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Article-No holds barred

Dr. Paul
Toronto — More aggressive abdominoplasty leads to better results in patients, says an aesthetic plastic surgeon here.

Speaking at a Toronto aesthetic surgery update, Malcolm Paul, M.D., F.A.C.S., clinical professor of surgery at the Aesthetic and Plastic Surgery Institute/University of California at Irvine, discourages fellow plastic surgeons from performing modified abdominoplasties. Modified abdominoplasty makes up less than 2 percent of the procedures that Dr. Paul performs.

"I have gotten away from performing that procedure," Dr. Paul tells Cosmetic Surgery Times. "I don't find that it yields successful results and patient satisfaction is not very high."

When more is better

Dr. Paul says that aggressive abdominoplasty takes another half hour to 40 minutes more than a standard full abdominoplasty, and yields an outcome that patients find superior.

"Patients say that they have a waistline that they haven't seen in years since before their first pregnancy," Dr. Paul says. "You can create an hourglass effect with aggressive liposuction. The patients might have a cylindrical shape, so they appreciate having a more contoured waistline."

The abdominoplasty is targeted at addressing abdominal deformities characterized by excess skin and subcutaneous tissue and laxity of the abdominal wall musculature. Pregnancy is the most common cause of abdominal deformity, most often multiple pregnancies.

Pregnancy can stretch the skin beyond its biomechanical capability to spring back and stretches the musculoaponeurotic structures of the abdominal wall. The result is stretching and thinning of these structures and diastasis of the rectus muscle.

Preoperative planning

Surgeons should plan before they perform an aggressive abdominoplasty, according to Dr. Paul. They should:

  • Ensure that patients aren't smoking.
  • Take a complete medical history and do a complete patient examination.
  • Advise patients to lose some weight before the procedure to optimize results.
  • Advise patients to postpone the procedure if they are planning another pregnancy.

The procedure is also contraindicated in morbidly obese patients. Clinicians should be alert for patients who have conditions such as heart disease, hypertension, diabetes or a history of thromboembolic disease. A more aggressive procedure also requires more recovery time.

The location of all scars on the abdomen should be documented and the presence of abdominal hernias should be noted. Diastasis of the rectus muscles should be noted as well. The condition and strength of the abdominal wall should be assessed. The amount, quality and elasticity of the abdominal wall skin should be thoroughly evaluated.

"You can perform aggressive abdominoplasty in terms of liposuction, but it has to be done safely in terms of the anatomy of the blood supply, so you don't risk poor wound healing," Dr. Paul says, noting the aggressive procedures require more suctioning.

"You can use liposuction to improve the waistline and thin out the abdominal wall flaps, so that the overall contours are better. You have to understand the anatomy and understand tension on the skin to do this. If you use a small cannula, you can get a great result."

Dr. Paul also routinely performs a preoperative bowel prep to optimize the outcome.

"The colon can be full of constipated stool," he says. "The bowel prep decreases colonic weight and minimizes the possibility of complications.

"If, after the procedure, the patient has an appearance of a flat tummy when standing up, but has excess skin and laxity when they are in a jackknife position, I think it's a second-class result," Dr. Paul says, noting radiofrequency technology should then be employed.

"When that does happen, you can use Thermage® to achieve more tightening of the abdominal wall," Dr. Paul says.

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