Ultrasound-assisted abdominoplasty: combining modalities in a safe and effective technique.

With this article, Dr. Abramson adds his experience with ultrasound-assisted liposuction to the growing body of literature that describes the use of a single-stage, combined-modality approach to treating abdominal lipodystrophy. Although the results that Dr. Abramson presents are encouraging, we believe it is important to emphasize a few salient points. First, Dr. Abramson uses the tumescent technique before performing lipoplasty. By definition, this technique infiltrates 2 to 3 cc of wetting solution for every 1 cc of aspirate.1 We have recently reported an update on the use of subcutaneous wetting solution in lipoplasty,2 and have found that there are no literature-supported, proven advantages in safety and efficacy using ratios greater than 1:1 (the “superwet” technique).3 Therefore, we personally use, and would recommend, the superwet technique over the tumescent technique on the basis of its ability to achieve a similar reduction in blood loss (approximately 1 percent of the volume aspirated) but without the potential for complications such as fluid overload and congestive heart failure. Furthermore, we agree with Matarasso4 that excessive infiltration with wetting solution can lead to more difficult electrocoagulation during flap dissection. Dr. Abramson reports infiltrations of up to 3000 cc, with lipoaspirations averaging 1000 cc. We believe the additional volume does not contribute to the ultimate aesthetic outcome but could potentially be a source of morbidity in some patients. Second, the author uses the Mentor Contour Genesis machine “at 85 percent power” to perform the ultrasound-assisted liposuction for 2 minutes above the rectus sheath and for 1.5 to 2 minutes to each flank area. He subsequently uses traditional suction to evacuate the lipoaspirate “both above and below Scarpa’s fascia but not directly under the dermis.” There are several points to be made here. Our experience is similar to the author’s, in that shorter treatment times decrease morbidity.5 However, it is difficult to apply a “standard” treatment time to each patient (i.e., 2 minutes). The author does not describe using ultrasound-assisted liposuction to achieve certain well-defined endpoints, such as loss of tissue resistance or blood-tinged aspirate.5 Some patients may, indeed, require less treatment time, and therefore this should be taken into consideration. Furthermore, we would recommend power settings of 50 to 60 percent, rather than 85 percent, to decrease potential unwanted thermal damage to surrounding tissues, including the fascia. One must also remember that there are numerous reports of fascial penetration and subsequent morbidity (and even mortality) from liposuction,6–10 and therefore extreme caution should be used when purposefully performing liposuction at a level just above the fascia. Finally, performing suction evacuation above the level of Scarpa’s fascia in the central abdomen, in the face of the flap undermining from a formal abdominoplasty, must be performed with extreme caution. This is the watershed area most susceptible to vascular compromise after an abdominoplasty (“the terrible abdominoplasty triangle”).11 Therefore, concomitant treatment to this area (in this plane) is, in our opinion, inviting potential disaster. One very important aspect of Abramson’s article that must not be overlooked is the areas of treatment versus no treatment. One must juxtapose the areas in Figure 1 with the Huger zones,12 describing the blood flow to the abdominal skin and subcutaneous tissue. Abramson chooses to treat the central abdomen and