High-definition abdominal liposuction with silicone tubing

Introduction: Recently, some authors have described high definition liposuction in the abdominal region, achieved by the vigorous marking of the grooves of the linea alba, linea semilunaris, and transverse tendinous intersections within the rectus abdominis muscle. The aim is to present a pilot study of high-definition abdominal liposuction technique using conventional material and silicone tubing in the dressings . Methods: Twenty cases were submitted to conventional liposuction, followed by superficial liposuction under the linea alba, linea semilunaris, and tendinous intersections, until a groove was formed at these sites. Flexible silicone tubing was externally fixed with Micropore tape in the linea alba, bilateral linea semilunaris, and tendinous intersections, and removed after 5 days. Results: A mean increase of 20 minutes was required to perform these steps. The marks of the silicone tubing were evident at the first follow-up, and less prominent at the second follow-up. No color change, ischemia, or significant pain was observed using this technique. After 3 months, there were no cases of dermatitis, cutis marmorata, seroma, infection, contour irregularity or need for additional procedures. Conclusion: High-definition abdominal liposuction was performed using conventional materials and externally fixed temporary silicone tubing.

is economically accessible, with satisfactory aesthetic results and low incidence of complications.

OBJECTIVE
To describe a superficial abdominal liposuction technique for the linea alba, linea semilunaris, and transverse tendinous intersections within the rectus abdominis muscle using conventional liposuction material, followed by dressings incorporating soft silicone tubing.

METHODS
This prospective pilot study included 20 patients (19 women and 1 man), who underwent abdominal liposuction under general anesthesia by the same surgeon.
All patients were marked on the abdominal region and other areas planned for liposuction, using a hydrographic pen on the day of surgery.The linea alba, linea semilunaris, and tendinous intersections within the rectus abdominis muscle were identified by abdominal contraction and marked in green (Figure 1).

INTRODUCTION
In 1993, Mentz et al. 1 were the first to perform superficial liposuction to define the abdominal musculature, and suggested the use of superficial liposuction in the linea alba, linea semilunaris, and transverse tendinous intersections, without use of foams or other material to better define the abdominal lines.
In 2003, Hoyos & Millard 2 introduced the concept of high-definition liposculpture, refining the original concept 1 for a 3-dimensional approach, in which not only the abdomen, but also the back, arms, and legs were treated using third-generation ultrasonic liposuction (Vaser).
Reston ® foam has been used in liposuction [3][4][5] .Despite the benefits, the application only lasts approximately 30 minutes, in addition to being associated with other problems 4,6,7 such as allergic dermatitis, blister formation, and postoperative hyperpigmentation.
Super-saturation of the abdominal region was performed with saline solution combined with epinephrine at a concentration of 1:500,000 and lidocaine at a concentration of 0.05%.
Liposuction was performed below (deep liposuction) and above (superficial liposuction) Scarpa's fascia, using 60-mL syringes in the usual manner, with cannulas 4 mm in diameter and 30 and 35 cm in length.
Liposuction was then performed under the linea alba and linea semilunaris, above Scarpa's fascia and close to the deep dermis (Figure 2), with the same 4-mm cannulas, but with the holes facing the dermis and using the contralateral hand for gripping and vigorous extra fat removal, until the formation of a groove was obtained in these locations, confirmed by the surgeon with a pinch test.
In the male patient, three 3-mm incisions were also made in the supraumbilical linea alba for superficial subdermal liposuction below the tendinous intersections of the rectus abdominis muscle, using 3-mm diameter cannulas, until groove formation was observed.
Next, 20% tincture of benzoin and 7-mmdiameter flexible empty silicone tubing were placed at the contour of the linea semilunaris (Figure 3) and the rectilinear supraumbilical linea alba; the tubing was fixed vertically with Micropore tape over the full length of the treated area (Figure 4).
The hollow silicone tubing was kept occluded for 5 to 6 days and then removed, but shapewear was maintained for 30 days.All patients underwent manual lymphatic drainage for a period of 30 days, starting at a variable period of 3 to 6 days.
Follow up was performed with clinical and photographic examination at 4-6 days, 3-4 weeks, and 3 months after surgery.

RESULTS
The additional superficial liposuction of the linea alba and linea semilunaris added an average time of 15 minutes to the procedure.Use of dressings with silicone tubing added 5 minutes.
The marks of the silicone tubing were very evident at the first follow-up, and were less prominent at the second follow-up.No color change, ischemia, or significant pain was observed with this technique.
After 3 months, the results were considered good (Figures 5 to 8), with no cases of cutis marmorata, dermatitis, seroma, infection, contour irregularity, or need for additional procedures.

DISCUSSION
In 2012, a randomized, blinded, controlled clinical trial 7 compared conventional liposuction with Vaser liposuction, and concluded that there is more retraction and less blood loss with Vaser, but no change in outcome in terms of pain, edema, or adverse effects.This work was limited in its validity 8 due to sampling methodology, financial conflicts, and commercial bias.The study also described the occurrence of seromas, burns, and prolonged edema, in addition to a longer learning curve and greater investment for equipment 9,10 .
The technique advocated in this study differs from those previously described by using silicone tubing, not previously described for use in liposuction dressings.The tubing is hollow and thin (7-mm diameter), and used in pre-planned locations, especially at the linea semilunaris, where the wavy shape helps the skin to adhere directly in the muscular plane; this enhances the appearance of the abdominal musculature, with a more natural final result, besides avoiding possible complications with foams, as previously described [3][4][5][6] .This technique required little additional surgical time, especially when compared to use of Reston ® and ultrasonic or laser liposuction, to achieve greater abdominal refinement.
This method can be added to any conventional liposuction technique, whether performed with syringe, aspirator, or vibro-liposuction, and can be used by any plastic surgeon familiar with liposuction who wants to achieve greater anatomical definition of the abdomen.
Both the medical team and patients reported greater satisfaction with this technique, compared to that without a high-definition approach.
The cases in this pilot study remain in follow-up for long-term evaluation with statistical analysis.

CONCLUSION
This study described the technique of superficial abdominal liposuction at the linea alba, linea semilunaris, and transverse tendinous intersections within the rectus abdominis muscle, using conventional liposuction material, followed by dressing that incorporated silicone tubing and shapewear.

Figure 1 .
Figure 1.Markings made on the day of surgery.Black: the usual liposuction markings.Green: markings at the linea alba and linea semilunaris for greater definition, with greater removal of fat by superficial subdermal liposuction.

Figure 3 .
Figure 3. Flexible, 7-mm hollow silicone tubing positioned at the contour of the linea semilunaris, to enhance adhesion of the skin to the aponeurosis.

Figure 2 .
Figure 2. Liposuction under the linea semilunaris, close to the deep dermis, using 4-mm cannulas with the holes facing the dermis.The contralateral hand is used for gripping and additional fat removal, forming a groove in these places.

Figure 4 .
Figure 4. Image of final dressing, with silicone tubing positioned on the linea alba and linea semilunaris and fixed with vertical Micropore tape.