figure 31-21).

Excess Liposuction. Removing too much abdominal fat may lead to unpleasant results for the patient. The goal is not to remove as much fat as possible, but rather to produce a result that will be most pleasing to the patient.

Many women desire as lean an abdomen as possible. For a woman who is somewhat plump, a lean abdomen might appear and feel unnatural. One should never assume that all women want the maximum amount of fat possible removed from the abdomen.

Mons Pubis. Liposuction of the mons pubis should be approached with caution. Excessive liposuction of the mons pubis may result in the area being so deficient in fat that normal sexual intercourse becomes painful.

References

  1. David LR, DeFranzo A, Marks M, Argenta LC: Posttraumatic pseudolipoma, J Trauma 40:396-400, 1996.
  2. Carpaneda CA: Postliposuction histologic alterations of adipose tissue, Aesthetic Plast Surg 20:207-211, 1996.
  3. Ovrebo KK, Grong K, Vindenes H: Small intestinal perforation and peritonitis after abdominal suction lipoplasty, Ann Plast Surg 38:642-644, 1997.
  4. Talmor M, Hoffman LA, Lieberman M: Intestinal perforation after lipoplasty: a case report and review of the literature, Ann Plast Surg 38:169-172, 1997.

Figure 31-1 A, Various features of abdominal superficial anatomy are highlighted by topographic contour drawings. Upper abdominal fat compartment consists of 1, supracostal abdominal fat pads; 2, epigastric fat pad; 3, lower abdominal fat compartment, which is bounded above by waistline sulcus and below by pubic area; and 4, inguinal fat pad, which is proximal to inguinal crease. B, Preoperative view. C, After microcannular tumescent liposuction.

Figure 31-2 Waistline sulcus is most visible in obese patients and is a manifestation of focal subcutaneous fibrosis. A, Waistline sulcus is transverse furrow that extends across abdomen at or above umbilical level. B, In some patients, waistline sulcus extends around entire torso. C, Similar appearance of mother and daughter suggests that abdominal surface anatomy is inherited. D, Patient demonstrates that not everyone has waistline sulcus.

Figure 31-3 Waistline fibrosis is transverse band of fibrous subcutaneous fat that extends across abdomen of most persons. In some obese patients, waistline fibrosis is associated with visible waistline sulcus. Scarpa’s fascia is oval-shaped sheet of fibrous tissue that extends across lower abdomen; its proximal extent seems to merge with waistline fibrosis.

Figure 31-4 Microcannular tumescent liposuction of abdomen can eliminate transverse waistline sulcus. A and B, Preoperative views of obese patient with prominent waistline sulcus and pendulous lower abdomen. C and D, Immediately after microcannular tumescent liposuction totally by local anesthesia, waistline sulcus and pendulous lower abdomen are less visible.

Figure 31-5 Sagittal section through abdomen illustrating important aspects of subcutaneous abdominal adipose tissue (see text).

Figure 31-6 Cadaver dissection of subcutaneous abdominal fat. A, Subcutaneous abdominal fat is shown divided into three areas. In upper and lower abdomen, skin has been dissected from subcutaneous fat. In midabdomen, dissection has followed a fibrous tissue plane, which is superficial in midline and becomes more deeply located as plane of dissection extends laterally. Deeper dissection through remaining midabdominal subcutaneous fat reveals fascia of abdominal rectus muscle. B, Digital dissection along plane at interface between midabdominal fat and fascia of rectus muscle. This plane of dissection is deep to Scarpa’s fascia and sub-Scarpa’s fat compartment. C, Dissection along deep surface of midabdominal subcutaneous fat reveals parasagittal neurovascular bundles. Arterial component of bundles originates deep to rectus muscle from epigastric artery and perforates muscle to supply cutaneous and subcutaneous tissues of medial abdomen. D, Further dissection reveals additional arterial perforators. In lower abdomen, anterosuperior epigastric vein originates near saphenofemoral junction and courses superficially to Scarpa’s fascia. E, Scarpa’s fascia extends across entire lower abdomen. F, Lateral circumflex vein originates near saphenofemoral junction near origin of anterosuperior epigastric vein. It is shown here as it penetrates Scarpa’s fascia midway on its course toward subcutaneous fat near anterior iliac crest.

Figure 31-7 Pseudolipoma on lower abdomen resulting from Pfannenstiel’s incision. This common transverse incision, approximately 2 cm above symphysis pubis, provides excellent access to pelvic contents.

Figure 31-8 Abdominal blood vessels of clinical importance for liposuction surgery include anterosuperior epigastric veins, lateral circumflex veins, and paramedian neurovascular bundles.

Figure 31-9 Umbilical hernia of significant size represents increased risk of liposuction injury to intraabdominal viscera and should be repaired by a general surgeon at least 8 weeks before liposuction. A, Cadaver dissection reveals umbilical hernia and demonstrates small distance between subcutaneous fat and intraperitoneal extension of hernia. B, Subtle bulge of umbilical hernia is visible within this patient’s umbilicus.

Figure 31-10 A, Total of 2500 ml of supranatant abdominal fat was removed from patient’s abdomen using microcannular tumescent liposuction totally by local anesthesia. Largest cannula used was 12-gauge Capistrano microcannula. B and C, Preoperative views. D and E, After tumescent liposuction. Abdominoplasty was unnecessary.

Figure 31-11 This patient had been told that abdominoplasty under general anesthesia was only option for removing pendulous apron of fat from her abdomen. After tumescent liposuction totally by local anesthesia, patient decided that skin excision was unnecessary. A and B, Preoperative views. C and D, Two months after tumescent liposuction.

Figure 31-12 After tumescent liposuction of abdomen, this patient decided further surgery was unnecessary. Residual laxity of skin was insufficient to warrant skin excision, even though secondary excision and rectus muscle plication could be accomplished totally by local anesthesia. A and B, Preoperative views. C and D, Six weeks after tumescent liposuction.

Figure 31-13 Liposuction can be accomplished with minimal scars. A and B, Preoperative views. C and D, Two months after tumescent liposuction.

Figure 31-14 Tumescent liposuction for moderate abdominal obesity can be accomplished entirely with 14-gauge Capistrano microcannula, as in this patient. A and B, Preoperative views. C and D, Four months after tumescent liposuction.

Figure 31-15 Tumescent liposuction for mild abdominal obesity. A, Preoperative view. B, After tumescent liposuction.

Figure 31-16 Tumescent liposuction procedures for male abdomen and flanks were accomplished on same day, and patient returned to work within 2 days. In males who have a much greater degree of obesity, liposuction of abdomen alone is sufficient challenge. In a large patient it is often prudent to avoid doing liposuction of both abdomen and other areas on same day. A and B, Preoperative topographic contour markings. C and D, Anterior views before and after liposuction. E and F, Lateral views before and after liposuction. G and H, Posterior views before and after liposuction.

Figure 31-17 A and B, Scars provide evidence of prior cosmetic abdominoplasty. With microcannular tumescent liposuction, such scars usually are no longer necessary.

Figure 31-18 Position for liposuction of abdomen and anterior thighs should be comfortable. Patient’s arms can be “politely” restrained by wrapping each in towel and then tucking towels under patient. Patient remains in complete control and can remove restraints simply by elevating back and extracting arms. This type of restraint reminds patient not to move arms or hands unconsciously across surgical field, gesture while talking, or scratch nose.

Figure 31-19 A to D, Examples of abdominal topographic contour drawings on different patients.

Figure 31-20 Sequential steps for placing absorptive compression pads and elastic compression garments after abdominal liposuction. A, Appearance of abdomen immediately after tumescent liposuction. B, Absorptive compression pads are first placed on upper abdomen, then lower abdomen. C, Elastic tube netting is pulled up and over thighs. D, Tube netting is stretched over torso. E, To facilitate application of elastic garment, absorptive compression pads are held in place by tube netting. F, Elastic compression garment is pulled up over legs. G, Garment is pulled onto torso, with arms inserted through openings. H, Torso binder is placed on lower abdomen, overlapping garment’s Velcro strips. I, One or two torso binders are placed over lower abdomen; additional binder is used to cover epigastric area. Bruising tends to occur with insufficient padding and compression.

Figure 31-21 Sagging abdomen with “inverted-smile” appearance of umbilical area results from thorough liposuction of lower abdomen and insufficient liposuction of upper abdomen.

CASE REPORT 31-1 Bleeding Associated with Abdominal Liposuction
I had done abdominal liposuction for this female patient years earlier with very good results. On several occasions I denied her requests for additional abdominal liposuction simply because there was little room for improvement. Ultimately, I acquiesced, thinking that the risks were minimal.
The repeat liposuction was notable only for an unusual degree of fibrosis around the umbilicus. I noticed no bleeding during surgery. Immediately after surgery, however, bleeding from several adits became evident. I noted a small hematoma approximately 5 cm lateral and distal to the umbilicus. Eventually the bleeding stopped after direct manual pressure and application of firm abdominal compression with pads and abdominal binders.
After surgical consultation the patient was admitted to the hospital for observation and discharged home the next day. After surgery I learned of her severe periumbilical infection as a newborn; the degree to which this caused excessive fibrosis and contributed to the bleeding is uncertain. In retrospect, my decision to do more liposuction was inappropriate.
Discussion. See text.


CASE REPORT 31-2 Concomitant Hysterectomy and Liposuction
In a hospital operating room, under general anesthesia, a 53-year-old woman had an endoscopic hysterectomy by a gynecologist followed by an abdominal liposuction by a surgeon of a different specialty. After the procedures the surgeons did not realize that a small incision through the rectus muscle used for the endoscopic procedure had dehisced, allowing a segment of small bowel to herniate into the subcutaneous space created by liposuction. Assuming that the mass represented a hematoma, the surgeon attempted to aspirate subcutaneous fluid by inserting a large hypodermic needle into it.
Over the next 10 days the patient’s condition deteriorated. When a general surgeon performed emergency exploratory surgery, the subcutaneous mass was found to consist of an abscess and mass of necrotic small intestine. After a partial small bowel resection the patient recovered.

*HK breast/torso garments (www.hksurgical.com).

Scientific Publication

  1. Klein, JA. Optimal Statistical Techniques in Estimating Patient Compliance. Preventive Med, 1979.
  2. Klein JA, Cole G, Barr RJ, Bartlow G, Fulwider C. Paraffinoma of the Scalp, Arch Derm 121:382-385,1985.
  3. Klein JA, Barr RJ. Verrucous Hemangioma, J Pediat Derm, 2:191-193,1985.
  4. McCullough JL, Peckham P, Klein J, Weinstein GD, Jenkins JJ. Regulation of epidermal proliferation in mouse epidermis by combination of difluoromethyl ornithine (DFMO) and Methylglyoxal Bis(guanylhydrazone) (MGBG), J Invest Derm 85:518-521,1985.
  5. Klein JA, McCullough JL, Weinstein GD. Topical tritiated thymidine for epidermal growth fraction determination. J Invest Derm 86:406-409,1986.
  6. Klein JA, Barr RA. Diffuse lipomatosis and tuberous sclerosis. Arch Derm 122:1298-1302,1986.
  7. Klein JA. The tumescent technique for liposuction surgery. J Am Acad Cosmetic Surg 4:263-267,1987.
  8. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Derm Surg Oncol 14:1124-1132,1988.
  9. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol 15:1081-1083,1989.
  10. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Derm Surg Oncol 16:248-263,1990.
  11. Klein JA, Barr RJ. Bannayan-Zonana Syndrome Associated with Lymphangiomyomatous lesions. J Pediat Dermatol 7:48-53, 1990.
  12. Klein JA. The Tumescent Technique: Anesthesia and Modified Liposuction Technique. Dermatol Clinics 8:425-437,1990.
  13. Stewart JH, Chen SE, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia, II. J Dermatol Surg Oncol 16:842-845,1990.
  14. Klein JA, Anesthesia for dermatologic cosmetic surgery. Coleman WP III, Hanke CW, Alt TH, Asken S, editors, Cosmetic Surgery of the Skin: Principles and Techniques. Philadelphia, B. C. Decker Inc. 1991, pp 39-45.
  15. Coleman WP III, Klein JA. Use of the tumescent technique for scalp surgery, dermabrasion, and soft tissue reconstruction. J Dermatol Surg Oncol 18:130,1992.
  16. Klein JA, Soins post-operatoires apres liposculpture utilisant la technique tumescente (Postoperative Care Following Liposuction by the Tumescent Technique), La Revue de Chirurgie Esthetique de Langue Francaise 17:5-8,1992.
  17. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 92:1085-1098,1993.
  18. Klein JA. Reply: Ethics of promoting patient safety and comity among surgical specialties. [letter] Plast Reconstr Surg 95:603-604,1995.
  19. Klein JA. Establishing a Dermatologic Surgicenter, Elson M, editor, Evaluation and Treatment of the Aging Face. Springer-Verlag, publishers, New York 1995, pp 255-260.
  20. Klein JA, Liposuction. Moy R, Lask G, editors, Principles and Techniques of Cutaneous Surgery. Mc Graw-Hill, New York, 1996, pp 529-542.
  21. Klein JA, Tumescent liposuction and improved postoperative care using Tumescent Liposuction GarmentsT. Dermatol Clinics, 13:329-338, April 1995.
  22. Klein JA, Tumescent Technique Chronicles: Local Anesthesia, Liposuction, and Beyond. Dermatologic Surg. 21:449-457, 1995.
  23. Klein JA, Epitomes, Dermatology: Tumescent technique for local anesthesia. West J Med 124) Klein JA. Tumescent liposuction with local anesthesia. Principles and Techniques of Cutaneous Surgery. Lask GP, Moy RL editors. McGraw-Hill, New York, 1996. pp 529-542.
  24. Klein JA, Anesthesia for dermatologic cosmetic surgery. Coleman WP III, Hanke CW, Alt TH, Asken S, editors, Cosmetic Surgery of the Skin: Principles and Techniques. 2nd Edition. Philadelphia, B. C. Decker Inc., 1997
  25. Klein JA. Two Standards of Care for Tumescent Liposuction. Derm Surg J 24:1194-1195,1997
  26. Klein JA, Kassardjian N. Lidocaine Toxicity with Tumescent Liposuction, a case report of probable drug interactions. Derm Surg J 24:1169-1174,1997
  27. Klein JA, Tumescent Liposuction, Chapter 9, in Dzubow LM, editor, Cosmetic Dermatologic Surgery, Lippincott-Raven, Philadelphia, 1998,p163-169.
  28. Klein AW, Narins RS, Klein JA. Tumescent Liposuction. Fitzpatrick's Dermatology in General Medicine, 5th edition, McGraw Hill, New York, 1999, pp2967-2969.
  29. Klein, JA. Intravenous fluids and bupivacaine are contraindicated in tumescent liposuction (letter), Plastic Reconstr Surg 102:2516-2518,1998.
  30. Klein JA. Anesthetic formulations of tumescent solutions. Dermatologic Clinics, 17:751-759,1999.
  31. Klein JA. Post-tumescent liposuction care: open drainage and bimodal compression. Dermatologic Clinics, 17:881-889,1999.
  32. Klein JA. Commentary: Fulton J. Modified Tumescent Liposuction. Dermatol Surg 25:764-766,1999.
  33. Klein JA. Discussion: Perry AW, Petti C, Rankin M. Lidocaine is not necessary in liposuction. Plast Reconstr Surg. 1999 Nov;104: discussion 1903-6
  34. Klein JA. Antibacterial effects of tumescent lidocaine. Plast Reconstr Surg. 1999 Nov;104:1934-6.
  35. Klein JA, Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction. Mosby, St. Louis, approx 500 pages. March, 2000.
  36. Klein JA. Pharmacology of Tumescent Liposuction. Ch 21. pp 443-445. In Cosmetic Surgery: An Interdisciplinary Approach, Narins RS editor, Marcel Dekker, New York, 2001.
  37. Klein JA Liposuction Using Dilute Local Anesthesia: Counterpoint. Dermatol Surg 29:1146-7, 2003.
  38. Klein JA, Is Tumescent Liposuction Safe?, Baran R, Maibach HI, Editors, Textbook of Cosmetic Surgery, 3rd ed. 2005, Chapter 64, pages 621-628, Taylor&Francis Publishers, London&New York (ISBN 1-84184-311-3)
  39. Kucera IJ, Lambert TJ, Klein JA, Watkins RG, Hoover JM, Kaye AD. Liposuction: contemporary issues for the anesthesiologist. J Clin Anesth. 18:379-87, 2006.