Lipoabdominoplasty with anatomical definition: a new concept in abdominal aesthetic surgery

Introduction

Restlessness, innovation, and the constant search within the surgical specialty for better and safer results are the pillars of scientific evolution.

The objective in the treatment of aesthetic and functional abdominal deformities, whether genetic or acquired, aims to correct sagging skin, lipodystrophy, and diastasis of the rectus abdominis muscles. In the past two decades, lipoabdominoplasty has largely changed the concepts of abdominal plastic surgery, through fundamental principles based on the knowledge of the anatomy of the abdominal flap. In this way, it offers better aesthetic results provided by the combination with liposuction and has low complication rates due to technical innovation that respects the abdominal anatomy and replaces traditional abdominal skin elevation with a cannula. As a consequence, the blood supply of the abdominal perforator vessels is preserved. In addition, this procedure creates a narrow central tunnel that allows for safe plication of the rectus abdominis muscles. Therefore, liposuction can be combined with abdominoplasty without increasing morbidity, while offering better aesthetic results and greater definition of body contour.

Current concepts of muscle definition have contributed to the current phase of lipoabdominoplasty with anatomical definition, bringing a more natural and defined appearance to the abdomen. In this way, the erasure of the anatomy is avoided by the inappropriate use of traditional liposuction, which can produce an aesthetically inferior result and a stigmatized abdomen.

The idea of abdominal definition was first published in 1993 by Mentz et al ., who called this approach “abdominal etching: differential liposuction to detail abdominal musculature” . Other works related to the topic contributed to the dissemination of the technique, with the application of new terminologies and technologies.

The new concept of lipoabdominoplasty with anatomical definition demonstrates aesthetic benefits, without compromising the safety of the traditional technique. In addition, it presents more natural results that promote a high degree of patient satisfaction.

Principles of the lipoabdominoplasty with anatomical definition

The fundamental principle of lipoabdominoplasty with anatomical definition still consists of preserving the perforating vessels of the abdominal wall, added to the new definition concepts, through refined and selective liposuction. Thus, a new phase of this technique began, which aims to create a more natural and defined body contour.

Patient selection

The best body aesthetic result, most similar to the ideal natural appearance, will depend directly on patient selection. Ideally the patient should have a healthy lifestyle, good dietary habits, regular physical exercise, good skin quality, and adequate muscle tone.

The ideal patient is the one who has: BMI below 25, without previous abdominal surgery, without comorbidities or smoking history, in addition to the aforementioned requirements.

The candidate for lipoabdominoplasty is one who has undergone changes resulting from pregnancy, who has functional and aesthetic deformities of the abdominal wall due to sagging skin, lipodystrophy and diastasis of the rectus abdominis muscles, which cause negative psychological, physiological and aesthetic effects on the patient.

Marking

As with any plastic surgery procedure, careful preoperative marking is crucial (see Video 28.1 ). Muscle areas must be individualized, following the concepts recommended by Ricardo Ventura for a definition of liposuction respecting the abdominal anatomical units. The most natural result will depend on the selection of the ideal patient and precise anatomical identification.

To obtain a result with three-dimensional definition, liposuction must respect the negative areas (concave shape) and the positive areas (convex shape). Therefore, some areas must be submitted to deep liposuction, others, superficial and deep, with greater or lesser intensity, depending on the proximity of the perforators and the areas to be defined.

With the aim of helping and standardizing the surgical marking, we have prepared a guide with the five abdominal areas to be addressed in this technique, as follows:

• Zone 1 (light green): corresponds to the positive areas located between the rectus abdominis muscles (above point A), flank and pubic areas. In these regions, liposuction is traditionally performed in the deep plane, with a slight gradient, which extends from the edges of the rectus abdominis to the linea alba, and to the semilunar lines on the flanks. It is completed with demarcation of the pubic region, flanks and iliac crests ( Fig. 28.1 ).

  

• Zone 2 (dark green): represents the negative areas of the central region in the linea alba, and the transition of the straight and oblique muscles, in the semilunar lines and costal edge. In these areas, liposuction is a little more intense, both in the deep and superficial planes (see Fig. 28.1 ).

• Zone 3 (yellow): region demarcated above the umbilicus (positive area), which, after resection of the abdominal flap, will slide down and correspond to the infraumbilical area, anatomically flat. Thus, very aggressive liposuction should not be performed, in order to avoid vascular compromise and deformity of the local anatomy (see Fig. 28.1 ).

• Zone 4 (red): corresponds to the rectus abdominis muscles (positive area), where the perforating vessels are present. This region must be respected with a smoother liposuction in the deep plane (see Fig. 28.1 ).

• Zone 5 (black point): represents the probable location of the new navel (point A) (see Fig. 28.1 ).

Upper abdomen

Marking is performed with the patient in the standing position, with the arms slightly abducted. For symmetrization purposes, a vertical midline (dotted) is drawn from the xiphoid process to the vulvar notch. Then, through a dynamic examination by contraction of the abdominal muscles, the negative areas are demarcated, corresponding to the alba and semilunar lines of zone 2. The width of the tracing in the linea alba (above point A – negative area), must correspond to the navel width, about 1.5 cm.

The most important anatomical area in marking is the semilunar line point (corresponding to the transition between the rectus abdominis and oblique muscles), which starts between the descending and ascending peaks of the costal border, at the angle of the tenth rib. At this point, a rhombus is created that follows the patient's anatomy, and follows with a vertical line (slightly curved) towards the iliopubic eminence, bilaterally. The abdomen has different shapes and peaks depending on the anatomy of each patient.

Lighting positioned above the patient can be used to promote the effect of light and shadows, if it is difficult to accurately identify these anatomical areas. The tracing follows the curves of the edges of the rectus abdominis and obliques, which correspond to portions of the tendinous intersections ( Fig. 28.2 ).

With the help of a ruler, all the marking points on both sides are checked, seeking symmetrization. It is important to confirm these lines with the patient in the standing position.