Marisa Marques

Abdominoplasty and Lower Truncal Circumferential Body Contouring

(usually two days of hospitalization in abdominoplasty and five days of hospitalization in the circumferential body contouring)

Generally abdominoplasty is indicated in patients whose laxity involves the supra and infraumbilical regions, limited to the anterior aspects of the lower trunk.
They include creating a flat abdominal contour, eliminating abdominal wall laxity, enhancing waist definition in some patients, and eradicating mons pubis ptosis if present. Stretch marks are common and may be limited to the infraumbilical region or may include both the infra- and supraumbilical skin. Rectus diastasis of the entire vertical extent of the abdomen is present in these patients, with the infraumbilical diastasis usually more extensive because of the position of the uterus during pregnancy.

Preoperatively abdominal wall laxity can again be detected by the “diver’s test” and physical examination.
Massive-weight-loss patients who reach a near-normal BMI may also present with lower truncal excess limited to the anterior abdomen. However they often present circumferential deformities that require more extensive circumferential excisions.

Patients who present excess intra-abdominal fat that would prevent flattening of the abdominal wall by placation are not good candidates for abdominoplasty. The outer skin fat envelope of the belly always conforms to the shape of an inner balloon whose anterior wall is made up of the abdominal muscle wall. If that wall is rendered convex in profile by virtue of overly abundant intra-abdominal contents, then the final profile of the belly will also be convex. Because abdominal contour flattening is one of the major goals of surgery, these patients are better served by weight loss prior to contemplating abdominoplasty-type procedures.

By the nature of an abdominoplasty, where an ellipse of tissue is removed from the lower abdomen, dog-ears can be created at the edges of the ellipse, especially in patients who already have lateral excess. Patients who present with deformities that extend beyond the anterior aspects of the lower trunk may require extending the abdominoplasty excision laterally, liposuction of the lateral and posterior trunk, and/or circumferential dermatolipectomy to attain the best possible contour.

Generally, as circumferential lower truncal dermatolipectomy has become more main stream in plastic surgery because of the massive-weight-loss population, the indications for isolated abdominoplasty have narrowed.
 
Important factors
Body Mass Index (BMI) = weight in kilograms/(height in meters) ²: the upper limit of normal BMI is 25; 26 to 30 is considered overweight; and 30 and above is considered obese. A variety of surgical approaches is required to treat patients in different BMI ranges.
Deposit fat: women typically deposit fat in the infraumbilical abdomen, lateral thighs, hips, and medial thighs; men tend to deposit fat in the flanks, the infraumbilical abdomen, and intra-abdominally; although these patterns are common, even within the same gender, dramatically different patterns of fat deposition are often present. 
Quality of the skin-fat envelope: women who have had one or more pregnancies tend to have abdominal skin laxity and stretch marks; the skin has been stretched beyond its ability to rebound back to its original elasticity; a similar process occurs with massive weight gain and subsequent weight loss in which the skin is over expanded, leading to a skin-fat envelope that is loose and inelastic.
 
Patient selection
Patients who have minimal to moderate subcutaneous fat excess and no abdominal wall laxity are good candidates for liposuction alone.
Patients who present with abdominal wall laxity and minimal abdominal skin excess limited to the infraumbilical region are good candidates for mini-abdominoplasty.
Patients who present with abdominal wall laxity of both the infra and supraumbilical regions and generalized skin excess limited to the anterior aspects of the lower trunk are good candidates for a full abdominoplasty.
As the deformities increase in magnitude and involve the lateral and posterior aspects of the lower trunk, circumferential truncal liposuction and/or dermatolipectomies become necessary.
Lower truncal body contouring procedures are often long and extensive in nature. Medical problems such as heart disease, diabetes, and lung disease must be under control before surgery is contemplated. Cigarette smoking also has a deleterious effect on blood supply and, when combined with the already compromised vascular supply of the abdominal skin, can lead to significant tissue necrosis.
 
Postoperative care
Return to desk work may only take 1 to 2 weeks, whereas return to heavy physical activity may take several weeks. The stitches are removed in 2 weeks. An abdominal bandage must be used for eight weeks.
 
Complications
Seroma, wound-healing problems/dehiscence, infections, tissue necrosis, hematoma, thrombotic events (deep venous thrombosis and pulmonary emboli), scar, contour asymmetry.


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