Abdominal aesthetic requirements are becoming popular, in view of pregnancy or aging leading to an excess of abdominal skin and diastasis of rectus abdominis muscle [1]. Besides that, genetic factors, obesity, and a sedentary lifestyle unfavourably enhance the appearance of the abdominal shape [2].

Lipoabdominoplasty is a common procedure to improve abdominal skin laxity, wrinkles, and abdominal bulging. Lipoabdominoplasty is not solely a combination of liposuction and abdominoplasty, but it has been developed as a revelatory procedure with various versions, gradually making it a mature technique [3]. In the last two decades, limited undermining combined with liposuction to lipoabdominoplasty with anatomic definition have replaced the wide undermining of the traditional lipoabdominoplasty [4, 5].

There were known evaluations of results after aesthetic abdominoplasty surgery based on objective measurements as well as subjective clinical assessment [1, 6, 7]. Combining both evaluation methods allowed better understanding of the outcomes for surgery and facilitated comparative studies and statistical analysis [1].

In this study, we prospectively analysed the outcomes of 20 patients who underwent Saldanha lipoabdominoplasty technique.

Purpose of the study

1. Compare aesthetic measurements outcomes before and after 3 months.

2. Compare clinical scale score for outcomes assessment of aesthetic surgery.

3. Describe the cases with complication.

Material and methods

Patients

Abdominal contour surgery candidates included female patients, who agreed to participate in the research study from June 2020 to June 2021, diagnosed with stage 3 or 4 of Matarasso abdominoplasty classification, and be indicated for total abdominoplasty using Saldanha technique [5, 8]. Exclusion criteria included abdominal hernia, current inflammatory or infection at the abdomen, prior liposuction or abdominoplasty procedure, intra-abdominal hypertension, history of pulmonary embolism or deep vein thrombosis, patients who are prone to keloid scar formation, and pregnancy within 12 months.

Methods

The study design is a cross-sectional description. The study subjects were 20 patients who performed a total aesthetic abdominoplasty with the Saldanha technique from June 2020 to June 2021.

General data was collected, including age, weight, height, BMI, smoking status, past medical history, caesarean section or natural birth, caesarean section scar position (horizontal/vertical), number of childbirth, and the type and number of previous abdominal surgery.

Surgery procedure

Individualised markings in the standing position consist of possible resection areas of abdominal skin, medial and lateral rectus muscle margin, incisions for liposuction, and possible neoumbilicoplasty position.

Superwet injection technique was used. Between 1 to 3 litres of fluid, including NaCl 0.9% and adrenaline 1:1 000 000, was infiltrated in the abdomen with a blunt needle. Subsequently after 20-25 minutes, power-assisted liposuction was performed using MicroAire’s PAL LipoSculptor instrument with the patient in a hyperextended position.

Saldanha’s selective liposuction technique was performed using cannulas of 4 mm with remaining thickness of skin above the incision ≥2 cm [5]. After that, downward mobility of the flap was evaluated. The abdominal flap was dissected at the pre-Scarpa fascia in the lower abdomen and at the pre-muscular fascia at the epigastric region. Additional liposuction at the infra-Scarpa fascia in the lower abdomen can be performed if needed. Tunnel undermining was performed at the supra-abdominal rectus fascia, from the umbilical region up to the xiphoid process, and the width was approximately within the internal borders of these muscles, but avoided undermining beyond the middle third of the muscles (Fig. 1). Only suture the fascia, but not the muscle to prevent bleeding, with cross or 3 circles stitches using non absorbing materials (Prolene 0.0 or Ethibond 1.0). Omphaloplasty was performed 7 to 9 cm above the scar using opposite U or cross shape incision. Due to a longer upper semilunar incision than the lower one, the skin sutures have to be laid symmetrical and toward the pubic tubercle on each side to prevent dog ears. The abdomen is closed at the fascia layer with PDS 2.0, at the subcutaneous layer with PDS 4.0, and finally at the cutaneous layer with Nylon 5.0. Three continuous aspiration drains were used. Wound closure was performed with the patient in a semi-sitting position and the knees flexed.

Fig. 1. Tunnel undermining (a). Marking for abdominis rectus fascia suturing (b).

For postoperative care: intermittent pneumatic compression was used, patients were seated in fowler position, immobilisation, removing the drains when fluid was less than 30 ml over 24 hours, removed stitches after 10-12 days, and application of abdominal compression bandage post surgery for up to 4 weeks.

Measurements

Aesthetic measurements were performed 3 times in total, before surgery and post surgery 1 and 3 months, by the same surgeon. Measurements included abdomen diameters, vertical distances, and objective evaluation using clinical scale score for outcomes assessment of aesthetic surgery of the abdomen. These were recorded at the last phase of expiration and the average of 3 readings were used. Abdomen diameters were measured from 10 cm below the xiphoid process at the umbilicus except when patients have extra abdominal skin-fat growing beyond the buttocks. Distances were from xiphoid process to umbilicus, from umbilicus to anterior labial commissure, from incision to anterior labial commissure, and from umbilicus to section line (Fig. 2).

Fig. 2. Aesthetic measurements.

Green line: distance from xiphoid process to umbilicus. White line: distance from umbilicus to anterior labial commissure. Yellow line: distance from umbilicus to section. Red line: distance from incision to anterior labial commissure; White arrow: abdomen diameters at under xiphoid process 10 cm. Yellow arrow: abdomen diameters at umbilicus.

Photographs were taken with a blue background, lighted up with 2 flashes, and the camera axis was parallel with the abdomen. Posing positions followed Dietl’s study with the upper end of the photograph at the upper breast pole and the lower end of the photograph at the caudal of the tibial tuberosity [6]. Photographs were obtained from 8 different views, including front view, side view at 450, lateral view standing straight, and lateral view bending forward 450, to help differentiate between the laxity of the abdominal musculature and skin from the lower abdominal adiposity (Fig. 3).

Fig. 3. Abdominal photographs were taken with blue background.

a—b — front view; c—d — stand straight side views at 45°; e—f — stand straight side views at 90°; h—g — 90° side view at 45° and bend in front 45°.

We utilised clinical scale score for outcomes assessment of aesthetic surgery from authors from University of São Paulo [1]. Scores were evaluated by 2 aesthetic surgeons who were not part of the research team. They score visual parameters such as abdominal volume, lateral contour, laxity/skin excess, navel appearance, and scar quality in the abdominal wall, using a simplified rating scale as follows: 0 = unsatisfactory, 1 = fair, 2 = good and/or absent scar. An explanatory table regarding the assignment of scores for each parameter is provided to the evaluator (Table 1). The sum of the scores gives a final score that ranges from 0 to 10, with 10 being the best possible score.

Table 1. Self-explanatory table to guide scoring of each parameter for assessment of the abdomen

Note. Scores are as follows: “0 — unsatisfactory”, “1 — fair”, and “2 — good”. The sum of the scores for each parameter gives the final score, which can range from 0 to 10.

Intra-surgery index included the amount of injected fluid (ml), amount of aspirate volume, flap weight, tunnel width, and rectus sheath suturing width. Postoperative complications included seroma, hematoma, skin necrosis, infection, and asymmetrical wound.

Statistic analysis. Data was analysed using SPSS Statistics v. 23. Statistical significance was defined as p<0.05. The mean differences were further evaluated using paired t-test.

Results

There were 20 patients who met the criteria for the study and underwent Saldanha lipoabdominoplasty technique. The average age was 41.45±9.58 SD with a BMI of 24.55±3.23 SD. All the patients were non-smokers. With regards to past medical history, one patient was in remission for uterus cancer, and another patient has type 2 diabetes mellitus on treatment.

Fifteen patients (75% of the cases) had previous abdominal surgery and abdominal scar, of which 12 were caesarean section (c-section), 1 was c-section and uterus resection for cancer treatment, 1 was c-section and open appendicectomy, and 1 was laparoscopic surgery for ectopic pregnancy. Twelve cases had a transverse scar at the lower abdomen, 2 cases had a vertical infraumbilical scar, and 1 case had an umbilical laparoscopic scar.

All candidates had prior pregnancy, with an average of 2.2 births per woman. Nineteen patients had only single birth pregnancy and 1 patient had a twin pregnancy. All patients have no further pregnancy plan.

Aesthetic measurements outcomes could be referred to Table 2. It showed significant improvement in abdomen diameter 10 cm below the xiphoid process, abdomen diameter at the umbilicus, and distance from xiphoid process to umbilicus, at 3 months post surgery with p<0.001. In this study, abdomen diameter at the umbilicus could be measured for all except 1 case which had extra abdominal skin leading to translation of the umbilicus downward to below the buttock level. BMI was also significantly decreased at 3 months post surgery compared with before the procedure (p=0.036), although there was a slight increase in BMI at 1 month post surgery (Table 3). The intra surgery measurements were shown in Table 4 for reference.

Table 2. Aesthetic measurements outcomes

Table 3. Weight and BMI comparison

Table 4. Intra-surgery measurements

The objective clinical scale score for outcome assessment showed significant improvement 3 months after surgery with p<0.001 (Table 5).

Table 5. Clinical score scale for outcomes assessment of aesthetic surgery (São Paulo score)

There were 3 cases that had complications post surgery (Table 6). One case was seroma with a size of 3×3 cm that developed on postoperative day 10 that eventually resolved with compression bandage. The other was ischemia of the distal abdominal flap that appeared on the second postoperative day which also recovered without complication after loosening the bandage and allowing the patient to lay in knee lifting and abdominal flexion position. The last case was related to wound suturing imbalance.

Table 6. Local complications list

Discussion

In our study, all candidates had no further pregnancy plan, with an average of 2.2 births per woman. Most candidates have an ideal body weight of BMI 24.55±3.23 kg/m2, appropriate with the purpose of the surgery, to contour abdominal shape more than losing weight. This is an important indication for total abdominoplasty, as it includes liposuction, removal of extra skin and fat flap, as well as repair of abdominal rectus diastasis especially after pregnancy [7]. Also, 75% of the candidates had scars from previous abdominal surgery, which could be incorporated as part of the surgical plan to hide or remove the scar in the same procedure.

Because we used superwet anaesthesia technique combined with liposuction at the infra-Scarpa fascia in the lower abdomen, the amount of fluid injected was much higher than the amount of fat removed during liposuction, with an average difference of 807.5 ml, resulting in a lighter average weight of abdominal flap (625.5 g) than that reported by A. Costa-Ferreira et al. [9].

When dissecting the tunnel, it was limited within the midlines of the 2 abdominis rectus muscles to preserve the perforator of the deep superior epigastric artery (PDSEA) and its branches, which has a consistent location in an area within a 2 cm radius located 6 cm below the subcostal margin and 4 cm from the abdominal midline [10] (Fig. 4). The width of the tunnel could be larger than 8 cm as recommended by Smith depending on the degree of abdominal rectus diastasis [10]. There was 1 case in our report that has a tunnel width of up to 12 cm, subsequently complicated by ischemia of the distal flap. This showed that respecting the PDSEA anatomy is the key to adequate flap perfusion [8]. In this report, abdominis rectus fascia suturing was performed on all cases within the boundary of the tunnel, undermining the distance from 3 to 11 cm, with an average distance of 6.5 cm.

Fig. 4. The perforator of the deep superior epigastric artery (PDSEA) and its branches.

Depending on the amount of fat from liposuction, it could affect the post surgery aesthetic measuring outcomes. Comparing to Matarasso’s study [7] which removed less fat from liposuction (1500 ml compared with 1942.5 ml), our study showed better results in abdomen diameter at umbilicus (–10.05 cm compared with –7.9 cm), distance from xiphoid process to umbilicus (–3.29 cm compared with –2.8 cm), and distance from umbilicus to anterior labial commissure (–6.64 cm compared with –5.09 cm).

In our study, the 3 months postoperative weight showed significant improvement compared to before surgery, although this index was higher at 1 month after operation. These results relate to previous studies, which researched the short-term outcomes after abdominal reconstruction and liposuction [11-13]. However, the short-term follow up of this study was unable to demonstrate how candidates maintain the contour and weight loss effect of the surgery long term, where self discipline in diet and exercise are critical.

The objective clinical scale score for outcome assessment was evaluated 3 months after surgery to reduce interruption from inflammatory and wound healing process. It showed a significantly better score after the procedure, from 3.9±1.94 to 8.7±0.7 out of a maximum score of 10 (Fig. 5). This score was higher than in Salles’s study, average of 6.75 in the abdominoplasty group and 7.73 in the liposuction group [1]. The difference could be due to evaluation time frame, which was 3 months postoperative in our study as compared to 12 months postoperative in Salles’s study; and also from surgical methods, which was a combination of abdominoplasty and liposuction in our study as compared to having 2 separated individual techniques in Salles’s study [1].

Fig. 5. Photographs of the patient before and after surgery.

a—d — average score of 4 before the surgery; e—h — average score of 9 after the surgery.

Seroma is the most common complication of abdominoplasty, among other possible complications including hematoma, ischemia/necrosis, infection or wound suturing imbalance. There were 3 cases of local complications in our study that resolved with conservative treatment.

For seroma complication, a small nodule was detected clinically and by ultrasound scan, and fully recovered with compression only. In addition to Scarpa fascia preservation during abdominoplasty, other practical techniques were applied in this study to prevent seroma formation, such as selective undermining, vessel ligation with suture or clip, quilting/PTS, high drain vacuum, volume control drain removal, immobilisation, and compression [3, 9, 14].

Regarding the ischemia complication, it occurred on postoperative day 2 at the distal border of the abdominal flap (Fig. 6). By removing the compressed bandage, covering the wound with moist gauze, maintaining fowler position and providing sufficient intravenous fluid, the ischemia only affected the epidermis layer which subsequently recovered fully without damaging the wound closure. There are several factors that interfere with blood supply to a flap, including the width of tunnel undermining which is relevant to blood supply preservation, liposuction technique, and flap tension when closing the wound [4, 15]. According to Grazer and Goldwyn’s study, if tunnel undermining damages the PDSEA, the flap necrosis ratio can be up to 5.4% [16]. Otherwise, this ratio decreases to 0.2% when tunnel undermining is limited within the midlines of the 2 abdominis rectus muscles to preserve these perforators [4]. Besides that, liposuction technique significantly determines flap survival. We used Saldanha’s technique with selective liposuction for different areas to avoid excessive trauma and to establish a natural contour and curves of the abdomen, avoiding the stigma of muscular hypertrophy [4, 5].

Fig. 6. Ischemia at the distal flap in the day 2 post-operation.

We had 1 case of asymmetrical wound suturing in this study (Fig. 7). The causes of this complication could be asymmetrical skin incision which could be prevented by careful marking before surgery, asymmetry in liposuction leading to difference in flap mobility at different sites, asymmetry in skin flap removal, or asymmetry when fixing the Scarpa fascia to the abdominal wall.

Fig. 7. Asymmetrical wound suturing.

a — before surgery; b — after surgery.

Conclusion

Lipoabdominoplasty using the Saldanha technique showed aesthetic improvement in abdominal shape, objective abdominal measurements, and overall weight loss. Furthermore, this procedure is safe with a low complication rate as compared with other traditional methods.

Authors’ contributions. Lam Quang An wrote the manuscript. Tran Van Duong edited the manuscript. All authors read and approved the final manuscript.

Acknowledgements. The authors would like to thank the staff at the Department of Plastic and Aesthetic Surgery, Cho Ray Hospital for their support and assistance in collecting the data of this study.

Ethics approval and consent to participate. The study was approved by the ethics committee of Pham Ngoc Thach University of Medicine under Decision No. 284/HĐĐĐ-TĐHYKPNT. Informed consent was obtained from all individual participants included in the study.

Consent for publication. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

Availability of data and materials. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Funding. The authors did not receive support from any organization for the submitted work.

Competing interests. No potential conflict of interest was reported by the authors.