Rdz F et al_Avelar AJCS 12-2011

The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 241
ORIGINAL ARTICLE
One Hundred Consecutive Lipoabdominoplasty
Procedures: ModiÞed Avelar Technique for Full
Abdominoplasty Without Panniculus Undermining—
Advances, Morbidity, and Complications
Filiberto Rodriguez, MD; Marvin A. Borsand, DO, FACOS, FAACS
Introduction: Abdominoplasty can be limited by preexist-
ing scars and is associated with postoperative drains, seromas,
and deep vein thrombosis (DVT). The Avelar technique has
been described as an alternative to extensive ßap dissection.
We adopted this technique in 2007.
Materials and Methods: The lower abdomen is marked
for planned resection. Liposuction is performed throughout
the entire abdomen below Scarpa’s fascia and superÞcially
in the lower abdomen to thin the redundant pannus. The skin
is sharply incised, and the thinned pannus is bluntly avulsed,
leaving the subcutaneous fat and vessels intact. The upper
abdominal skin can be slid over the deep fascia, preserving
the perforating vessels. A narrow tunnel is dissected from
the umbilicus to the xiphoid for rectus plication. The umbili-
cus is transposed in the usual manner. All patients receive
DVT prophylaxis with perioperative heparin, sequential
compression devices, and Lovenox. Surgery is ambulatory,
and drains are not routinely used.
Results: Between April 2007 and December 2010, 100
consecutive lipoabdominoplasty procedures were performed.
There were no DVTs and no deaths. One patient sustained
small-bowel injury during liposuction, which was immedi-
ately recognized and successfully repaired. Five hematomas
(28 ± 28 mL) occurred within the early postoperative period,
2 of which became infected. Four hematomas responded to
local drainage, but 1 required surgical evacuation 3 months
later. The incidence of late seroma was 0%. Two marginal
skin necroses occurred in patients with preexisting Kocher
and laparotomy scars, which healed without ill effect.
Conclusions:Theincidenceofwounddehiscence,seroma,
hematoma, and DVT after lipoabdominoplasty is less than
that reported for traditional abdominoplasty.
Abdominoplasty is the fourth most frequently
performed cosmetic surgical operation in the
United States.1
Over the years, several technical reÞne-
ments have signiÞcantly improved the results of
abdominoplasty, yet the most common approach for
abdominal contouring remains traditional abdomino-
plasty with extensive undermining of the abdominal
ßap at the deep fascia up to the costal margin for
advancement. This approach, however, signiÞcantly
compromises the blood supply to the abdominal ßap
as the large central perforators are sacriÞced during
the ßap elevation, leaving the ßap dependent on its
lateral blood supply. Despite increased awareness and
efforts to decrease the morbidity associated with
traditional abdominoplasty, the procedure continues to
be plagued with several complications, which include
seroma formation (the most common, 5–22%), hema-
toma (6.9%), infection (12.1%), wound ischemia, skin
necrosis of the infraumbilical area, and deep vein
thrombosis (DVT) with venothromboembolism (VTE)
(0.34–3.4%).2–6
The decreased blood supply to the abdominal ßap
has led to advocacy against any liposuction of the
central abdomen (zones 2 and 3) at the time of
abdominoplasty in order to minimize the risk of ßap
necrosis.7
The extensive dissection also disrupts the
lymphatic drainage, which predisposes abdominoplasty
to seroma formation, causing most surgeons to routinely
use drains in an attempt to avoid this complication.
Although progressive tension sutures without the use
of drains, as described by Pollock and Pollack8
has
Received for publication June 21, 2011.
From the Body Sculpting Center, Scottsdale, Ariz.
Presented in part at the International Symposium of Minimal Invasive
Plastic Surgery and Dermatology, Bangkok, Thailand, April 2011, and the
World Academy of Cosmetic Surgery 2nd Annual Meeting, Vienna, Austria,
September 2011.
Corresponding author: Filiberto Rodriguez, MD, The Body Sculpting
Center, 2255 N Scottsdale Rd, Scottsdale, AZ 85257 (e-mail: Filiberto
RodriguezMD@gmail.com).

242 The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011
recently been shown to decrease the incidence of
seroma after abdominoplasty from 24% to 1.7%,9
this
technique has not been universally adopted. Moreover,
the fear of hematoma after the extensive dissection for
abdominoplasty may prevent surgeons from instituting
anticoagulation for DVT prophylaxis, even though
excisional contouring surgery of the abdomen remains
associated with the highest rate of thromboembolic
disease for cosmetic surgery,6
and despite published
recommendations from the American Society of Plastic
Surgeons based on the guidelines devised by the
American College of Surgeons.10,11
Alternative techniques have been described for
abdominoplasty that do not entail extensive ßap eleva-
tion and dissection.3,12,13
These techniques involve
various adaptations of aggressive liposuction in the
deep abdominal subcutaneous tissue to enable forward
advancement of the abdominal ßap after excision of
the redundant pannus. Although these techniques have
been shown to decrease the incidence of postopertive
complications,3,13,14
these methods have idiosyncrasies,
such as en bloc excision of the redundant pannus with
the umbilicus and the creation of a neoumbilicus,12
excision of small areas of skin the suprapubic region
and the upper abdomen along the inframammary
folds,3
and disruption of “skin-retaining ligaments,”13
which may preclude wide acceptance.
In 2007, the senior author (M.A.B.) began adapting
the principles of the Avelar technique to his mini-
abdominoplasty procedures (lower abdominoplasty
without translocation of the umbilicus) and has since
expanded the technique to all conventional and ßeur-de-
lis abdominoplasty procedures. The resulting modiÞ-
cations have emerged as a hybrid procedure combining
the principles of the Illouz suction abdominoplasty,12
conventional abdominoplasty with diastasis repair and
transposition of the umbilicus, and the Avelar tech-
nique for aggressive liposuction and blunt avulsion of
redundant tissue without undermining of the upper
abdominal ßap.3
The procedure has been simpliÞed to
eliminate the idiosyncratic aspects of these alternative
approaches, and a streamlined, simpliÞed technique
has emerged. This lipoabdominoplasty procedure has
proven safe and convenient when combined with
concomitant additional cosmetic procedures, with cir-
cumferential liposuction of the ßanks and back in par-
ticular. We have also been able to abandon the routine
use of postopertive drains and implement an aggressive
anticoagulation protocol for DVT prophylaxis with
minimal hematoma and seroma complications.
Patients and Methods
One hundred consecutive patients underwent
lipoabdominoplasty from April 2007, when we Þrst
adopted the procedure into our practice, through
December 2010. Of the patients, 99% were women.
The average age was 39 years (range, 18 to 62), and
the average body mass index (BMI) was 27.3 ± 4.0
(range, 20.7 to 38.9). Of the patients, 87 underwent
full abdominoplasty (Figures 1 through 3), 9 underwent
a lower abdominoplasty without translocation of
the umbilicus (ie, mini tummy tuck), and 4 patients
underwent a ßeur-de-lis abdominoplasty (Figure 4). In
addition, 65 patients underwent concomitant circum-
ferential torso liposuction of the ßanks and back, and
32 patients underwent liposuction of additional areas
(eg, thighs, chin, arms). Further, 6 patients had fat
transfer for gluteal augmentation, 1 patient underwent
fat grafting to the face, and 3 patients had additional
body contouring surgery (eg, thigh lift or mid-body
lift). Concomitant breast surgery, either implant
augmentation alone or with mastopexy, was done in
37 patients; 3 patients underwent intra-abdominal tubal
ligation, and 1 patient underwent vaginoplasty. The
overall incidence of concomitant additional procedures
was 95%, with an average of 1.8 ± 1.0 (mean ± SD)
procedures performed per patient.
Surgery was performed in a licensed outpatient
surgery center under local anesthesia with intravenous
sedation and monitored anesthesia care. The usual
length of surgery was 4 hours, and patients were
discharged within 2 hours after surgery. All patients
received aggressive DVT prophylaxis consisting of
5000 units of heparin subcutaneously at the time of
surgery, use of sequential compression devices during
surgery, and 10 days of Lovenox (SanoÞ-Aventis,
Bridgewater, NJ) 40 mg subcutaneously after surgery.
Operative Technique
Preoperatively, the redundant pannus is marked on
the patient. Circumferential liposuction of the back
and ßanks is performed while the patient is in the
prone position when indicated using a super-wet tu-
mescent technique. The patient is then rotated to the
supine position, and liposuction of the entire abdomen
is performed in the deep plane below Scarpa’s fascia.
This deep liposuction allows the upper abdominal skin
and subcutaneous tissue to be slid over the deep fascia
while preserving the perforating vessels as multiple
pedicles. Additional liposuction is performed in the
upper abdomen as needed to optimize its thickness
and enhance the Þnal contour. Liposuction is then

performed aggressively in the superÞcial plane in the
previously marked lower abdominal redundant pannus
to thin this tissue to facilitate excision.
After liposuction and before the skin is incised, the
patient is ßexed and the skin is tailor-tacked with towel
clamps to ensure that successful closure will be
possible once the pannus is excised. This is a critical
distinction from traditional abdominoplasty as the skin
excision is predetermined as opposed to being deter-
mined after the ßap has been elevated and the patient is
ßexed. The skin is sharply incised along the preopera-
tive markings, the umbilicus is freed circumferentially,
and the thinned pannus is bluntly avulsed via the Avelar
technique, leaving the underlying subcutaneous fat,
connective tissue, and vessels intact. A narrow tunnel
is dissected, when indicated, from the umbilicus to the
xiphoid, allowing complete diastasis plication from
the xiphoid to pubis. The patient is then ßexed, and
the abdominal incision is closed under minimal tension,
with interrupted deep dermal staples (INSORB, Incisive
Surgical, Plymouth, Minn) and a running subcuticular
3-0 polydioxanone Quill suture (Angiotech Pharma-
ceuticals, Vancouver, British Columbia). The patient
is then ßattened, and the umbilicus is transposed in
the usual manner. Drains were placed in 11 patients
(11%) depending on the degree of exposed fascia after
avulsion of the pannus.
Results
There were no deaths or incidents of DVTs. One
patient with a preexisting laparotomy scar required
small-bowel repair at the time of abdominoplasty as a
result of small-bowel injury from the liposuction
cannula. She was admitted to the hospital overnight
and recovered without incident. Five hematomas
(28 ± 28 mL) occurred within the early postoperative
period, 2 of which became infected. Four hematomas
responded to local drainage, and 1 required surgical
evacuation 3 months later. No seromas occurred
beyond the 6-week postoperative period. Fluid collec-
tions within the initial 6-week postoperative period
Figure 1. Before-and-after photographs of a 43-year-old woman (weight, 185 lb; body mass index, 34.5; full abdominoplasty
with abdominal liposuction, 750 mL; total lipoaspirate, 2100 mL). The postoperative photograph was taken 2 months after
surgery.

were managed with periodic tapping in 9 patients (26
± 25 mL). Four superÞcial stitch abscesses occurred,
which were successfully treated with oral antibiotics.
Marginal skin necrosis occurred in 2 patients with
preexisting Kocher and full midline laparotomy scars,
respectively, which healed without ill effect (Figure 5).
Good abdominal contour was achieved with lipoab-
dominoplasty (see Figures 1 through 4), and patient
satisfaction was high, as evidenced by our patient
referral rate of 68%.
Discussion
Over the past 30 years, increased attention has been
placed on the incidence and avoidance of the compli-
cations associated with abdominoplasty, which include
seroma formation (the most common, 5–22%), hema-
toma (6.9%), infection (12.1%), wound ischemia, skin
necrosis of the infraumbilical area, and DVT with
VTE (0.34–3.4%).2–6
Various methods for reducing complications are
described in the literature. For seroma, recommenda-
tions include quilting sutures,2,15
Þbrin glue,16
and
progressive tension sutures without the use of drains,8
which has recently been shown to decrease the
incidence of seroma after abdominoplasty from 24%
to 1.7%.9
To avoid ßap necrosis, Matarasso empha-
sized that liposuction of the central abdomen (zones 2
and 3) should not be performed at the same time as
abdominoplasty because of concerns of jeopardizing
the tenuous blood supply of the abdominal ßap
following ßap elevation and dissection.7
For DVT prophylaxis, the American Society of
Plastic Surgeons formed a task force on DVT in 1999
that published recommendations based on the guide-
lines devised by the American College of Surgeons.10,11
The focus on DVT after abdominoplasty stems from
the fact that excisional contouring surgery of the
abdomen is associated with the highest rate of throm-
boembolic disease in cosmetic surgery.6
Although the
with abdominal, ßank, and back liposuction, 6750 mL; total lipoaspirate, 8700 mL). The postoperative photograph was taken
3 months after surgery.

etiology of DVT after abdominoplasty is beyond the
scope of this article, an increase in intra-abdominal
pressure after diastasis repair, which may retard
venous return, combined with decreased ambulation
after the procedure, may contribute. Historically, the
incidence of DVT after isolated abdominoplasty was
reported at 1.1% in a 1977 review of 10490 cases,
with pulmonary embolus (PE) in 0.8% and death from
PE in 0.1% of patients.17
A more recent report from
2010 found the incidence of VTE to be 0.34% after
abdminoplasty alone, 0.67% after abdminoplasty with
concomitant additional cosmetic procedures, 2.17%
with abdominal, ßank, and back liposuction, 2050 mL; total lipoaspirate, 2500 mL). The postoperative photograph was taken
4 months after surgery.

after abdominoplasty with intra-abdominal procedures,
and 3.4% after cirumferential abdominoplasty.6
Despite
these staggering statistics, perioperative anticoagulation
is not routinely instituted by plastic surgeons (oral
communication, University of California, Los Angeles
Department of Plastic and Reconstructive Surgery,
2008–2009), perhaps because plastic surgeons remain
more concerned about hematoma after the extensive
ßap dissection and choose to not apply the American
College of Surgeons DVT prophylaxis guidelines, which
did not speciÞcally include plastic surgery patients.6,11
A recent report discussing preventive measures to
reduce thromboembolism after cosmetic surgery, how-
ever, reveals that abdominoplasty patients fall into
moderate to high risk for DVT and warrant periopera-
tive chemoprophylaxis against DVT with Lovenox, in
addition to early ambulation and use of sequential
compression devices during surgery.18
Hence, sur-
geons performing abdominoplasty should aggressively
seek to minimize the risk of DVT for their patients.
Figure 4. Before-and-after photographs of a 46-year-old woman (weight, 116 lb; body mass index, 22.3; ßeur-de-lis abdomi-
noplasty with abdominal liposuction, 400 mL; total lipoaspirate, 1100 mL). The postoperative photograph was taken 3 months
after surgery.
An alternative approach for abdominoplasty may
help address and minimize these complications. In
1992, Illouz12
introduced the concept of the suction
abdominoplasty. Instead of extensive undermining of
the abdominal ßap at the deep fascia up to the costal
margin, Illouz described liposuction of the upper
abdomen to loosen the supraumbilical subcutaneous
tissue sufÞciently to allow downward advancement.
The redundant lower abdominal tissue was then
excised en bloc with the umbilicus. Undermining of
the midline enabled diastasis repair from the xiphoid
to the pubis. A neoumbilicus was created after
advancement of the upper abdomen and closure. The
purported advantages of this method are that it simpli-
Þes the procedure and avoids inherent complications
because undermining and subsequent devascularization
are avoided.12
Although some surgeons have reported
success with this technique19
and variations,13
it has
failed to gain wide acceptance.

In 2002, Avelar introduced a fundamentally different
approach for abdominoplasty that completely avoids
undermining and resection of the panniculus.3
Because
of the high incidence of complication rates after
conventional abdominoplasy in the 1980s, Avelar
abandoned conventional abdominoplasty and abdomi-
noplasty combined with liposuction from 1988 to
1998. During that time, Avelar carefully studied the
vascularization of the subcutaneous tissue after
liposuction.20
From these studies, a method for
abdominoplasty was described wherein small areas of
skin were excised from the suprapubic region and the
upper abdomen along the inframammary folds.3,14
Liposuction was performed throughout the abdomen
in the deep layer below Scarpa’s fascia, which allowed
the panniculus to be slid easily over the muscular
aponeurotic wall while preserving all the perforating
vessels. A fundamental element of the skin resection
technique was to perform aggressive liposuction of the
full thickness of the skin to be resected and then blunt
avulsion of this skin, rather than sharp dissection off
the fascia, thereby leaving the connective tissue and
the arterial, venous, and lymphatic vessels between
the muscles below and the thin layer of subdermal
structures above.3,14
Umbilical transposition was not
necessary, and drains were not used. Only 2 cases of
seroma treated with syringe aspiration occurred in
Avelar’s series of 97 patients, and there were no cases
of hematoma, skin ischemia, or necrosis, although
the use of perioperative anticoagulation was not
discussed.3
Our modiÞcations of the Avelar technique for
abdominoplasty have resulted in a hybrid procedure
combining the principles of the Illouz suction abdom-
inoplasty, conventional abdominoplasty with diastasis
repair and transposition of the umbilicus, and the
Avelar technique for aggressive liposuction and blunt
avulsion of redundant tissue without undermining the
panniculus. The procedure has been simpliÞed to
eliminate the idiosyncratic aspects of these alternative
approaches,3,12
and a streamlined, simpliÞed technique
has emerged. This lipoabdominoplasty procedure has
proven safe and convenient when combined with
concomitant additional cosmetic procedures.
The application of liposuction as a dissection tool
throughout the upper abdomen (without ultrasound or
laser) causes less vascular trauma to the ßap and less
bleeding than undermining with cautery or scalpel.13
Liposuction selectively disrupts the deep dermal
attachments while preserving the ßexible perforators,
thereby enhancing ßap circulation by creating a vascular
Figure 5. Before-and-after photographs of a 44-year-
old woman (weight, 213 lb; body mass index, 41.3; full
abdominoplasty with abdominal and ßank liposuction,
2600 mL; total lipoaspirate, 4200 mL). The postoperative
photographs were taken 2 weeks and 3 months after
surgery, respectively, showing successful wound healing
in this patient with large preexisting full midline
laparotomy scar.

supporting tissue layer composed of a rich network of
blood vessels, lymphatics, connective tissue, and
nerves. This supporting tissue layer also provides a
deep layer devoid of devascularized fat and ensures
even ßap thickness and deep defatting without surface
irregularities.13
Moreover, circumferential liposuction
of the ßank and back not only optimizes the contour
correction (see Figure 3) but also facilitates abdominal
advancement anteriorly for a tension-free closure.
Our experience shows that circumferential liposuction
of the abdomen, ßanks, and back can be safely
performed in conjunction with the Avelar abdomino-
plasty technique without ßap necrosis. Even in the
presence of extensive preexisting surgical scars, such
as a right upper quadrant Kocher scar or a full midline
laparotomy, which are known risk factors for lower
skin necrosis after abdominoplasty because of the loss
of perforating vessels, the Avelar technique allows for
full abdominoplasty with minimal wound morbidity.
Although a lower midline laparotomy scar from the
umbilicus to the pubis does not normally contribute to
wound complications, because it is typically excised
as part of the abdominoplasty procedure, there is a
signiÞcant difference with a full midline laparotomy
(from xiphoid to pubis), as in our patient shown in
Figure 5. The upper abdominal skin remains compro-
mised by the surrounding scar tissue, and indeed in
this patient (Figure 5), the contracted upper component
of the midline scar limited the downward traction we
were able to place on the abdominal skin, resulting in
excess tension, which also contributed to the wound
necrosis in this area. Perhaps by performing a ßeur-
de-lis abdominoplasty (as shown in Figure 4) rather
than a standard tummy tuck, excision and revision of
the midline scar could have prevented possible skin
necrosis.
The reported incidence of seroma after abdomino-
plasty varies widely (5–22%).5
This variation may be
attributable to differences in deÞnition, because seromas
are deÞned as ßuid collections occurring after drain
removal, and the time of drain removal varies widely
from patient to patient and author to author.13
Hence,
in this report, seromas were deÞned as ßuid collection
persisting beyond the typical 6-week postopertive
interval as deÞned by Brauman and Capocci.13
Our
incidence of late seroma after lipoabdominoplasty was
0%. Consequently, drains are not routinely used, and
periodic tapping is performed for ßuid collections
during the early postoperative period as indicated
(9%). We note that most ßuid collections tend to occur
either in the most dependent aspect along the incision
or superiorly in the area of central dissection for
diastasis repair—perhaps of the thermal injury induced
by cautery in this area. The decision to place drains
(11%) is determined intraoperatively based on the de-
gree of fully exposed abdominal fascia after the blunt
avulsion of the lower abdominal pannus.
In addition to the decreased incidence of seroma,
lipoabdominoplasty has permitted us to implement an
aggressive anticoagulation protocol for DVT prophy-
laxis with minimal hematoma complications. This
aggressive protocol for DVT prophylaxis resulted in a
0% incidence of DVT in this series, despite the high
rate of concomitant additional procedures (95%) with
4% of patients undergoing additional intra-abdominal
procedures, which would typically be associated with
an incidence of 2.17% for DVT in the literature.6
With
this aggressive anticoagulation protocol for DVT
prophylaxis, our incidence of hematoma remained low
(5%) and was less than the recently reported incidence
of 6.9% after abdominoplasty by Araco and colleagues
in 2009.5
We suspect that our low hematoma rate
results from a combination of the tumescent technique
for the liposuction, which is fundamental for the Avelar
technique; minimal dissection; and the application of
pinpoint cautery for hemostasis after blunt avulsion of
the lower abdominal pannus.
The Avelar technique for lipoabdominoplasty rep-
resents a signiÞcant technical advance and departure
from traditional abdominoplasty, which results in
decreased seroma, bleeding, and wound complications.
It also allows for safe, aggressive DVT prophylaxis. In
particular, the Avelar technique enhances the safety of
abdominoplasty even in patients with BMI greater
than 30 (Figures 1 through 3). Average BMI in our
series was 27.3 ± 4, and it ranged from 20.7 to 38.9.
Only 50% of the patients had a BMI less than 30. As
is well known, abdominoplasty is not a weight-loss
procedure. Hence, once a patient is determined to be
a satisfactory candidate for abdominoplasty, BMI is
not a factor in the decision whether to use the Avelar
technique. Since adopting the Avelar technique for
abdominoplasty in April 2007, this has been our
exclusive approach for abdominoplasty, and this
report reßects the outcomes of 100 consecutive cases.
However, the Avelar technique does expose patients
to the risk of intestinal or organ perforation from the
liposuction or tumescent cannula, especially those
with preexisting surgical scars as in one of our patients.
The risk of intra-abdominal injury during liposuction,
although rare, is well known. As discussed in a recent
plastic surgery Maintenance of CertiÞcation article,
“Intestinal or organ perforation from the liposuction

cannula, though rare, usually occurs with a preexisting
abdominal scar. The abdomen, thorax, retroperitoneum,
and major vessels in the subcutaneous space are all
potential areas into which a cannula can be misdirected
and potentially result in major injury.”21
Because
liposuction throughout the abdomen and, especially,
aggressive liposuction in the lower abdomen are
fundamental components of the Avelar technique,
surgeons adopting this technique for abdominoplasty
must exercise caution and maintain a high index of
suspicion for possible penetration of the fascia during
abdominal liposuction, especially in patients with
preexisting scars. A high index of suspicion and
awareness should prompt a thorough examination of
the exposed fascia after avulsion of the lower abdminal
pannus. If identiÞed, a fascial defect warrants an
exploratory laparotomy through the already exposed
fascia so that any injuries can be immediately repaired.
In our patient, an immediate bowel repair was associ-
ated with an excellent cosmetic result and minimal
morbidity.
Conclusion
We conclude that lipoabdominoplasty, performed
as a hybrid procedure combining the principles of the
Illouz suction abdominoplasty, conventional abdomi-
noplasty with diastasis repair and transposition of the
umbilicus, and the Avelar technique for aggressive
liposuction and blunt avulsion of redundant tissue
without undermining of the panniculus, allows for
effective treatment of localized adiposity, excess
abdominal skin, and diastasis recti. The Avelar tech-
nique results in decreased seroma, bleeding, and
wound complications compared with published results
after standard abdominoplasty. In particular, the Avelar
technique enhances the safety of abdominoplasty even
in patients with BMI greater than 30. It also allows for
aggressive DVT prophylaxis with minimal risk of
hematoma. Meticulous technique and a high index of
suspicion for possible intra-abdominal injury are critical
during the abdominal liposuction, especially in
patients with preexisting scars.
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