M.R. Khalifeh, MD

Abdomen Liposuction

Double board certified plastic surgeon

Abdomen Liposuction is of the most popular areas for liposuction. It is also a more complex area to analyze since factors other than subcutaneous fat can limit the effectiveness of the procedure.

The main reason people seek my advice regarding abdomen liposuction is obviously that they want a slimmer, flatter, and more muscular appearing abdomen. However there are many causes of abdominal protrusion and abdominal cosmetic concerns that have to be separately addressed. There are some elements that caused protrusion that can be readily improved with liposuction (or associated procedures such laser liposuction). There are other elements of abdominal protrusion that cannot be improved and some that can even be worsened by liposuction. It is therefore important to obtain a consultation that focuses on the both the pros and cons of the procedure, for your specific anatomy.

Causes of a Protruding Abdomen:

Patients come to us because their analysis is that they have a “fat” abdomen. They often show me what they are bothered by squeezing and pinching a large portion of their belly. Our own analysis of their complaints starts by subdividing the problem into its root causes as follows:

A)

Superficial Abdominal Fat: The superficial abdominal fat is the fat located below the skin but above the abdominal muscles (see figure one below). This is the area that is most readily treatable with liposuction (and closely associated procedures such as laser lipo, J plasma lipo, and VASER liposuction). The most important changes you will see if you decide to undergo a liposuction procedure is changes to the superficial fat layer. The more fat this layer contains, the more it contributes to the unsightly appearance that is bothering a patient.

A good candidate will typically have a noticeable fat pocket sitting between the skin and the muscle layer. With liposuction, the instruments are inserted below the skin and stay above the abdominal muscles and are used to thin out this area, producing a flatter appearance. Thinner cannulas are used to thin out the level above the scarpas fascia to protects skin from irregularity, and thicker ones can be used in layer below the scarpas fascia where fat can be removed more aggressively.

b)

The next cause of abdominal protrusion is the deep fat layer also referred to more appropriately as the visceral fat layer (see figure one above). The visceral fat layer is located below the abdominal muscles. The visceral fat layer is also intimately related and connected to the viscera which is another word for abdominal organs. This means that it cannot be separated or removed without damaging important intra abdominal structures and for that reason the only way to lose the visceral fat layer is via diet and exercise. If your abdominal protrusion is caused by the deep fat layer or the visceral fat layer liposuction will not be successful producing a flat appearance of the abdomen. It is difficult for patients to distinguish between the protrusion caused by the deep layer vs the protrusion caused by superficial fat amenable to liposuction. This is where a consultation with an experienced doctor becomes important.

c)

The next cause of abdominal protrusion is laxity of the abdominal muscles, also known as rectus muscle diastases. The primary cause of this looseness is of course pregnancy. The muscles are designed to make space for the enlarged uterus during pregnancy and after pregnancy a certain degree laxity remains. The more weight is gained during pregnancy especially multiple pregnancies the more stretched out these muscles become and the less likely they are to fix themselves at the end of the pregnancy. This condition of separation of the abdominal muscles is called rectus muscle diastasis and occurs when the two abdominal recti muscles which are usually fused at the midline become separated and the layer between them is a thin layer that cannot hold back what is behind it. Rectus muscle diastasis will make the abdominal organs and visceral fat bulge out since there is no strong layer to keep them tucked in.

It is important to note that rectus muscle diastasis is not fixed by liposuction and pre-existing rectus muscle diastasis makes people a bad candidate for liposuction but good candidates for a tummy tuck. To learn more about a tummy tuck click: Tummy Tuck Washington DC

d)

The final cause of unhappiness with abdominal protrusion skin laxity creating a pooch of tissue beneath the belly button. Note that the lower abdomen tends to contain more subcutaneous fat than the upper abdomen. This creates a pouch of tissue caused by a combination of excess skin and excess subcutaneous fat. This pouch of tissue will improved to a certain degree with liposuction and laser liposuction as the subcutaneous fat is stripped. The skin retraction will vary from patient to patient and the skin laxity cannot be completely eliminated with liposuction alone. Despite this inherent limitation, many patients will still be satisfied with a well performed procedure because it will decrease the pouch visibility especially in clothing but they have to be educated that the pouch cannot be eliminated. For the patch to be more completely eliminated has to be cut away skin and fat and that can be done during a tummy tuck procedure. Energy devices such as the smartlipo laser liposuction device and the j-plasma device can stimulate the skin to retract and tighten, although this effect will not replace the benefits of a tummy tuck if the skin excess is great.

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How liposuction treats the protruding abdomen:

All liposuction and related similar procedures marketed under different names (Sonobello™, Airsculpt™, Trisculpt™, Evosculpt™, Smartlipo™, etc) begin with making a skin opening and inserting a solution to minimize bleeding and numb the area. After that, the fat is either melted and/or removed using a variety of instruments, and this is where the procedures may differ a bit. The most important factor in determining results is the experience of the surgeon as liposuction is a very visual process, rather than one that can be truly automated by machinery.

At DCcosmetics, we keep the incisions to the lower abdomen where they are not very visible. Thru that incision tumescent fluid is inserted which will both numb the fat layer with lidocaine and vasoconstrict the tissues to minimize bleeding using epinephrine( adrenaline) within the tumescent fluid. After these two steps, the fat can be either suctioned directly such as in traditional liposuction or we sometimes add an additional step to melt the fat and deliver heat to the skin such as is done in laser lipo, smart lipo or J-plasma (renuvion). After the subcutaneous fat is removed compression is applied to help minimize swelling and stick the skin back to the muscles.

Dr. Khalifeh Demonstrates Abdominal Liposuction

What elements cannot be treated with abdomen liposuction:

There are elements that cannot be changed with abdominal liposuction, and we will let you know at the time of the consultation if these elements are going to limit your results. After abdominal liposuction the muscles remain the same and the visceral content remains the same. If these factors were contributing significantly to the protrusion of the abdomen the results will be limited as the skin will adhere to the muscle and the contour will follow the existing muscle contour. It is very important to get a good opinion at the onset. We find that larger centers that are staffed by sales associates rather than medical providers tend to under educate patients and over-promise results.

Skin retraction after liposuction of the abdomen

Skin retraction is important and minimizing flabby skin. After liposuction the skin will snap back to a certain degree. This retraction is variable and depends on the thickness of the dermis, the age of the patient, the existence of pre-existing stretch marks, as well as other genetic and lifetime factors. Newer procedures such as smart lipo and laser lipo as well as J-plasma are designed to deliver energy to the underlying part of the skin called the dermis which promotes retraction in certain studies for up to 20% more than traditional liposuction alone. For that reason in cases with abdominal stretch marks we highly recommend smartlipo to help the skin retract. We always tell patients, however, that if you need a tummy tuck due to excessive skin or muscle issues, smartlipo or J-plasma will not be able to change that.

Risks of abdominal liposuction

Liposuction is one of the most commonly performed cosmetic surgeries and is considered very safe in capable amounts and limited volumes. That said, There are a variety of risks to all liposuction, including bleeding, infections, seromas (fluid collections) , hematomas (blood collections), skin scarring or loss (even away from the site of the incisions), risks of anesthesia (general or awake), risks of fluid shifts or fluid overload (these are mainly associated with larger volume liposuction over 5000 cc), as well as cosmetically oriented risks such as skin irregularity, fat irregularity, lumpiness. Patient factors such as smoking and diabetes as well as their medication list will contribute to their risk profile.

In addition, there are specific risks to abdominal liposuction. One of the risks is inadvertent puncture of the muscles resulting in possible trauma to the internal organs. It is important to choose a board-certified plastic surgeon who knows his anatomy and has experience to minimize this risk. This risk is higher in patients with a lot of muscle laxity or a lot of visceral fat and it is also higher if there is a herniation in the visceral components to the subcutaneous level which was not picked up on physical exam. Again this risk is extremely small as long as the surgeon is experienced. The second increased risk in the abdomen is that because of the rich lymphatics the abdomen area tends to produce more fluid collections postoperatively and sometimes these fluid collections known as seromas must be drained. While this is not a big risk of the procedure it does involve visits to the office for possible repeated drainages. If undrained these fluid collections can cause infections or harm the results of the surgery. Occasionally a small drain is used to help drain the fluid faster after the procedure. The incisions can also be left open although if they are gaping this will result in a unfavorable scar. For that reason, we prefer to close them and sometimes we will close them while leaving a small stent to promote drainage.

Other risks of abdominal liposuction include skin irregularities. The abdomen is a sensitive area to skin irregularities which can decrease the cosmetic appearance of the results. Again, in capable hands this risk is minimized.

Other risks relate to the technology used during liposuction, such as burns with the J plasma or even with the laser that is used. The FDA has issued an advisory against using J-plasma during liposuction (as of late 2022), and for that reason J-Plasma is rarely used outside the neck area.

What other body areas are commonly combined with abdomen liposuction:

The most common area to be combined with abdominal liposuction is typically the love handle or lower back flank region. This combination is used to give a narrow waistline in a 360 degree fashion. In addition to often adding the lower back/flank to the abdomen, we recommend treating the full abdomen, rather than just the lower half, even when most of the fat is in the lower half. Subdividing the abdomen into two sections in patients that have mainly a lower abdomen pouch is tempting however overtime the areas that have been treated will become noticeably different than the areas that haven't been treated.

We will sometimes do other areas that bother the patient as well, such as arms, thighs, chin….The most important determinant on what can be treated at the same time is related to the volume of fat removed. Our surgeons will help assess any areas that bother you, and if the volume does not seem excessive, they can be typically combined. We do however remind patients not to try to “lose” weight using liposuction, ie, don’t do too much liposuction. One or two areas is preferred, as the fat may go elsewhere if you don’t keep the weight off.

Before & After Liposuction

Alternatives to abdomen liposuction

The main nonsurgical alternative to abdominal liposuction is weight loss via diet and exercise, sometimes also aided by new weight loss drugs. This will result in an overall loss of fat and in some cases this is enough to treat to produce a cosmetically pleasing appearance if there is a lot of loose skin or loose muscles.

The main surgical alternatives to liposuction is the abdominoplasty surgery, or tummy tuck. This is used in cases where there is significant muscle activity or skin laxity that will limit the results of liposuction. Sometimes a removal of the excess skin restricted to the lower abdomen and can be performed even under local anesthesia and in those cases the surgery is called the mini abdominoplasty.

Recovery after abdomen liposuction

There are several recovery time periods to consider during liposuction of the abdomen. You will need help for the first day after surgery, although you will be able to move around normally. If you work from home, we recommend 48 hours off. If you commute to the office, we recommend 72 hours off. For light exercise such as walking briskly, you can expect to be able to do that at the 5 day mark. After the one week mark, the recovery tends to be “as tolerated”. If you are able to tolerate activity, then you can try to do it, and as long as you are wearing the compression garment. You will see some results at the three week mark, and good results around the 6 week mark. You will need to wear compression for 4-6 weeks after surgery.

Scarring from abdomen lipo incisions.

In general , the incisions of abdominal liposuction are small and heal well. The umbilicus is often used as an entrance point to hide the scars. Two lower abdomen incisions are also commonly used, one on each side, which tend to be 4mm (about 1/8 of an inch) long and tend to fade well over time.

Conclusion

Abdomen liposuction is one of the more popular liposuction procedures as both men and women look for a narrower waistline and more accentuated muscular look. It is important to consult with an experienced doctor as the results in this area is dependent on both the surgeon’s experience and their ability to evaluate whether the patient is a good candidate for the procedure since their effectors such as muscle laxity and skin laxity that often come into play.