KLAGENFURT, AUSTRIA — Analyses of data from 243 consecutive cases support the conclusion that modified Avelar abdominoplasty is a superior approach for removing excess abdominal skin and fat. It can be performed as an ambulatory procedure and results in high patient satisfaction — all while avoiding the serious complications associated with conventional abdominoplasty, according to Peter Lisborg, M.D.
The modified Avelar technique is performed using tumescent local anesthesia and incorporates liposuction of the upper and lower abdomen to allow skin advancement without wide undermining.
STUDY DETAILS Dr. Lisborg, a private practitioner in Klagenfurt, Austria, reported the outcomes from his large series of surgeries performed between April 2002 and September 2010. The patients ranged in age from 20 to 82 years, and more than 90 percent were women. Only 26 patients had rectus diastasis repair, which is performed only when needed.Overall, 85 percent of patients were satisfied with the outcome. The safety review showed no intraoperative complications and minor postoperative complications that were easily managed. Hematomas requiring evacuation were not observed. A suture fistula developed in 13 patients (5.5 percent) and one patient was admitted to the hospital for management of a minor wound infection, although inpatient care was not absolutely necessary, Dr. Lisborg says.
There were no other infections and no cases of seroma or necrosis. Only two patients experienced postoperative pain for more than one week, and all patients but one returned to normal activity within one week.
"With its extensive undermining, conventional abdominoplasty creates a huge wound surface and profound devascularization, and it is associated with a prolonged hospital stay and high rate of complications," Dr. Lisborg says. "These events ... are eliminated or minimized using the technique introduced by Juarez Avelar, M.D., that avoids wide undermining to preserve the perforating vessels and maintain flap perfusion.
"Furthermore, using IV sedation with tumescent local anesthesia in a modification introduced by Guillermo Blugerman, M.D., allows the surgery to be performed as an ambulatory procedure and further enhances safety by avoiding risks associated with general anesthesia," he says. "Considering operative morbidity, I believe the Avelar technique is the biggest breakthrough that has occurred in abdominoplasty."
Dr. Lisborg says the greater safety of the modified Avelar technique allows for more liberal criteria in selecting patients for abdominoplasty. He discusses a patient with a history of open cholecystectomy who safely underwent the modified Avelar procedure: "In this case, there would be a relative contraindication to performing conventional abdominoplasty due to the risk of skin necrosis after extensive undermining," he says. "However, the danger is avoided with the Avelar technique because it maintains blood supply in the flap."
When performing the modified Avelar procedure, Dr. Lisborg's tumescent anesthetic solution contains lidocaine, epinephrine and sodium bicarbonate, and the total infiltrated volume ranges from 4 to 7 liters (mean 4.5 L). He also performs liposuction of the hips for body contouring in addition to the abdominal liposuction (moderate in the upper abdomen and radical under the skin to be resected), done as part of the Avelar procedure.
After the liposuction, superficial skin resection is performed only through the dermis, with attention to preserving the subcutaneous structures, including the arteries, lymph vessels and nerves. "I perform full-thickness skin excision without de-epidermization, which saves time, while preservation of the lymph system in addition to the arteries eliminates the need for drain placement and the risk of seroma," Dr. Lisborg says.
When performing full abdominoplasty with umbilicus transposition, undermining is carried out only to the medial plane. If rectus diastasis repair is needed, undermining of the median plane is continued superiorly to the xiphoid. A V- or U-shaped incision is made for umbilicus transposition because there is a risk of stenosis when making a round cut into the abdominal flap. After umbilicus transposition, direct wound closure is carried out by folding over the subcutaneous structures. Sutures to the deep fascia are used if a lifting effect or the pubic region is not desired.
PROVING THE PRINCIPLE In order to obtain objective evidence that the Avelar technique preserves perfusion, Dr. Lisborg has been measuring skin circulation before and after surgery using laser Doppler flowmetry. Results show a hyperemic response at 24 hours post-op in all regions undergoing tumescent anesthesia, with a return to preoperative levels in two to three days.
"The hyperemia represents a vasodilatory reaction to ischemia that is induced by the epinephrine in the tumescent anesthetic solution, but importantly, we have not seen any evidence of significant reduced perfusion after the Avelar technique," Dr. Lisborg says.
To establish a benefit for maintaining circulation using the modified Avelar technique versus conventional abdominoplasty, Dr. Lisborg hopes to obtain ethics committee approval for conducting a comparative study. "Although I no longer perform conventional abdominoplasty with wide undermining of the flap because I consider it unethical, we would need to enroll just 10 patients in each group to achieve sufficient power to demonstrate a statistically significant difference," he says.