Liposuction (Abdomen)

Overview

Liposuction, also known as suction-assisted lipectomy, is one of the most frequent cosmetic surgical procedures performed globally. Liposuction is primarily a body shaping technique that employs vacuum suction to remove subcutaneous adipose tissue in specific anatomical regions.

It is important to highlight that liposuction should not be presented as a weight loss technique, it is not commonly seen as a weight-loss treatment or an alternative to weight-loss surgery. If you're overweight, you're more likely to lose weight with diet and exercise or bariatric operations like gastric bypass surgery than by liposuction.

Liposuction has seen a number of technical and procedural advances (e.g., lasers, ultrasound) since its start in the early 1980s.

Abdominal Liposuction is a surgical operation that removes fat from the tummy using a suction method.

Other names for abdominal liposuction include tummy tuck and abdominoplasty.

The abdomen responds exceedingly well to liposuction and should be considered one of the most essential anatomic areas to be treated by liposuction for a variety of reasons:

• Because localized fat deposits develop often in this region in both men and women, it is one of the most frequently requested places for liposuction by both sexes, particularly in women following delivery.
• Additionally, the abdomen involves distinct anatomic, procedural, and maintenance difficulties that must be addressed in order to obtain best results in liposuction surgery.

Basic Anatomy

The abdomen is split into two different anatomic regions: the lower abdomen and the upper abdomen (epigastrium), which are frequently separated in obese people by a visible transverse depression, the waistline sulcus.

The upper abdomen is often significantly more fibrous, especially around the waistline sulcus (waistline fibrosis), and it is also a lot more tender location for liposuction.

The lower abdomen extends down from the waistline fibrosis, which is generally slightly above the umbilicus.

Lower abdominal fat is sometimes more prominent in, or even totally restricted to, the peri-umbilical area. However, the dome-shaped contour of the lower abdomen is often related to inadequate muscle tone in addition to the fat deposition.

Previous pregnancy predisposes the abdominal rectus muscles to separation and stretching (diastasis), resulting in increased protuberance of the lower abdomen.

Liposuction has little effect on the additional roundness of the abdomen caused by this disorder. A surgical plication (folding) of the rectus sheath is required for improvement to occur.

Liposuction has little effect on abdominal stretch marks (striae distensae).

There have been no reports of negative effects on future pregnancies in young women who get abdominal liposuction. Furthermore, measures obtained by liposuction are unaffected by subsequent pregnancy and parturition with normal gravid weight increase and maintenance of a good diet following pregnancy. 

Preoperative evaluation

Assessment of the patient:

Patients coming for abdominal liposuction should always be informed about the multifactorial nature of abdominal bulging. In simple situations, particularly in younger patients who eat well and exercise consistently, diet- and exercise-resistant fat deposits can be readily eliminated by liposuction.

Muscular laxity, poor posture, and rectus diastasis may all play a part in more challenging situations. Palpation as the patient attempts a partial sit-up is useful for assessing the tone and condition of the abdominal muscles as well as the thickness of the diastasis recti.

Patients are advised to exercise abdominal muscles before to and after liposuction if there is no diastasis. This increases muscular tone, which adds to the ultimate result. Patients have considerable time to impact outcomes through exercise because there is usually a month or more between the consultation and surgery. In addition to testing muscle tone during the consultation appointment, the doctor must evaluate the patient for the presence of any hernias, as well as any surgical scars.

Liposuction is most suited for individuals who are at or near their optimal body weight; however, people with mild to moderate abdominal obesity can benefit from liposuction. If a patient is significantly overweight, the doctor will explain that the overall improvement may be minimal until a sufficient quantity of weight is gone. In order to demonstrate motivation, the patient may be requested to drop 10 pounds (or establish another appropriate weight reduction target) prior to scheduling liposuction surgery. If necessary, a carbohydrate-restricted weight reduction regimen is advised, which is a great approach to drop ten or twenty pounds in a very short period of time.

Prospective patients are always given abdominal liposuction before and after images of previous patients who have had liposuction surgery to set fair expectations.

Fat distribution in men may differ from that in women. Excess fat, for example, is more diffusely distributed in the upper abdomen and is more likely to be deep to the musculofascia. Similarly, the fat in most males with protruding abdomens is deep to the musculoaponeurosis (sheath-like tendon of the muscle), making them poor candidates for liposuction.

As a result, it is critical that the patient be properly evaluated by the doctor while standing, with the real quantity of subcutaneous fat measured by pinching the skin. If there is a significant amount of intra-abdominal fat behind the fascia, the patient should be aware that liposuction will not entirely eliminate the bulge. 

Preoperative investigations:

Standard laboratory tests, such as renal function tests, liver function tests, complete blood count with differential, platelet count, prothrombin time, and partial thromboplastin time, are ordered prior to surgery. A hepatitis screening and HIV test are also conducted. 

Patient’s instructions:

• Patients are given many pages of material, including basic tumescent liposuction information, a permission form, and preoperative and postoperative instructions.
• Patients are usually given a 5-day course of antibiotics commencing one day before the operation.
• They are also advised to wash with an antibacterial cleaner in the week preceding surgery.
• Patients are advised to stop taking any drugs that may increase bleeding prior to surgery. Salicylates, NSAIDs, and vitamin E are examples.
• Prior to surgery, patients are fitted with suitable compression garments. These are labeled with the patient's name and stored until the day of operation.
• On the day of operation, the patient should wear loose-fitting, comfortable clothing that can be readily removed and changed.
• It is typically recommended that women wear a soft sports bra. This keeps the breasts out of the surgical field while also giving some privacy throughout the surgery.
• Patients are also asked to wear a hospital gown and medical underpants. 

Photographing and marking:

After signing the consent form, the patient is photographed with a Polaroid camera and a 35-mm slide camera. The Polaroid photographs are great for reference throughout the operation and also serve as a backup if the 35-mm camera fails.

The surgical site is then labeled. The doctor would usually start by asking the patient to pinch the regions that are bothering him or her.

Prior to marking, the doctor demonstrates to the patient how to pinch the skin to establish the line of demarcation between normal and adipose skin.

The doctor then uses an indelible black marker to pinpoint the location of localized fat buildup.

The doctor will use a red permanent marker to highlight any depressions, minor hernias, or other locations that should be avoided.

In addition to the palpable fat accumulation, the doctor draws dots to denote suction cannula access points. These are inserted to allow the cannulae to crisscross throughout each location to be treated and vary from surgeon to surgeon, with each having his or her own preference.

In general, the surgeon intends to make two incisions in the pubic area, one on each side, 3 to 5 cm from the midline and immediately below the distal border of the treatment location.

Another access point is proposed on either side, towards the lateral margins of the defined treatment zone, about the waist level.

A fifth midline incision is frequently made right below the sternum to get access to the upper abdomen. A periumbilical incision may be used by many other surgeons. 

Sedation and anesthesia

The patient is given preoperative medicine after signing the operation permission form. The drug of choice differs from doctor to doctor. Many doctors have patients self-medicate with a light sedative before to surgery, and if necessary, may administer a preoperative intramuscular injection of meperidine and promethazine. Others may supplement or substitute midazolam for preoperative sedation.

Some surgeons are conservative and use 1 to 2 mg of lorazepam or 5 to 10 mg of diazepam by mouth, sublingually, and avoid meperidine since some patients experienced prolonged orthostatic hypotension after surgery when it was given as a pre-operative medicine.

Tumescent anesthesia is provided by professional nurses who have received special training in this procedure.

Using a multi-port infuser and an electric peristaltic pump, the anesthetic is administered through predefined entry sites in the skin.

A 0.075 percent lidocaine solution is often employed, which provides appropriate anesthetic in the great majority of abdominal liposuction patients. A 0.1 percent tumescent solution may be utilized in rare cases in individuals known to be very sensitive or who have a history of poor "take" with local anesthetic.

Points of pain or (hot spots) are frequently observed during the treatment if a region is not entirely tumesced; however, a modest dose of additional anesthesia will usually address the problem promptly.

Before fat extraction begins, the patient is given the option to relieve his or her bladder if required. 

Procedure

In general, fat extraction advances from deep to superficial fat deposits. The cannula is held in the dominant, more strong hand, which moves it back and forth across the treatment site in a violin-bow motion.

The non-dominant hand is used to assist guide the cannula, check its depth in the fat, maintain track of the cannula tip's location, and assess the amount of leftover fat. Furthermore, the nondominant hand can stimulate more thorough fat removal by pinching the skin and subcutaneous tissue around the cannula. For these reasons, liposuction surgeons frequently refer to the non-dominant hand as the "smart hand."

Several cannulae of varying sizes and shapes are used during liposuction surgery of the abdomen. Many liposuction surgeons will start with a bigger cannula (3.5 to 4.0 mm) to remove deeper fat deposits and then go more superficially in the skin with smaller cannulae (3.0,2.5, or 2.0 mm). With this method, the canals created by the cannulae get narrower in diameter as one moves from the deepest fat to the surface.

This approach enables for the removal of the most fat, even that found superficially in the skin. Superficial fat sculpting is thought to improve skin retraction and tightness, resulting in a more attractive end result. In a newer technique, a mid-sized cannula is commonly used to "loosen up" the treatment site preparatory to debulking with a bigger, typically more aggressive cannula. As previously stated, the surgeon will utilize increasingly smaller cannulae after debulking.

The location and amount of fat present at the surgical site decide the kind and size of cannula. Because the upper abdomen is significantly more fibrous, a more aggressive cannula, such as a 3.0-mm Eliminator, is frequently required, allowing the operator to quickly move the cannula through the fibrous bands.

Because of the extensive fibrosis in the upper abdomen, greater bleeding and pain might be expected. The majority of fat removal happens with the first debulking in the lower abdomen, where fat is loosely organized, less wrapped in fibrous tissue, and more easily eliminated.

The operator should try to keep the cannula at the lowest level of fat and utilize lengthy, complete strokes that cover the whole area to be treated. Depending on the amount of the fat deposit, a cannula with a diameter of 3.5 to 4.0 mm will be utilized for debulking. In recent years, there has clearly been a trend toward the usage of smaller cannulae.

If the operator is unable to remove palpable fat from a certain location during debulking and contouring, he or she will perform further incisions to have better access.

It is not uncommon to find previous surgery scars in the lower abdomen during liposuction. Small, blunt cannulae are used to gently explore them. Suctioning continues if the cannula easily slides beneath or through the scar. If this is not possible, the operator will suction up to the scar from all sides, making additional access incisions as needed.

The final sculpting is done with a 2.5-mm Klein cannula, which is used to remove any adhering fat around the entrance incisions and "feather" the borders of the treatment site. Feathering is accomplished by making consistent cannula strokes into untreated regions around the periphery of the treatment site. This ensures that the transition between treated and untreated regions is more gradual.

The periumbilical region warrants special consideration for a variety of reasons:

1. Operators are apprehensive to impinge on this region too closely or vigorously for fear of "breaking through into the peritoneum" (although this could only occur in the presence of an umbilical hernia).
2. The region is more fibrous than the lower abdomen around it, making fat extraction more difficult.
3. Finally, this is a more sensitive location for the patient, frequently need further injections of either tumescent or full-strength lidocaine solution.

During periumbilical liposuction, the index finger of the "smart hand" is inserted into the umbilicus. This allows surgeons to feel the tip of the cannula as it abuts the umbilicus and eliminates any danger of it passing through it. Smaller cannulae of 3.0-mm or less are more suitable in this application. 

Postoperative care

Postoperative compression, removal of excess tumescent fluid, and avoidance of impact activity are all thought to be important factors in the final result of abdominal liposuction.

Some surgeons stitch the incision sites together, whereas others do not. Others believe that everything feasible should be done to encourage tumescent fluid outflow, and that multiple unsutured access points should be used to accomplish this.

Generally, the upper incisions, which do not contribute much to drainage, are sutured, and the lower (pubic) incisions are left unsutured to encourage drainage.

Remarkably, whether sutured or not, all wounds normally heal in about a week after any sutures are removed.

Patients are told that leaking usually lasts 2 or 3 days and that they should use sanitary napkins at the incision sites to absorb the blood-tinged fluid.

Although this is true for the great majority of individuals receiving abdominal liposuction, a few patients may experience leakage for a week or longer.

Excess fluid may accumulate in wounds that seal prematurely or become plugged, causing protracted swelling that interferes with skin retraction. As a result, it has been suggested that 1.5- or 2.0-mm exit "drains" be constructed by dermal punching in the area of highest dependence to encourage drainage.

Compression garments are inserted soon after surgery to apply near continuous compression to the treated region for a 2-week period.

The nurses will stand the patient up and "milk" the treatment site of blood-tinged tumescent fluid that has formed in the suctioned region before applying compression.

On postoperative day one, the first visit to the shower can be rather stressful since the patient may feel a little light-headed and has to struggle with applying cloths over each of the wounds, even if they are bleeding.

We recommend that the patients have a close friend or family member accompany them to their first shower and that they prepare towels, bandages, and tape before entering the shower.

Crotchless clothes are advised so that the patient does not have to take them on and off every time he or she uses the bathroom. Garments should be snug but not too tight.

After the first two weeks of wearing the garments almost constantly, patients are recommended to reduce their wear time to roughly 12 hours per day for another week or two.

Fortunately, postoperative discomfort is usually mild. This is normally treatable with acetaminophen, but in few cases, codeine is required.

At rest, there is usually minimal discomfort, but when the patient stretches, rotates, or sits up, he/she should expect some pain across the abdominal muscles. This improves dramatically in two weeks and is nearly gone after one month.

Following liposuction, lumpiness, irregularity, and hardness are usual, especially in the lower abdomen. After 1 to 3 months, this progressively improves, becoming softer and smoother. A little swelling, irregularities, or numbness may last for 3 to 6 months. 

Complications

The use of real tumescent liposuction, in which the patient is aware, has alleviated the majority of significant issues recorded with conventional (general anesthesia) abdominal liposuction.

Adverse outcomes such as considerable blood loss, minor intestinal perforation, and peritonitis are most frequently the result of incorrect cannula advancement below the fat compartment.

Complications of this nature can be prevented by evaluating the patient for hernias or scars before the surgery and maintaining constant awareness of where the cannula tip is during operation.

Obviously, if abdominal wall penetration is suspected, quick surgical consultation is required. The most likely indicators are unusual aches and symptoms of peritoneal irritation.

Multiple adverse sequelae have been recorded in the surgical literature, mostly in patients having general anesthesia for liposuction. There have been reports of pulmonary embolism or fat embolism following abdominal liposuction, however these appear to be considerably more common when abdominoplasty is performed concurrently with the liposuction treatment.

Pulmonary edema has also been documented following liposuction; however, it is worth noting that this happened in a patient who received 2200 mL of intravenous fluid in addition to 7900 mL of tumescent fluid.

A recognized advantage in true tumescent liposuction is that the quantity of tumescent fluid utilized for anesthesia is enough hydration to maintain fluid and electrolyte balance, and intravenous fluid administration is not necessary nor indicated.

Skin irregularity, seroma development, hematoma, skin ulcerations, erosions, and bruises are less serious problems that might occur after abdominal liposuction. These are prevalent and, for the most part, self-limiting.

Abdominal Liposuction Cost

Liposuction on the upper and lower abdomen costs around $3,800 on the low end and $8,000 on the high end in the United States, whereas liposuction on the lower abdomen costs from $2,500 to $7,500. 

Conclusion

Liposuction is primarily a body contouring procedure that uses vacuum suction to remove subcutaneous adipose tissue in certain anatomical areas.

The abdomen responds quite well to liposuction and is one of the most important anatomic regions to be addressed with liposuction.

The upper abdomen is frequently much more fibrous, particularly around the waistline sulcus (waistline fibrosis), and it is also a much more painful region for liposuction.

Lower abdomen fat is occasionally more evident in, or entirely limited to, the peri-umbilical region. However, in addition to fat accumulation, the dome-shaped contour of the lower abdomen is frequently associated with insufficient muscular tone.

Liposuction has minimal effect on the increased abdominal roundness induced by this condition. Improvement requires a surgical plication (folding) of the rectus sheath.

If there is no diastasis, patients are recommended to train their abdominal muscles before and after liposuction. This enhances muscle tone, which enhances the final outcome.

Liposuction is most suited for persons who are at or near their ideal body weight; nevertheless, liposuction can help people with mild to moderate abdominal obesity.

If a patient is severely overweight, the doctor will explain that until a considerable amount of weight is lost, the total improvement may be small.

Patients are provided several pages of paperwork, including fundamental tumescent liposuction information, a consent form, and preoperative and postoperative instructions.

Postoperative compression, evacuation of excess tumescent fluid, and avoidance of impact activity are all regarded to be essential variables in abdominal liposuction outcomes.

The use of true tumescent liposuction, during which the patient is conscious, has eased the majority of critical complications associated with traditional (general anesthesia) abdominal liposuction.

Skin irregularities, seroma formation, hematoma, skin ulcerations, erosions, and bruising are some complications that may arise during abdominal liposuction. These are common and, in most cases, self-limiting.