Modified Lipoabdominoplasty: Updating Concepts

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We read with great interest the article entitled “Modified Lipoabdominoplasty: Updating Concepts” published in July of 2016 by Ribeiro et al.1 We agree with these modifications, yet we would like to point out some procedures.
We have been using modified lipoabdominoplasty since 2004. We studied 365 patients between January of 2011 and December of 2015, merging liposuction with ultrasound VASER (Sound Surgical Technologies LLC, Denver, Colo.) liposuction. Currently, we perform liposuction of the flanks and lower back and sacrum, treating both deep and superficial layers and perform liposuction of the pubis closed with suture points.
The article describes two important incongruities. First, Dr. Ribeiro does not use tumescent infiltration, because the author infiltrates a range between 500 and 2500 ml and only aspirates 1 to 2.2 liters, which stands for superwet infiltration. In our routine, we infiltrate 4 to 6 liters and aspirate 1.5 to 2.5 liters. Adequate hydration of the body by an anesthesiologist is highly important to prevent complications resulting from variations of blood pressure when rotating patients.
Second, it is possible to lipoaspirate under the Scarpa fascia, to prevent a bulging inferior abdomen. In our routine, the patient undergoes previous resection of the infraumbilical area as described by Ronaldo Pontes.2 We preserve the Scarpa fascia at its external layer, but the medial layer is removed for plication of the rectus muscle.
In our technique, we start with liposuction of the flanks, waist, and lower back, in lateral decubitus position. Then, the patient is changed to the dorsal position for liposuction of the whole abdomen, including the infraumbilical region. Finally, liposuction of the pubis with ultrasound-assisted VASER is performed to avoid the spread of bacteria from the pubis to other regions. At the supraumbilical region, after selective undermining, we use our fingers to separate the upper area at the level of the xiphoid appendix, as described by Ewaldo Bolivar Souza Pinto.3
We would also like to add a few details. We use the X suture for plication of the rectus muscle, similar to Fabio Nahas’ technique,4 with excellent proximity to the diastasis of the rectus. We infiltrate the rectus muscle with bupivacaine, following Aldo Motura’s procedure,5 which allows the use of minor doses of analgesics and opioid medications. We use progressive traction sutures, as was done by Pollock and Pollock,6 with absorbable Vicryl 2-0 suture (Ethicon, Inc., Somerville, N.J.), one supraumbilical and two paramedian infraumbilical continuous sutures; and progressive traction sutures, which permit traction of the flap to lower direction with minor traction of the scar and the umbilicus. The scar is in good position. It does not have drains,7 which enables early ambulation of patients.
Sequential venous pump pressure therapy is used during surgery, and after 2 hours the operation is over. We administer 20 mg of low-molecular-weight heparin 2 hours after spinal anesthesia and another dose of 20 mg 6 hours later. On the second and third days, 40 mg of low-molecular-weight heparin per day is used. These minimal modifications to lipoabdominoplasty, previously described by Saldanha et al.,8 have proved to result in better and stable outcomes for body contouring.
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