AMERICAN ACADEMY OF COSMETIC SURGERY

THE AMERICAN JOURNAL of COSMETIC SURGERY

Five and a Half Years' Experience With the Avelar Lipoabdominoplasty Procedure: Analysis of Complication Rates Quita Lopez, MD

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ORIGINAL ARTICLE

Five and a Half Years' Experience With the A velar Lipoabdominoplasty Procedure: Analysis of Complication Rates Quita Lopez, MD

Introduction: The Avelar lipoabdominoplasty procedure has been described in the literature as a safe procedure with fewer complications than traditional abdominoplasty because oflimited upper abdominal dissection, which spares the superior neurovascular bundles along with the lymphatics. In the author's published article in 2008, 80 patient charts were evaluated retrospectively, and the complication rates were compared with other studies presented in the literature. The purpose of this study is to compare the complication rates of the first 2 years to the subsequent 3 ~ years since the procedure was adopted. The Avelar minilipoabdominoplasty procedures were also reviewed, and the complication rates were compared with those of the full Avelar procedures. Materials and Methods: A retrospective review was performed of records of patients who underwent a full or miniA velar lipoadominoplasty procedure from July 1, 2007 to December 31,2010. Results: A total of89 patient charts were reviewed. There were 73 fulllipoabdominoplasty and 16 mini-lipoabdominoplasty procedures peiformed by the author. The mean age of the patients was 42 years; 46% had general anesthesia and 54% had conscious sedation. In the 89 patients who underwent both types of procedures, there was 1 case of skin necrosis ( 1.1% incidence compared with a 3. 7% incidence the first 2 years), 4 seromas (4.5% incidence compared with 12.5% incidence in the original study), and no deep venous thromboses or hematomas. For the fulllipoabdominoplasty procedures, the skin necrosis rate was 1.4% compared with 3.9% in the 2008 study, and the seroma rate was 5.5% compared with 13.0%. There were 9 small skin dehiscences ( 10% incidence), and there were 4 postoperative infections ( 4.5% incidence). The mini-lipoabdominoplasties had none of these complications. Received for publication December 5, 2012. From the Aesthetic Laser Center, Fresno, Calif. Corresponding author: Quita Lopez, MD, Aesthetic Laser Center, 6081 N First #101, Fresno, CA 93710 (e-mail: [email protected]). DOl: 10.5992/AJCS-D-12-00060.1

Conclusions: The complication rates have decreased in the subsequent 3~ years compared with the first 2 years. This is probably due to increased surgeon experience, not operating on smokers in the second part of the study, and using the Erchonia EML (Erchonia Medical Inc, Mesa, Ariz) on all patients pre- and postoperatively. The rates were lower than those reported for traditional abdominoplasties. There were none of the above complications for the miniabdominoplasties using the Avelar technique.

bdominoplasty is a common procedure for abdominal contouring. Since Avelar 1•2 described his technique of combining liposuction with lipectomy and avoiding large upper flap undermining, the complication rates for the procedure have been shown to be lower than with traditional abdominoplasty. Lipoabdominoplasty and A velar abdominoplasty are terms that are often used synonymously by some surgeons. There have been subtle variations on the technique described by various surgeons. A common theme among all is liposuction along with limited dissection in the upper abdomen and sometimes lower abdomen when a mini versions are performed. The Avelar lipoabdominoplasty technique is becoming more popular among surgeons who do abdominal contouring procedures. It is possible to salvage at least 80% of the blood supply to the abdomen. 3 Graf et al4 showed that 60% of the perforators were preserved with a modified technique that involved limited upper flap dissection with full en bloc dissection of the lower flap where there was transection of the inferior epigastric and external iliac vessels. The size and flow rate are increased in the remaining vessels due to hypoxic stimulation. This is a technique that the author employs with patients with larger body mass index (BMI) who have a large inferior pannus. Patients with smaller BMis

A

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have only the dermis excised, salvaging most of the blood supply along with the lymphatics and nerves. With the mini-lipoabdominoplasty procedure, liposuction is performed in the deep and superficial layers, and the excess skin in the lower abdomen is excised just below the dermis. There is usually no dissection of the lower flap except when lower diastasis is present. The midline is then dissected up to the umbilicus to allow plication for correction of a diastasis. The umbilicus is not transposed; hence, a small amount of dead space is created, and there is the preservation of an even greater amount of blood supply, nerves, and lymphatics; this probably accounted for there being no complications in the parameters studied. Methods A retrospective review of medical charts was performed between July 2007 and December 2010. There were 73 full Avelar lipoabdominoplasties and 16 minilipoabdominoplasties performed. All of the patients were women. The mean age was 42 years, with a range from 21 to 72 years. The average BMI was 28.6 kg/m2 (range, 20-41 kg/m2). The mean BMI for patients undergoing mini-lipoabdominoplasty was 25.8 kg/m2 (range, 20-31 kg/m2). Forty-four patients had liposuction of other body parts along with the abdominoplasty, and 14 patients had concomitant breast surgery. This included implant placement, implant with simultaneous lift, or just mastopexy. Fat grafting to the face was done in 9 patients, and 5 had simultaneous fat grafting to the buttocks. One patient had a labioplasty procedure at the same time, and another had a brachioplasty procedure. Hence, all of the patients undergoing mini-lipoabdominoplasty had other procedures performed. The overall incidence of concomitant procedures was 75%. All surgery was performed in an accredited office surgery center. Surgical Technique

The patient was marked preoperatively, and tumescent anesthesia consisting of 0.05% lidocaine was used. In a liter of normal saline, 0.8 mg of 1:1000 epinephrine and 10 mg of 8.4% bicarbonate were also placed. Forty-six percent of the patients had general anesthesia, and 54% had conscious sedation. In the original study, 41% had general anesthesia and 59% had conscious sedation. The Erchonia EML Laser (Erchonia Medical Inc, Mesa, Ariz) was used during infiltration to facilitate liquefaction of fat prior to liposuction. The Mangubat disruptor was also used before liposuction was initiated. Liposuction was performed

below and above Scrapa' s fascia in the upper abdomen to allow sliding of the flap. Liposuction is also performed aggressively in the lower flap, and Scarpa fascia is usually not well preserved in the author's opinion. Patients with larger BMis who have significant fat in the lower flap had an en bloc dissection of the lower abdomen and drain placement horizontally in the lower abdomen. Here, the inferior epigastric and external iliac vessels, which are zone 1 and 11 vessels as described by Huger, 5 are transected, and there is also injury to the lymphatics in this region. The excess skin is then measured and marked, and it is tested before excision by pulling together with Koeker clamps. The excess skin is excised, the umbilicus is released, and the stalk is tagged. The vertical midline is also released up to the xyphoid process if needed. This vertical tunnel is mostly limited to the internal borders of the rectus abdominal muscles. A Saldanha retractor is placed in the midline, and the author has made more aggressive releases in the latter 3¥2 years to better plicate the superior fascia for better correction of a diastasis defect. The retractor stretches the midline and allows for better visualization of the fascia. The vessels will be located more laterally on stretched-out abdominal muscles; hence, a larger tunnel can be dissected safely. Fat is resected in the lower midline to expose the fascia, and it is plicated if needed. The incision is closed in 2 or 3 layers, and the umbilicus is transposed. A Jackson-Pratt drain is placed horizontally in patients with full-thickness excision of the lower flap. Activated platelet-rich plasma (PRP; Harvest Technologies, Plymouth, Mass) is sprayed in the flap prior to closure and along the incision after closure. PRP has been shown in the literature to promote wound healing. 6--11 All patients wear pneumatic compression stockings if they have general anesthesia, and they also have their knees flexed during surgery. All patients wear knee-high compression hose for 14 days, and Lovenox (Aventis Pharmaceuticals Inc, Bridgewater, NJ) is given to high-risk patients for 3 days. Compression garments are worn for a minimum of 2 weeks. The mini-lipoabdominoplasty procedure is similar, but the umbilicus is not translocated, and there is almost no dissection of the lower flap. Only the midline is dissected up to the umbilicus if plication is needed for lower diastasis repair. Drains are not placed in these procedures. Prior to performing the skin excision, liposuction is performed in the other areas, usually the flanks. As

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Table 1. Postoperative Complication Rates (%)

2008 study (n = 77) Current study (n =73)

Skin Necrosis 3.9

Seromas 13.0

1.4

5.5

noted, 50% of the patients had liposuction of other areas done in addition to the Avelar lipoabdominoplasty. All of the mini-lipoabdominoplasty patients had additional liposuction for improved body contouring. Patients undergoing other procedures had those procedures performed prior to the abdominoplasty, except for fat grafting to the face, which was done last. Results In the original study, 12 the author performed a retrospective review of the charts between June 2005 and June 2007. There were 80 patients, with 77 having full lipoabdominoplasties and 3 having mini-lipoabdominoplasties. The mean age of the patients was 44 years (range, 24-76 years). The average BMI was 30.1 kg/m2 (range, 20-42 kg/m2) . There was an overall 3.7% skin necrosis rate, and the full lipoabdominoplasties had a 3.9% rate, which was lower than most studies found in the literature (range, 1.2-20% ). In the second part of the study, the overall rate decreased to 1.1% and to 1.4% for the fulllipoabdominoplasties (Table 1). This occurred despite more aggressive release of the stromal structures in the midline to allow for better fascial plication. No smokers were operated on in the second study. The overall seroma rate decreased from 12.5% to 4.5%. The full lipoabdominoplasty rate decreased from 13.0% to 5.5% (Table 1). The decreased rate probably reflects better selection of patients who need drain placement. With full-thickness excision of the lower flap, the lymphatic tracks in this area are usually damaged along with the lower part of zone 1 and zone 2 vessels. Hence, the author now places drains routinely in these patients. The Erchonia 635-nm lowlevel laser was also used on all patients postoperatively in the second series. Most patients were not treated with the low-level laser in the 2008 study. Only patients in the last 2 months of the first study were treated, which amounted to about 12 of 80. The lowlevel laser has been shown to enhance wound healing and increase vascularization after surgery. 13• 14 This might also have contributed to the decreased skin necrosis rate in the second series as all the patients

Deep Venous Thromboses 0 0

Hematomas 0 0

were treated with the low-level laser. Jackson 15 used PRP on his adominoplasty procedures and showed less seroma formation, and drains were used for a shorter amount of time. PRP was used on most patients in the first and second study. There were no deep venous thromboses or hematomas in either series (Table 1). There was an overall 4.5 % infection rate and 10% dehiscence rate in the second series. Most of the infections were minor and were treated with oral antibiotics, and all dehiscences were small. Please see Figures 1 to 9 for before and after photos. Discussion The lipoabdominoplasty procedure as described by Avelar 1•2 has been shown to be safe and have decreased complications compared with traditional abdominoplasty procedures. Avelar started performing these procedures in 1998 after doing cadaver studies and research for 10 years. In his studies, he found that liposuction below Scarpa's fascia allowed sliding of the superior flap and that the neurovascular bundles were able to be preserved because of limited dissection. He

Figure 1. Sixty-year-old patient (height: 150 em; weight: 84 kg) had liposuction of waist and hips with an Avelar abdominoplasty (side view).

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Figure 4. Thirty-nine-year old (height: 165 em; weight: 74.5 kg) had liposuction of waist, hips, inner thighs, and knees and an Avelar mini-abdominoplasty (front view).

Figure 2. Sixty-year-old (height: 150 em; weight: 84 kg) had liposuction of waist and hips with an A velar abdominoplasty (front view).

measured the length of the preserved vessels and found them to stretch 4 times their length. Fat above Scarpa's fascia was retained to maintain a uniform thickness and avoid irregularities. He also closed Scarpa's fascia to avoid indentations and decrease the tension on the scar. Initially, the excess skin was removed suprapubically and in the inframammary region. The fascia was not plicated in his original studies. Avelar later modified his procedure and plicated in the midline and transposed the umbilicus. Liposuction has allowed the surgeon to improve

Figure 3. Thirty-nine-year-old (height: 165 em; weight: 74.5 kg) had liposuction of waist, hips, inner thighs, and knees and an Avelar mini-abdominoplasty (side view).

patient contouring along with salvaging the neurovascular bundles and lymphatics. This allows the flap to be closed without the usual undermining up to the costal margins. Saldanha et al 3 showed that the upper flap was undermined only 30% compared with standard abdominoplasties. In their article, Brauman and Capocci 16 discussed skin-retaining ligaments, which caused skin creases on patients in the upper abdomen. They felt that these were vertical layers of fascia that attach the skin to the deep fascia and make the downward advancement more difficult. The skin will usually retract back later, making the result less aesthetically pleasing. They used scissors or blunt dissection in lateral tunnels to release the ligaments selectively. With their experience, they were able to preserve the perforators while releasing the ligaments. The authors also felt the release of the skin-retaining ligaments decreased the tension on the skin incision, which is a cause of flap necrosis. They showed a 1.7% necrosis rate in their series of 337 patients (Table 2).

Figure 5. Forty-five-year-old (height: 160 em; weight: 72 kg) had an Avelar abdominoplasty.

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Figu~e

6. ~ifty-year-old (height: 165 em; weight: 84.5 kg) had lzposuctwn of the lower back, waist, and hips and an A velar mini-abdominoplasty (side view).

Samra et al 19 compared complication rates in 161 patients who underwent a lipoabdominoplasty (n = 93) versus a traditional abdominoplasty (n = 68). They found the lipoabdominoplasty had a complication rate of 4.30% compared with 11.76% (P = .126). These were what they called perfusion-related complications, including skin necrosis, wound infection, and wound dehiscence. In the patients who were at high risk, which included smokers and patients with significant upper abdominal scars, the complication rates were not statistically significant. There are numerous studies in the literature in which wound healing, postoperative pain, and inflammation are improved with the low-level laser. 16.zO-zz.zs.z6 Bensadoun and Naif2 3 performed a meta-analysis on 33 relevant articles, which showed that low-level laser therapy reduced the risk of oral mucositis (relative risk, 2.45). Treatment also reduced the severity of oral mucositis and decreased the duration to 4.38 days. This was clinically significant (P < .0009). The authors concluded that there was moderate-to-strong evidence

Figure 7. Fifty-year-old (height: 165 em; weight: 84.5 kg) had liposuction of the lower back, waist, and hips and A velar mini-abdominoplasty (front view).

Figure 8. Forty-six-year-old (height: 155 em; weight: 79 kg) had liposuction of the lower back, waist, and hips and an Avelar abdominoplasty along with breast augmentation (side view).

in favor of low-level laser therapy for treating cancer therapy-induced oral mucositis. It was well tolerated and relatively inexpensive. The author's decreased skin necrosis rate during the second study probably reflects the use of the low-level laser, which has shown to improve flap survival by 50% in rats. Tenehaus et al 24 produced random-pattern skin flaps on mice. Since the low-level laser at 635 nm is known to increase mitochondrial activity and adenosine triphosphate production in cells, it was used to treat half the animals. Perfusion was measured by laser Doppler before and after surgery. Mean flap loss was 25% in the nontreated group and 9% in the treated group. There was more than a 50% reduction in ischemia or apoptosis in the zone of stasis in the lowlevel laser-treated group. This was statistically

Figure 9~ For~-six-year-old (height: 155 em; weight: 79 kg) had lzposuctwn of the lower back, waist, and hips and an Avelar abdominoplasty along with breast augmentation (front view).

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Table 2. Lonergan and Mangubat 17 (n =67)* Rodriguez and Borsand 18 (n =100)* Saldanha et al 3 (n =445)* Brauman and Capocci, 16 (n =337)t Current study (n =150)*

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Complication Rates (%) as Reported in the Literature Skin Necrosis 3 2 0.2 1.7 2.6

Seroma 6 9 0.4 1.4 9.3

Infection 7 4 n/a 1.4 4.0

Deep Venous Thromboses 0 0 0.2 0 0

Hematomas 0 5 0.2 .29 0

*Lipoabdominoplasty performed. tLipoabdominoplasty with selective release of skin-retaining ligaments. significant (P < .01). The perfusion measured at the distal flap showed an upregulation at day 4, which was statistically significant between the tested group and control group (P < .05). There was about a 50% increase in blood perfusion in the group treated with the low-level laser. No smokers were operated on in the second series. The mini-lipoabdominoplasty maintains the most blood supply; hence, there were no cases with skin necrosis. Overall seroma rates decreased from 12.5% to 4.5%, and fulllipoabdominoplasty rates decreased from 13% to 5.5% (Table 1). Modification of Avelar's original technique involving en bloc dissection of the lower flap causes more dead space formation and injury to the inferior vessels and lymphatics. Huger5 noted that the lymphatic drainage follows the vascular blood supply pretty closely. When a full-thickness excision is performed, there is routine placement of drains in the lower abdomen. The Avelar mini-lipoabdominoplasty procedures have limited dissection and almost no injury to the vessels and lymphatics. There were no seromas in the 16 cases the author performed. In summary, the potential mechanisms for a decreased seroma rate in the second series is probably due to avoiding injury to the upper and lower abdominal lymphatic vessels. When the lymphatics are injured during an en bloc dissection in patients with larger BMis, drains are Table 3.

now placed routinely until the serous output is less than 30 mU24 h. Reducing the exposed rectus fascia and having a fat-to-fat interface during closure of the flap might also help. Eliminating the amount of dead space is also a factor. The use of PRP in the lower flap has been shown by Jackson 15 to decrease seroma formation. The low-level laser10•11 •13 has been shown to improve wound healing. This might also have contributed to the decreased rate, but more studies are needed to confirm this. There were no deep venous thromboses or hematomas in either series (Table 1). This is probably in part due to the use of the tumescent solution that contains epinephrine, which causes vasoconstriction, and to the use of compression garments after surgery, along with meticulous dissection and careful control of bleeding. Patients also ambulate the evening of surgery and are mobile and wear compression stockings. Lovenox prophylaxis is also given to high-risk patients. Table 3 is a statistical analysis of the complication rates between the 2 studies. Even though they are not statistically significant to the P > .05 level, there is a trend toward decreased rates. Having a higher sample size might have shown statistical significance. Please review Table 2 for complication rates published by different authors on the abdominoplasty procedure.

Results of the z Test Comparing the Complication Rates in the Current Study to the Complication Rates in the 2008 Study*

Complication

Proportion for Current Study (n =73)

Proportion for 2008 Study (n =77)

ZScore

P Value (2-Tailed)

All Skin necrosis Seromas

.068 .014 .055

.169 .039 .130

-1.89 -0.96 -1.58

.059 .337 .114

Statistical Significance

P>.05 P>.05 P>.05 *Statistical analysis of the complication rates from the 2 studies showed that the complication rates between the 2 studies were not statistically significant to the P > .05 level, but there was a trend for decreased rates in the current study.

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Conclusion The Avelar lipoabdominoplasty has been shown to be a safe and effective procedure for treating skin laxity and localized adiposity and for correcting diastasis recti. In the author's first published study, she showed a decreased complication rate compared with traditional abdominoplasty procedures reported in the literature. Comparing a similar case number in the subsequent 3~ years showed a further decrease in complication rates, probably due to the author's increased experience with the procedure and the use of PRP and the low-level laser to increase skin perfusion after surgery. Mini-lipoabdominoplasty procedures using the Avelar technique were performed with other concomitant procedures for better body sculpting, and there were no noted complications in this series. The author opines that most blood supply is spared since there is very little undermining with the procedure. The additional procedures performed on these patients did not increase the complication rates. References 1. Avelar JM. Abdominoplasty without panniculus undermining and resection: analysis and 3 year follow-up of 97 consecutive cases. Aesthet Surg J. 2002;22: 16-25. 2. Avelar JM. Abdominoplasty combined with lipoplasty without panniculus undermining: abdominolipoplasty-a safe technique. Clin Plast Surg. 2006;33:79-90. 3. Saldanha OR, Frederico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg. 2009;124: 934-942. 4. Graf R, de Araujo LR, Rippel R, et al. Lipoabdominoplasty: liposuction with reduced undermining and traditional abdominal wall flap resection. Aesthetic Plast Surg. 2006;30:1-8. 5. Hugar W. The anatomic rationale for abdominal lipectomy. Am J Surg. 1979;45:612-617. 6. Driver VR, Hanft J, Flylling CP, et al. A prospective, randomized trial of autologous platelet-rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage. 2006;52:68-74. 7. Sakata J, Sasaki S, Handa K, et al. A retrospective, longitudinal study to evaluate healing lower extremity wounds in patients with diabetes mellitus and ischemia using standard protocols of care and plateletrich plasma gel in a Japanese wound care program. Ostomy Wound Manage. 2012;58:36-49.

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8. Saad S, Elhahat A, Elsherbiny K, et al. Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study. Int Wound J. 2011;8:307-312. 9. Marx RE, Carlson ER, Eichstaedt RM, et al. Platelet rich plasma: growth factor enhancement for bone grafts. Oral Surg. 1998;85:638-646. 10. Garg AK. The use of platelet rich plasma to enhance the success of bone grafts around dental implants. Dent Implantol Update. 2000;11:17. 11. Marx R. Platlet-rich plasma: evidence to support its use. J Oral Maxillofac Surg. 2004;62:489-496. 12. Lopez Q. Two year experience with the Avelar abdominoplasty. Am J Cosmetic Surg. 2008;25:92-96. 13. Lopez Q. Treatment of large skin necrosis following modified Avelar abominoplasty with the Erchonia EML 635 nm laser and platelet-rich plasma. Am J Cosmetic Surg. 2009;26:29-34. 14. Yu W, Nairn JO, Lanzafame RJ. Effects of photostimulation on wound healing in diabetic mice. Lasers Surg Med. 1997;20:56-63. 15. Jackson RF. Using PRP to promote healing and prevent seroma formation in abdominoplasty procedures. Am J Cosmetic Surg. 2003;20:185-193. 16. Brauman D, Capocci J. Liposuction abdominoplasty: an advanced body contouring technique. Plast Reconstr Surg. 2009;124:1685-1695. 17. Lonergan I, Mangubat EA. The Avelar lipoabdominoplasty: initial operative experience and results in 67 consecutive patients. Am J Cosmetic Surg. 2008;25:251-263. 18. Rodriguez F, Borsand MA. One hundred consecutive lipoabdominoplasty procedures: modified Avelar technique for full abdominoplasty without panniculus undermining-advances, morbidity, and complications. Am J Cosmetic Surg. 2011;28:241-250. 19. Samra S, Sawh-Martinez R, Barry 0, et al. Complication rates of lipoabdominoplasty versus traditional abdominoplasty in high-risk patients. Plast Reconstr Surg. 2010;25:693-690. 20. Aras MD, Gungormus M. Placebo-controlled randomized clinical trial of the effect of two different low laser therapies (LLLT)-intraoral and extraoralon trismus and facial swelling flowing surgical extraction of the lower third molar. Laser Med Sci. 2010;25:641-645. 21. Kim H, Kweon OK, Kim WH. Enhanced wound healing effect of canine adipose-derived mesenchymal stem cells with low-level laser therapy in athymic mice. J Dermatol Sci. 2012;1811:291-295.

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22. Chow RT, Johnson Ml, Lopes-Martins RA, et al. Efficacy of low-level therapy in the management of neck pain: system review and meta-analysis of randomized placebo or active-treatment controlled trials. Lo.ncet. 2009;374:1897-1908. 23. Bensadoun RJ, Nair RG. Low-level laser therapy in the prevention and treatment of cancer therapyinduced mucositis: 2012 state of the art based on literature review and meta-analysis. Curr Opin Oncol. 2012;24:363-370. 24. Tennhaus M, Bhavsar D. Efficacy of LLLT for reduction in TNF alpha, cellular apoptosis, and tissue necrosis following induction of a partial thickness

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burn and ischemic skin flap. Photonics in Dermatology and Plastic Surgery Meeting and SPIE Symposium on Biomedical Optics; 2008; San Jose, Calif. 25. Jackson RF, Roche G, Mangione T. Low-level laser therapy effectiveness for reducing pain after breast augmentation. Am J Cosmetic Surg. 2009;26:144-148. 26. Jackson RF, Roche G, Butterwick KJ, et al. Low-level laser-assisted liposuction: a 2004 clinical study of its effectiveness for enhancing ease of liposuction procedures and facilitating the recovery process for patients undergoing thigh, hip and stomach contouring. Am J Cosmetic Surg. 2004;21:191-198.