Abdominal Etching: Differential Liposuction to Detail Abdominal Musculature Aesthetic Plastic Surgery

ABDOMINAL ETCHING: ENHANCING CONTOUR THROUGH DIFFERENTIAL LIPOSUCTION Published 1993 in Aesthetic Plastic Surgery AUTHORS: Henry A. Mentz, III, M.D., F.A.C.S., F.I.C.S.* + Mark D. Gilliland, M.D. Christopher K. Patronella, M.D.

AFFILIATIONS: *Associate Clinical Teaching Staff, Division of Plastic Surgery, Baylor College of Medicine Houston, Texas Clinical Assistant Professor, Division of Plastic Surgery, Baylor College of Medicine Houston, Texas +Associate Clinical Teaching Staff, Division of Plastic Surgery, St. Joseph Hospital Houston, Texas ADDRESS: 6624 Fannin, Suite 2260 Houston, Texas 77030

INTRODUCTION: Both men and women frequently seek consultation for liposuction to improve abdominal contour. Most patients are interested in reducing the abdominal fat pad and achieving a more athletic appearance. Traditional liposuction of the abdomen uses deep liposuction, preserving a subcutaneous pad to minimize irregularities.

This typically produces a generalized reduction of abdominal fat but also results in a plate-like abdomen that can leave an unnatural or "operated" appearance. Abdominal etching was developed to provide a "washboard" abdomen in body builders. It has been most successful in body builders with less than 15% body fat and appropriate long-term expectations.

We have not found this technique useful for "weekend athletes" who have inadequate muscular bulk and fluctuating weight; it can leave "excess" contouring if these patients add weight. Also, if patients are not sufficiently muscular, results may appear artificial. Therefore, the abdominal etching technique has been modified for patients who desire a muscular, healthy-appearing abdomen but are not dedicated athletes committed to lifetime fitness. Patients must be selected carefully, and preoperative marking must be accurate.

Modified abdominal etching utilizes "differential" liposuction. Lateral to the rectus muscle, the abdominal fat pad is aggressively thinned; superficial to the rectus, the fat pad is left thicker, reflecting the patient's natural anatomy. The linea alba superior to the umbilicus and the lateral edge of the rectus are "etched" to define further the abdomen. Special care is used periumbilically to prevent a "doughnut" (residual periumbilical fat).

PATIENTS AND METHODS: This study reviews patients treated with Modified Abdominal Etching. All patients were in good or excellent physical condition who desired a reduction of abdominal fat and a more-athletic appearance. On the morning of surgery, markings are made with the patient standing. Trunk flexion may be necessary to outline landmarks.

The linea alba, the linea semilunaris, abdominal topography, and the liposuction access sites are accurately marked. These incisions are usually at the umbilicus and bilaterally in the pubic hair. If the flanks are also to be liposuctioned, access sites are marked just lateral to the anterior superior iliac spines and sometimes posteriorly, low on the buttocks. A #11 blade is used to make 2 mm punctures.

The punctures are stretched with iris scissors. A pump with a 2 mm infusion cannula is used to instill the tumescent fluid which consists of one liter normal saline, one cc of 1:1000 epinephrine, 50 cc of 1% lidocaine, and sometimes one cc of 10 mg/cc triamcinolone. Triamcinolone is used for its purported speedier resolution of postoperative edema and diminution of reduce postoperative bruising. One to two liters of solution are typically needed, with elapse of 15 minutes for epinephrine-induced vasoconstriction.

When more areas are treated, the lidocaine is often reduced to 25 cc to reduce the total lidocaine dose. A 2, 3, and 4 mm cannulae are used for liposuction. "Cross-tunneling" is done in all areas. Aggressive deep and superficial liposuction are performed lateral to the rectus muscle. A specifically-designed "etching cannula" can be used for linear etching. The linea alba is enhanced by aggressively liposuctioning a 1 cm strip from the umbilicus to the xiphoid.

Etching is similarly done along the edge of the linea semilunaris. It is also necessary to etch 2-3 cm surrounding the umbilicus to prevent a periumbilical "doughnut." The remaining abdominal fat pad is thinner lateral to the semilunaris, at the superior linea alba, and periumbilically. The fat overlying the rectus muscles may be two to three times thicker. At intervals, the pad thickness should be checked for symmetry and smoothness.

The intraoperative results closely correlate with the final results. Superficial erythema, especially in the "etched" areas, is often seen intraoperatively. Horizontal etching at the horizontal rectus furrows should only be done on patients who fit criteria for the abdominal etching technique. The incisions are left open. Dressings consist of ABD's or 4x4's, adhesive foam (RestonTM), and a binder. The foam remains in place for one week; patients shower wit it in place and dry it with a towel or blow-dryer before placing the binder.

The binder is worn for at least two weeks. The foam gradually loosens after about a week; as it does, its edges can be trimmed. Exercise is allowed five days after surgery. RESULTS: More than 20 patients under abdominal etching or Modified Abdominal Etching as outpatients over an 18-month period. Abdominal binders are worn from two to six weeks. No patient had seroma, skin loss, or major complication.

Early in the series, the periumbilical "doughnut" appeared in patients with moderate reduction of abdominal fat; in later patients, this excess was eliminated by more-vigorous liposuction. Skin laxity, particularly above the umbilicus, did cause postoperative wrinkling in older and sun-damaged patients.

Problems with waviness occurred below the umbilicus, where care must be taken to evaluate thickness irregularities intraoperatively. More fat should be left overlying the rectus, thicker near the xiphoid and gradually thinned toward the pubis to promote appearance of a flatter lower abdomen.

DISCUSSION: Generally, a smooth, even fatty layer is most important in liposuction. Contour irregularities of the abdomen are easily created and remain readily visible. Problems with skin excess and wrinkling make the abdomen a difficult area for liposuction. Many surgeons leave a centimeter of fat under the skin to "buffer" irregularities and prevent skin wrinkling.

This technique does not accomplish the goals of many young, athletic patients. Furthermore, generalized liposuction can leave the abdomen too flat, revealing an "operated" or unnatural appearance. Differential liposuction is another approach to abdominal contouring. Leaving a thicker fat pad over the rectus with etching at the midline and lateral edges can re-create the athletic abdomen.

Differential liposuction may also be used to prevent residual deformities. Residual periumbilical fat is a contour deformity complication of generalized(even thickness) liposuction. In patients with moderate or excess fatty tissue around the umbilicus, the periumbilical area telescopes on itself leaveng a "doughnut" deformity, caused by leaving equal thickness in a conically-shaped area. As the surrounding skin contracts and flattens, the periumbilical skin and fat collapse to form a ridge, resulting in an area thicker than the surrounding fat and causing a residual and obvious excess.

Aggressively thinning the fat pad in a fluted umbilicus allows skin retraction and prevents this telescoping phenomenon. There are seven principles of muscular etching:

* 1) Thorough counseling is necessary. Long-term issues of future weight changes, postoperative irregularities, and possible metabolic effects of liposuction are discussed.

* 2) Preoperative marking is important. The patient is marked with a permanent marker while standing. Intermittent flexion of the trunk can assist the marking. The patient checks the marks in the mirror to corroborate operative goals.

* 3) Superficial tumescent liposuction (pressurized infusion technique) is used to reduce blood loss and lessen the incidence of contour irregularities, fluid depletion, and postoperative pain.

* 4) Cannulae are chosen for each area. Small Mercedes cannulas can be used when the fat aspirates easily. Larger cannulae can be used if the tissue is more fibrous. The etching cannula is most traumatic and should only be used for etching; it has beveled edges which cause subdermal trauma when directed toward the skin. This "internal dermabrasion" may assist with skin contraction.

* 5) Careful, frequent monitoring of tissue thickness by the "pinch method" helps prevent gouging and dimples. Uneven areas can be smoothed by cross-tunneling without suction.

* 6) Wounds are left open to allow serosanguinous fluid drainage.

* 7) Adherent foam pads (RestonTM) plus a compression garment contribute to reduced postoperative edema and a faster recovery time.

CONCLUSION: Abdominal etching was designed specifically to enhance highly developed abdominal musculature in the body builder. Modified abdominal etching utilizes "differential" liposuction to create an athletic abdomen in weekend athletes. The procedure has minimal risks and is easily performed. The surgeon selectively reduces the abdominal fat, creating thickness variations based upon the patient's anatomy.

The patient's athletic appearance is enhanced by refining the abdominal bulk to approach the chiseled, horizontal and vertical "furrows" seen in classic anatomical drawings of the abdomen.

REFERENCES: ... Mentz HA, Gilliland MD, and Patronella CK: "Abdominal Etching: Differential Liposuction to Detail Abdominal Musculature" Aesthetic Plastic Surgery 17:287-290, 1993. ... Lewis CM: "Early Experience of Aspirative Lipoplasty of the Abdomen" Aesthetic Plastic Surgery. 11:33-40, 1987. ... Gilliland MD, Mentz HA, Patronella CK: "Major Liposuction Without Blood Transfusion: A Prospective Study in 122 Patients" Paper Presented to the American Society of Aesthetic Plastic Surgery, Boston, Massachusetts, April 1993. ... Gilliland MD, Mentz HA, Patronella CK: "Major Liposuction Without Blood Transfusion: A Prospective Study in 167 Patients" Presented to the 12th Congress of the International Society of Aesthetic Plastic Surgery. Paris, France. September 1993. ... Gilliland MD, Mentz HA, Patronella CK: "Abdominal Etching: Utilizing Differential Liposuction for Detailed Skin Retraction" Presented to the 11th Annual Meeting of the Lipoplasty Society of North America. New Orleans, Louisiana. September 1993.