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    Experts in abdominoplasty face off regarding optimal techniques


    The art and science of abdominoplasty has developed over the years, resulting in a variety of incision and suturing techniques as well as optimal administration of anesthesia. The progressive adjustments made to this popular cosmetic surgery also have facilitated improvements in the areas of pain mitigation, safety and downtime, all while enabling physicians to achieve consistent and positive aesthetic outcomes, several surgeons say.

    "Patients are not only concerned about the aesthetic quality of results, but also the overall ease of recovery and downtime associated with elective surgery such as abdominoplasty. Specific approaches regarding suturing techniques and anesthesia can help in realizing this goal," says Lu-Jean Feng, M.D., a plastic and reconstructive surgeon and medical director of the Lu-Jean Feng Clinic, Cleveland.

    SURGICAL TECHNIQUES Though many surgical techniques continue to improve, flap necrosis, dehiscence and particularly seroma are some of the potential complications that can result following an abdominoplasty.

    In a traditional abdominoplasty, the surgeon typically will perform a wide undermining of the tissues, usually requiring drains in the postoperative period. According to Dr. Feng, use of progressive tension sutures (PTS) not only circumvents the need for drains; they also help to reduce local complications such as the formation of seromas and hematomas.

    The Avelar technique, on the other hand, involves the use of liposuction and typically requires minimal undermining, which may or may not necessitate the use of PTS (depending on the surgeon's perspective). Furthermore, the plane of dissection in the Avelar technique is not as deep and wide as with traditional abdominoplasty, which is helpful in preserving the blood supply and lymphatics.

    Less damage to these structures not only results in a decreased risk of tissue necrosis; it also reduces the potential need for drains, says Alan Matarasso, M.D., F.A.C.S., a plastic surgeon in New York City.

    Dr. Cuzalina
    Says Angelo Cuzalina, M.D., D.D.S., a board-certified cosmetic surgeon at Tulsa Surgical Arts Oklahoma Cosmetic Surgery Center, Tulsa, and 2011 president of the American Academy of Cosmetic Surgery, "The problem with the progressive suture technique is that the patient is going to have a longer surgery. However, if you put them in perfectly and you get really good at it, PTS can work very nicely and can potentially help decrease the incidence of seroma."

    The Avelar technique results in less wound tension on the final incision line, which might in turn lead to less wound complications. According to Dr. Cuzalina, many surgeons who use this technique do not find the need to use PTS or drains because they are not elevating a big flap.

    A recent chart review study comparing the rate of seroma formation and outcomes in 121 abdominoplasty patients who received progressive tension sutures; progressive sutures and drains; or drains alone showed no difference in the incidence of seromas among the three patient groups (Kahn U. Eur J Plast Surg. 14 July 2011 [Epub ahead of print]). Nevertheless, the study did show that those patients who received PTS and drains had less drainage.

    According to Dr. Matarasso, the use of PTS can be time-consuming, and some surgeons may feel these sutures do not warrant the elimination of a drain. Moreover, PTS may also technically alter the surgical procedure, he says.

    "Aside from using drains and/or PTS, one can also consider changing the level of dissection, leaving a loose areolar plane on the rectus muscle. Changing the level of dissection can help preserve the lymphatics, which may reduce drainage and allow you to remove the drains sooner," he says.

    However, according to Dr. Feng, "Progressive tension sutures do not take longer in surgery once the surgeon gets past the learning curve. They can provide better definition of the abdominal contour such as the 'six-pack' definition. Moreover, because the upper abdominal flap is progressively advanced inferiorly, the final incision is lower on the abdomen and has less wound tension at the incision, and thus less scarring and better circulation at the incision."



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