Title: Abdominoplasty with Circumferential Liposuction: A Review of 1000 Consecutive Cases
Abstract: Sir: We read with interest the article authored by Sozer et al. describing their vast experience with abdominoplasty with concurrent circumferential liposuction.1 Their aesthetic results are exceptional and their concept of approaching the entire trunk as an aesthetic unit is indeed how the abdominoplasty patient should be approached. We had already described the same central unit approach to abdominoplasty with circumferential liposuction, an approach we have been practicing since the 1990s and published in a series of articles regarding liposuction abdominoplasty.2,3 Our articles described abdominoplasty with concurrent circumferential liposuction, performed under local anesthesia with sedation, an approach we continue to prefer as a means of preventing deep venous thrombosis/pulmonary embolism. In a series now totaling more than 600 consecutive patients since 1996, we have successfully prevented and avoided deep venous thrombosis/pulmonary embolism. Our approach to abdominoplasty with circumferential liposuction is identical to that of Sozer et al.; however, our operations are more complex and our patient population is at least as challenging. The mean body mass index of our patients was 29.34 kg/m2. The mean amount of supernatant fat removed was 2174.7 ml (maximum, 8200 ml); 59.1 percent underwent concurrent procedures and additional contouring; 16.3 percent underwent buttock fat grafting; and 52 had massive weight loss, necessitating body uplifts, and so on. Our flap undermining extends beyond the costal margin to the inframammary crease, higher and wider than that described by Sozer et al., and 90 percent of our abdominoplasties would be classified as extended abdominoplasties using the classification system of Sozer et al. Our abdominoplasty technique uses a rich network of vessels lining the flap’s deep surface to distribute blood supply to the undermined flap, resulting in an increased flap excursion and obviating the need for vertical incisions. Our complications included a seroma rate of 2 percent, an infected seroma rate of 1 percent, and one hematoma. Fifteen of Sozer’s patients sustained deep vein thromboses despite anticoagulant prophylaxis; three of the 15 experienced pulmonary emboli and one of the three died (one per 1000 deaths). Thus, despite following practice recommendations, venous thromboembolism still occurred. This raises questions about the validity of practice recommendations on deep vein thrombosis prevention. Furthermore, anticoagulants in abdominoplasty have risks. Dini et al. sustained a serious bleeding complication rate of 29.6 percent and had to discontinue their study of anticoagulants in abdominoplasties.4 We sustained one hematoma—the only time we used anticoagulants. In contrast, we have never experienced deep vein thrombosis in the more than 600 abdominoplasties performed since 1996 and in hundreds of additional body contouring procedures performed since 1990. Although abdominoplasty is a known risk factor for deep vein thrombosis, and which is likely potentiated by general anesthesia, abdominoplasty under local anesthesia with sedation has been largely overlooked. Under general anesthesia, muscle tone is reduced (lessening the effectiveness of the muscle pump mechanism), and positive-pressure ventilation lessens the effectiveness of the respiratory pump, further reducing venous return.5 Sedation better maintains muscle tone and enables evaluation of abdominal laxity under truer physiologic conditions, preventing abdominal wall overtightening, respiratory dysfunction, and a further increase in intraabdominal pressure.6 Safety data for the year 2012 from Florida and Alabama implicating abdominoplasties under general anesthesia in surgical deaths and the information in this letter back our call to readers to consider abdominoplasty under local anesthesia. DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this communication. Daniel Brauman, M.B.B.S., M.D., Ph.D.Private PracticeWhite Plains, N.Y. Rene R. W. J. van der Hulst, M.D., Ph.D.Department of Plastic SurgeryUniversity Medical Center MaastrichtMaastricht Berend van der Lei, M.D., Ph.D.Department of Plastic SurgeryUniversity Medical Centre GroningenGroningen, and Bergmann ClinicsZwolle and Heerenveen, The Netherlands