INTRODUCTION
In 1993, Mentz et al.1 were the first to
perform superficial liposuction to define the abdominal musculature, and
suggested the use of superficial liposuction in the linea alba, linea
semilunaris, and transverse tendinous intersections, without use of foams or
other material to better define the abdominal lines.
In 2003, Hoyos & Millard2 introduced
the concept of high-definition liposculpture, refining the original concept1 for a 3-dimensional approach, in which not
only the abdomen, but also the back, arms, and legs were treated using
third-generation ultrasonic liposuction (Vaser).
Reston® foam has been used in liposuction3-5.
Despite the benefits, the application only lasts approximately 30 minutes, in
addition to being associated with other problems4,6,7 such as
allergic dermatitis, blister formation, and postoperative hyperpigmentation.
This pilot study aimed to present a superficial liposuction technique using
conventional materials, followed by dressings incorporating soft silicone
tubing; the technique is easy for plastic surgeons to learn, and is economically
accessible, with satisfactory aesthetic results and low incidence of
complications.
OBJECTIVE
To describe a superficial abdominal liposuction technique for the linea alba,
linea semilunaris, and transverse tendinous intersections within the rectus
abdominis muscle using conventional liposuction material, followed by dressings
incorporating soft silicone tubing.
METHODS
This prospective pilot study included 20 patients (19 women and 1 man), who
underwent abdominal liposuction under general anesthesia by the same
surgeon.
All patients were marked on the abdominal region and other areas planned for
liposuction, using a hydrographic pen on the day of surgery. The linea alba,
linea semilunaris, and tendinous intersections within the rectus abdominis
muscle were identified by abdominal contraction and marked in green (Figure 1).
Figure 1 - Markings made on the day of surgery. Black: the usual liposuction
markings. Green: markings at the linea alba and linea semilunaris
for greater definition, with greater removal of fat by superficial
subdermal liposuction.
Figure 1 - Markings made on the day of surgery. Black: the usual liposuction
markings. Green: markings at the linea alba and linea semilunaris
for greater definition, with greater removal of fat by superficial
subdermal liposuction.
Two 7-mm incisions were made in the pubic region, inside the swimwear line or in
previous scars (Figure 1).
Super-saturation of the abdominal region was performed with saline solution
combined with epinephrine at a concentration of 1:500,000 and lidocaine at a
concentration of 0.05%.
Liposuction was performed below (deep liposuction) and above (superficial
liposuction) Scarpa’s fascia, using 60-mL syringes in the usual manner, with
cannulas 4 mm in diameter and 30 and 35 cm in length.
Liposuction was then performed under the linea alba and linea semilunaris, above
Scarpa’s fascia and close to the deep dermis (Figure 2), with the same 4-mm cannulas, but with the holes facing
the dermis and using the contralateral hand for gripping and vigorous extra fat
removal, until the formation of a groove was obtained in these locations,
confirmed by the surgeon with a pinch test.
Figure 2 - Liposuction under the linea semilunaris, close to the deep
dermis, using 4-mm cannulas with the holes facing the dermis. The
contralateral hand is used for gripping and additional fat removal,
forming a groove in these places.
Figure 2 - Liposuction under the linea semilunaris, close to the deep
dermis, using 4-mm cannulas with the holes facing the dermis. The
contralateral hand is used for gripping and additional fat removal,
forming a groove in these places.
In the male patient, three 3-mm incisions were also made in the supraumbilical
linea alba for superficial subdermal liposuction below the tendinous
intersections of the rectus abdominis muscle, using 3-mm diameter cannulas,
until groove formation was observed.
Next, 20% tincture of benzoin and 7-mm-diameter flexible empty silicone tubing
were placed at the contour of the linea semilunaris (Figure 3) and the rectilinear supraumbilical linea alba;
the tubing was fixed vertically with Micropore tape over the full length of the
treated area (Figure 4).
Figure 3 - Flexible, 7-mm hollow silicone tubing positioned at the contour
of the linea semilunaris, to enhance adhesion of the skin to the
aponeurosis.
Figure 3 - Flexible, 7-mm hollow silicone tubing positioned at the contour
of the linea semilunaris, to enhance adhesion of the skin to the
aponeurosis.
Figure 4 - Image of final dressing, with silicone tubing positioned on the
linea alba and linea semilunaris and fixed with vertical Micropore
tape.
Figure 4 - Image of final dressing, with silicone tubing positioned on the
linea alba and linea semilunaris and fixed with vertical Micropore
tape.
The hollow silicone tubing was kept occluded for 5 to 6 days and then removed,
but shapewear was maintained for 30 days.
All patients underwent manual lymphatic drainage for a period of 30 days,
starting at a variable period of 3 to 6 days.
Follow up was performed with clinical and photographic examination at 4-6 days,
3-4 weeks, and 3 months after surgery.
RESULTS
The additional superficial liposuction of the linea alba and linea semilunaris
added an average time of 15 minutes to the procedure. Use of dressings with
silicone tubing added 5 minutes.
The marks of the silicone tubing were very evident at the first follow-up, and
were less prominent at the second follow-up. No color change, ischemia, or
significant pain was observed with this technique.
After 3 months, the results were considered good (Figures 5 to 8), with no cases
of cutis marmorata, dermatitis, seroma, infection, contour irregularity, or need
for additional procedures.
Figure 5 - A 31-year-old preoperative female patient.
Figure 5 - A 31-year-old preoperative female patient.
Figure 6 - A 31-year-old female patient, 3 months postoperatively.
Figure 6 - A 31-year-old female patient, 3 months postoperatively.
Figure 7 - Preoperative 34-year-old male patient.
Figure 7 - Preoperative 34-year-old male patient.
Figure 8 - A 34-year-old male patient, 3 months postoperatively.
Figure 8 - A 34-year-old male patient, 3 months postoperatively.
DISCUSSION
In 2012, a randomized, blinded, controlled clinical trial7 compared conventional liposuction with Vaser liposuction,
and concluded that there is more retraction and less blood loss with Vaser, but
no change in outcome in terms of pain, edema, or adverse effects. This work was
limited in its validity8 due to sampling
methodology, financial conflicts, and commercial bias. The study also described
the occurrence of seromas, burns, and prolonged edema, in addition to a longer
learning curve and greater investment for equipment9,10.
The technique advocated in this study differs from those previously described by
using silicone tubing, not previously described for use in liposuction
dressings. The tubing is hollow and thin (7-mm diameter), and used in
pre-planned locations, especially at the linea semilunaris, where the wavy shape
helps the skin to adhere directly in the muscular plane; this enhances the
appearance of the abdominal musculature, with a more natural final result,
besides avoiding possible complications with foams, as previously described3-6.
This technique required little additional surgical time, especially when compared
to use of Reston® and ultrasonic or laser liposuction, to achieve
greater abdominal refinement.
This method can be added to any conventional liposuction technique, whether
performed with syringe, aspirator, or vibro-liposuction, and can be used by any
plastic surgeon familiar with liposuction who wants to achieve greater
anatomical definition of the abdomen.
Both the medical team and patients reported greater satisfaction with this
technique, compared to that without a high-definition approach.
The cases in this pilot study remain in follow-up for long-term evaluation with
statistical analysis.
CONCLUSION
This study described the technique of superficial abdominal liposuction at the
linea alba, linea semilunaris, and transverse tendinous intersections
within the rectus abdominis muscle, using conventional liposuction
material, followed by dressing that incorporated silicone tubing and
shapewear.
COLLABORATIONS
RSG
|
Conception and design study; conceptualization; data curation;
realization of operations and/or trials; writing - original draft
preparation.
|
CMM
|
Conception and design study; investigation
|
NBR
|
Conceptualization.
|
EBG
|
Project administration; supervision.
|
HFCG
|
Project administration; supervision.
|
LMF
|
Project administration; supervision.
|
REFERENCES
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Aesth Surg J. 2007;27(6):594-604.
3. Brandy DA. Reston Foam for the Reduction of Ecchymoses
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suction-assisted Lipoplasty. Plast Reconstr Surg.
2012;129(4):681e-9e.
8. Swanson E. Improved skin contraction after VASER-assisted
lipoplasty: is it a change we can believe in? Plast Reconstr Surg.
2012;130(5):754e-6e.
9. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical
application of VASER--assisted lipoplasty: a pilot clinical study. Aesthet Surg
J. 2002;22(2):131-46.
10. de Souza Pinto EB, Abdala PC, Maciel CM, dos Santos Fde P, de Souza
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1. Escola Paulista de Medicina, Universidade
Federal de São Paulo, São Paulo, SP, Brazil.
2. Universidade Federal de Santa Catarina,
Florianópolis, SC, Brazil.
3. Hospital Universitário, Florianópolis, SC,
Brazil.
Corresponding author: Rogerio Schützler Gomes, Av. Trompowsky, nº
291 sala 303, Torre 1 - Centro - Florianópolis, SC, Brazil, Zip Code 88015-300.
E-mail: plasticarogerio@gmail.com
Article received: October 23, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.