Ultrasound-Assisted Abdominoplasty: Combining Modalities in a Safe and Effective Technique

David L. Abramson, M.D.

Body contouring surgery, particularly of the abdomen, has evolved during the past 20 years. The addition of liposuction to the armamen­tarium of the surgeon and the subsequent de­velopment of the tumescent technique have enabled surgeons to become more aggressive in their approach to abdominoplasty. Patients with difficult body types formerly needed both abdominoplasty and liposuction, which would be performed as separate procedures. The use of liposuction of the flanks has become com­mon, but more recently it has been shown that liposuction of the upper flap can be performed safely as part of an abdominoplasty. Now, the use of ultrasound-assisted liposuction can be performed as part of an abdominoplasty. This provides some advantages that are associated with ultrasonic liposuction, with minimal added risk to the patient.

Materials and Methods

In 1998, I published an article describing my technique for tumescent abdominoplasty, which involved the infusion of tumescent fluid, liposuction of the flanks and upper abdominal area, and rectus plication.1 Since that time, I have shifted my practice and perform all cos­metic surgical procedures in a hospital setting. Over the past 3 years, I have routinely used ultrasound-assisted liposuction following tu­mescent infusion as part of my abdomino­plasty. Tumescent infusion consisting of 20 cc of 2% lidocaine with epinephrine 1 mg/liter is used. Usually, between 1500 and 3000 cc of tumescenl fluid is used, depending on body type. There were 24 patients in this series. Ini­tially, the external ultrasound machine that provides 3 W/cra9 was used for the iirst three patients; for the remaining 21 patients, I used internal ultrasonic energy applied using the Mentor Contour Genesis machine (Mentor Corporation, Santa Barbara, Calif.) at 85 per­cent power. The Contour Genesis machine is applied for 2 minutes to the upper flap, above the rectus sheath (Fig. 1, area A), and for 1.5 to 2 minutes to each flank area (Fig. 1, area Q. Essentially no ultrasound is used lateral to the rectus sheath and superior to the abdomino-plasty incisions (Fig. 1, area B). After the ultra­sound, an evacuation phase with a 4-mm Mer­cedes cannula is then performed in all areas that had ultrasonic energy applied. Liposuc-(.ion in area A was performed both above and below Scarpa's fascia but not directly under the dermis. At the completion of the liposuction, the previously marked skin incisions are made and the upper flap is elevated off of the ab­dominal wall above the rectus sheath only. This is carefully performed to minimize disruption of the blood vessels supplying the upper skin Hap.

After elevation of the flap and excision of the excess skin, rectus plication is then performed. Marcaine 0.5% (Astra USA, Westborough, Mass.) is then infused lateral to the plication to help provide postoperative pain relief. The bed is then reflexed approximately 20 to 30 de­grees, and closure is performed using 2-0 Vicryl the skin, both of which have been reported with ultrasonic liposuction. Pain management consisted of oral agents only, and patients were discharged home with Vicodin ES (Knoll Phar­maceutical Company, Whippany, N.J.) for pain and antibiotics while the drains were in place. All patients were satisfied with their results. In particular, they noted improvement in the supraumbilical area (Figs. 2 and 3) and in the lateral flank and waist areas (Figs. 4 and 5). A thinner appearance in the supraumbilical area can only be achieved widi direct excisional lipectomy, which will have a more profound effect on the vascular supply of the flap.

Discussion

Plastic surgeons are always trying to achieve the best possible result for their patients. Fre­quently, the patient who presents with abdom­inal adiposis benefits from both abdomino-plasty and liposuction. Historically, there has been trepidation regarding liposuction of the abdomen at the time of abdominoplasty. How­ever, risk of injuring the blood supply to the abdominal flap is likely to be greater from overaggressive undermining of the flap, creat­ing loss of the perforators or too much tension on the flap itself, leading to vascular compro­mise. The use of the tumescent infusion has several effects, including reducing pain and blood loss and increasing the amount of lidocaine that can be safely administered.2"4 Tu-mescem infusion causes constriction of the blood vessels in the area above the rectus sheath. Consequently, there is likely to be a lower incidence of injury to these vessels dur­ing the ultrasound-assisted liposuction. Tumes-cent infusion has also been shown to be helpful in combination with surgical procedures. Nguyen et al.5 described the procedure of tu-mescent miniabdominoplasty. Matarasso6 and Rohrich and Matarasso7 also described the use of liposuction as an adjunct to abdominoplasty, whereas Cardenas-Camarena and Gonzalez8 re­ported the use of large-volume liposuction combined with extensive abdominoplasty.

This series follows my previous report of six cases of tumescent abdominoplasty reported in 1998. During that study, liposuction in the up­per flap and flanks was performed. The addi­tion of ultrasonic energy to the area provides additional fat removal, particularly above the new umbilical site, which creates a more natu­rally improved aesthetic appearance. The use of ultrasound for a short time followed by an evacuation phase allows removal of significant amounts of fat while minimizing trauma to the operative area. Zocchi9 introduced the use of ultrasonic energy with liposuction in the late 1980s. The infusion of a tumescent infusion combined with the more gentle ultrasound-assisted lipoplasty causes less damage to the vascular supply of the flap. The reasons to use ultrasonic energy include the ability to remove greater quantities of fat, a potential decrease in blood loss, and an improvement in difficult fibrous areas. Initial experience with ultrasonic liposuction led to complications that had been almost nonexistent with tumescent liposuction. One of the frequent criticisms of ultrasonic liposuction of the abdomen is the high inci­dence of seroma. However, Rohrich et al.10 showed that by decreasing ultrasound time and increasing the evacuation phase, the seroma rate decreased to 2.6 percent. However, se­roma has not been a factor, most likely because drains are placed for the abdominoplasty. An­other advantage associated with the applica­tion of ultrasonic energy is the conversion of this energy to heat. This heat can reverse the temperature decreases that occur following the infusion of the tumescent fluid.10 This can be particularly helpful in maintaining core tem­perature in patients who will be discharged later the same day. Another and more signifi­cant complication from the application of ul­trasound just below the dermis is skin loss.11 To avoid this, ultrasound is not used directly below the dermis.

Summary

Abdominoplasty is a surgical procedure to improve the contour of the abdomen by removal of excess skin and fat and by plication of the rectus abdominis. Historically, this removal of skin and fat has been limited to direct excision. However, over recent years the addition of liposuction first to the flank areas and then to the upper abdominal flap has improved the result that can be obtained in a single surgical procedure. This series represents a further expansion of existing modalities by using ultrasound-assisted liposuction in the flank areas and above the rectus sheath to aid in removing more adipose tissue while limiting trauma to these areas. The series of 24 patients who underwent this procedure had uniformly excellent results and no significant complications.

This illustrates that ultrasonic energy can be applied safely to the upper abdominal flap above the rectus sheath and the flank area, thereby facilitating the removal of adipose tissue without increasing the risk of complications to the patient. The use of ultrasound-assisted liposuction on the upper abdominal flap and flank areas can help improve the aesthetic result with minimal increased risk of morbidity.
David L. Abramson, M.D 42A East 74th Street New York, N.Y. 10021 plasticsurgerdoc@yahoo. com

REFERENCES
1. Abramson, D. L. Tumescent abdominoplasty: An ambuiatory office procedure. Aesthetic Plast. Surg. 22: 404,
2. Hanke, C. W., Bernstein, G., and Bullock, S. Safety of
tumescent liposuction in 15,336 padents: National survey results. DermatoL Surg. 21: 459, 1995.
3. Ostad, A., Kageyama, N., and Moy, R. I. Tumescent
anesthesia with alidocaine dose of 55 mg/kg is safe for liposuction. Dermaloi Surg, 22: 11, 1996.
4. Pitman, G. H., AkerJ. S., and Tripp, J. D. Tumescent
liposuction: A surgeon's perspective. Clin. Plast. Surg. 23: 633, 1996.
5. Nguyen, T. T., Kim, K. A., and Young, R. B. Tumescent mini abdominoplasty. Ann- Plait. Surg. 38: 209, 1997.
6. Matarasso, A. Liposucuon as an adjunct to a full abdominoplasty. Plast. Reconstr. Surg. 95: 829, 1995.
7. Rohrich, R., and Matarasso, A. Liposuction as an ad-
junct to a full abdominoplasty revisited. Plast. Reconstr. Surg. 106: 1197, 2000.
8. Cardenas-Camarena, L., and Gonzalez, L. E. Large volume liposuction and extensive abdominoplasty: A feasible alternative for improving body shape. Plast. Reconstr. Surg. 102: 1698, 1998.
9. Zocchi, M. New perspectives in liposculpturing; The
ultrasonic energy (Abstract). Presented at the 10th Congress of die International Society for Aesthetic and Plastic Surgeons, Zurich, Switzerland, September 1989.
10. Rohrich, R.J., Beran, S.J., Kenkel, J. M., Adams, W. P.,
Jr., and DiSpaltro, F. Extending die role of liposuction in body contouring with ultrasonic assisted lipo-suction. Plast. Reconstr. Surg. 101: 1090, 1998.
11. Bruno, G., Amadei, F., and Abbiad, G. Liposculpture
with ultrasound: Biomedical considera dons. Aesthetic Flast. Surg, 22: 401, 1998.