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Classification for Indications of
Lipoabdominoplasty and Its
Variations
Wilson Novaes Matos Jr, MD; Ricardo Cavalcanti Ribeiro, MD; Ricardo Alves Marujo,
MD; Rogerio Porto da Rocha, MD; Sergio Miguel da Silva Ribeiro, MD; and
Fernando V. Carrillo Jiminez, MD
Drs. Matos and Cavalcanti Ribeiro are Professors in the Postgraduate Course in Plastic Surgery at Santa Casa General Hospital (CESANTA) in Rio de Janeiro,
Brazil. Drs. Jiminez and da Silva Ribeiro assisted Dr. Matos with the manuscript. Dr. Marujo is in private practice in São Paolo, Brazil. Dr. Porto da Rocha is
Professor of Anatomy at the University of Medicine of Santos in São Paolo, Brazil. The authors are all members of the Brazilian Society of Plastic Surgery.
Background: Lipoabdominoplasty, the combination of lipoplasty with classical abdominoplasty, presents new opportunities
for the treatment of abdominal lipodystrophy.
Objective: The author analyzed 211 patients who underwent lipoabdominoplasty from 2000 to 2004.
Methods: After the preoperative physical examination, the patients were classified into 9 different groups according to the
indications for the most appropriate technique in each case. Patient groups ranged from those presenting with mild fat panniculus and good quality skin to massive weight loss patients with a high degree of flaccidity. Techniques used in treating the
various patient groups included lipoplasty alone, 3 variations of lipominiabdominoplasty, 4 variations of lipoabdominoplasty,
and abdominoplasty alone. The surgical principles used in the variations of lipoabdominoplasty included dissection and sculpturing of the subcutaneous deep layer and superficial layer through lipoplasty, selective undermining and plication of the anterior rectus sheath, preservation of the perforator vessels, preservation of Scarpa’s fascia and deep fat, skin resection, and
umbilical transposition.
Results: Two hundred eleven patients were treated between January 2000 and May 2004. Results were good, with high
patient satisfaction regardless of variations in technique. There was no loss of sensibility in the suprapubic region in any
patients. Among patients who underwent lipoabdominoplasty, there were low complication rates of epidermolysis (1.5%),
seroma (1%), hematoma (1%), and necrosis (0.1%). There was no incidence of seroma, necrosis, or hematoma in the lipominiabdominoplasty subgroups I and II; in subgroup III, there was a 2% incidence of necrosis. Seroma was noted in 2% of
patients who underwent reverse lipominiabdominoplasty. Similar low complication rates were observed in other groups.
Conclusions: The classification of lipoabdominoplasty indications offers good options for treatment of the abdominal region.
Lipoplasty, selective undermining, and maintenance of Scarpa’s fascia help reduce surgical trauma that is the main factor
affecting hematoma and necrosis rates. The learning curve for these classifications is fast because the described procedures are
already familiar to most plastic surgeons. (Aesthetic Surg J 2006;26:417–431.)
A
bdominal plastic surgery has evolved greatly since
Callia’s1 original description in 1965, in response
to demands for better results, smaller scars, faster
postoperative recovery and, above all, fewer postoperative complications. The introduction of lipoplasty, first
reported by Illouz2 in 1980, revolutionized the treatment
of lipodystrophy in all regions, and particularly in the
abdominal area. Papers associating lipoplasty with
abdominal plastic surgery involving a small skin resection
were published by Hakme3 1985 and by Wilkinson4 in
1986. Several studies suggested clinical and therapeutic
classifications for the treatment of abdominal lipodystrophy.5-7 The first description of the association between
lipoplasty and full abdominoplasty was reported in 1991
by Matarasso,8,9 who performed lipoplasty of the abdominal flap with wide undermining and classified the areas
that could be aspirated.
In 1992, Illouz10 described an abdominoplasty without undermining after abdominal lipoplasty, naming it
“mesh undermining,” with restricted indications. In
1999, Shestak11 published papers in which he associated
lipoplasty, partial removal of suprapubic skin, and
restricted undermining. In 1999 and 2000, Avelar12,13
proposed the overall treatment of the abdominal subcutaneous fat pad with deep lipoplasty, without undermining and without fat pad resection, using video
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Table 1. Classification of lipoabdominoplasty and variations
Procedure
Subgroup
Skin
Muscles
No flaccidity
No diastasis
I: Lipoplasty, suprapubic
resection with or without
lower plication
Light/mild infraumbilical
flaccidity
With/without lower
diastasis
II: Lipoplasty, suprapubic
resection and total or
infraumbilical plication,
downward traction of the
umbilicus
Light/mild infra- and
supraumbilical flaccidity
Partial or total diastasis
III: Lipoplasty, suprapubic
resection, plication,
transposition of the umbilicus
Mild infra- and supraumbilical
flaccidity, high umbilicus
Partial or total diastasis
Lipoabdominoplasty
Lipoplasty, total plication,
supraumbilical resection
Excessive skin over entire
abdomen
Total diastasis
Classic abdominoplasty
Dermolipectomy, herniorrhaphy,
plication
Excessive skin over entire
abdomen
Diastasis, ventral hernia
Lipoplasty
Lipominiabdominoplasty
Figure 1. Lipoabdominoplasty classification. A, Lipominiabdominoplasty, Type I; B, Lipominiabdominoplasty, Type II; C, Lipominiabdominoplasty,
Type III; D, Lipoabdominoplasty; E, Reverse lipoabdominoplasty; F, Vertical lipoabdominoplasty; G, Anchor lipoabdominoplasty; H, Postbariatric
lipoabdominoplasty.
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A
B
Figure 2. Lipominiabdominoplasty Type I. A, After deep and superficial lipoplasty of the abdominal region, Scarpa’s fascia is visible, preserved with the
deep fat tissue. B, An elliptical incision is made in Scarpa’s fascia for performance of the rectoabdominal muscle plication in the inferior abdominal region.
A
B
Figure 3. Lipominiabdominoplasty Type II. A, After deep and superficial lipoplasty of abdominal region, Scarpa’s fascia is visible, preserved with the
deep fat tissue in the hypogastrium. B, Umbilical suture in the midline before rectoabdominal plicature in patients with superior abdominal skin flaccidity.
endoscopic diastasis suturing,14 with suprapubic and
partial inframammary skin removal for the upper
abdomen, without transposing the navel. And in 2001,
Saldanha15,16 proposed the association of lipoplasty with
classical abdominoplasty through performance of selective flap undermining, suturing of the rectoabdominal
muscles, complete resection of the infra-umbilical skin,
and umbilicus transposition, naming his technique
“lipoabdominoplasty.”
Since 2000, we have used this technique to treat the
abdominal region. The varied indications were the basis
for changes in surgical strategy and technique, depending
Classification for Indications of Lipoabdominoplasty
and Its Variations
on the need for treatment of the abdominal structures.
The classification of lipoabdominoplasty indications
enabled us to standardize and systemize the associated
lipoplasty and classic abdominoplasty techniques. It is
based on 5 surgical phases:
1. Dissection and sculpturing of the subcutaneous
deep layer and superficial layer through lipoplasty.
2. Selective undermining and plication of the anterior
recti sheath.
3. Preservation of the perforator vessels.
4. Preservation of Scarpa’s fascia and deep fat.
5. Skin resection and umbilical transposition.
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A
B
Figure 4. Lipominiabdodminoplasty Type III. After deep and superficial lipoplasty of the entire abdomen, selective undermining was performed in the
area of diastasis for plicature. Scarpa’s fascia is visible, preserved with the perforant vessels in the inferior abdomen. B, An enlarged skin incision was
made in the infraumbilical region (hypogastrium), resulting in a vertical scar. Then extended elliptical resection of the suprapubic skin was performed
with transposition of the umbilicus and omphaloplasty. The umbilical oriface was closed, leaving a 3- to 4-cm scar at the hypogastrium region.
Based on this analysis, we propose a new clinical-therapeutic abdomen classification to indicate the best technique for each case (Table 1, Figure 1).
During the physical examination, we took note of
skin features, such as elasticity, laxity, wrinkles, surface
irregularities, and presence of scars. The position of the
navel, its distance in relation to the pubis and xyphoid
appendix, and scarring in the hypogastrium were used as
initial parameters to indicate the amount of skin to be
removed and the future positioning of the umbilical scar.
The thickness, the amount, and the disposal of the fatty
tissue were evaluated to estimate the amount of fat to be
aspirated. We also diagnosed the presence, degree, and
localization of rectoabdominal diastasis for plication
(supraumbilical or infraumbilical localization) to better
determine the best technique to be used. Body contouring lipodystrophies in other areas, such as the flanks, gluteus, sacrum, and pubis, were also evaluated.
loss, and previous pregnancies can result in flaccidity,
stretch marks, and loss of dermis elasticity. The subcutaneous abdominal tissue is divided into 2 layers, separated by Scarpa’s fascia. The areolar or the superficial
layer is composed of small, firm, and compact
adipocytes. The lamellar or deep layer, composed of
regular and loose globules, 17 is where the largest
amount of fat is found in abdominal lipodystrophy,
and is thus the main layer to be treated. The rectoabdominal muscles are involved by aponeuroses that cross
the midline; at this region, we observe flaccidity and
diastasis of those muscles. According to Taylor,18 80%
of the abdominal wall blood supply comes from the
abdominal perforating branches of the lower and upper
epigastric arteries. The other 20% comes from the
intercostal arteries, loin arteries, and upper external
iliac arteries. The lymph vessels run to the inguinal
regions and armpits. Innervation is provided by the last
6 intercostal nerves and the great and small abdominogenital nerves.
Applied Anatomy
Surgical Technique
The skin has particular attributes with respect to
elasticity, thickness, and mobility. Alteration of the
cutaneous tissue by factors related to obesity, weight
Saline solution and epinephrine at a concentration of
1:1,000,00017 were infiltrated. The abdomen was aspirated by the “scanner” technique, with the cannula
Preoperative Evaluation
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A
B
C
D
Figure 5. Lipoabdominoplasty. A, Deep and superficial lipoplasty. B, Lipoplasty of the superficial layer in the inferior abdomen with Scarpa’s fascia
and the fat deep tissue preserved. Selective undermining was performed with a bistoury only in the diastasis region of the rectoabdominal muscle for
plication in the superior abdomen and elliptical incision of Scarpa’s fascia in the inferior abdomen for the plicature. C, Rectoabdominal plicature and
Scarpa’s fascia suture. Deep fat tissue over the inferior abdomen. D, Final result before elliptical skin resection and omphaloplasty.
A
B
Figure 6. Anchor lipoabdominoplasty. A, Marking of the skin resection before lipoplasty. B, Skin resection after lipoplasty without flap undermining.
Classification for Indications of Lipoabdominoplasty
and Its Variations
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A
B
C
D
Figure 7. A, C, Preopererative views of a 36-year-old woman with 1 previous pregnancy, mild abdominal lipodystrophy, and a flaccid inferior abdominal region. B, D, Postoperative views 8 months after lipominiabdominoplasty Type I and lipoplasty of the flanks and legs.
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A
B
Figure 8. A, Preoperative view of a 48-year-old woman with 2 previous pregnancies, previous breast augmentation, and inferior diastasis of the rectoabdominal muscles. B, Postoperative view 13 months after lipominiabdominoplasty Type I with plicature. Her breast implants were also replaced
with round, high-profile silicone gel implants placed under the muscle.
holes turned laterally, using short circular movements
into the superficial and deep layers rather than conventional undermining.
Infra-umbilical skin resection, plication of the rectoabdominal muscles, and mobilization of the umbilicus were performed, depending on the circumstances of
each case. Scarpa’s fascia was always preserved, except
in the classic abdominoplasty, to keep the superficial
fatty layer flat, preserving lymphatic drainage and
suprapubic sensibility. Aspirative drainage was used
postoperatively, with the closed suction drain placed
into the selected undermining region and removed by
the third to fifth postoperative day in all cases in which
lipoplasty was performed.
Lipominiabdominoplasty I
This technique was considered for patients who presented with light or mild skin flaccidity in the infraumbilical region, with or without inferior diastasis. After
lipoplasty of the abdomen and surrounding areas was
performed, an elliptical fuse of skin located in the suprapubic area,19 as well as the entire superficial fatty layer,
was removed in such a way that the flap was advanced
over the preserved Scarpa’s fascia (Figure 2, A). When
inferior abdominal diastasis was present, Scarpa’s fascia
was removed at the medial line to perform the rectoabdominal muscle plication in the inferior region and
suture the superficial fascia borders (Figure 2, B).
Lipominiabdominoplasty II
Lipoplasty
Lipoplasty was indicated exclusively for those patients
who presented with a light or mild fat panniculus and
good quality skin.
Classification for Indications of Lipoabdominoplasty
and Its Variations
This procedure was indicated for patients with light
or mild skin flaccidity at the upper and lower abdomen
in whom partial or total diastasis and high positioning of
the umbilical scar were present. After lipominiabdomino-
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A
B
C
D
Figure 9. A, C, Preoperative views of a 45-year-old woman with 1 previous pregnancy, an inferior scar, abdominal lipodystrophy, excessive skin, and
diastasis of the rectoabdominal muscles. B, D, Postoperative views 1 year after lipominiabdominoplasty Type II and lipoplasty of the waist.
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A
B
C
D
Figure 10. A, C, Preoperative views of a 42-year-old woman with 2 previous pregnancies, an inferior scar, abdominal lypodistrophy, excessive skin,
and diastasis of the rectoabdominal muscles. B, D, Postoperative views 1 year after lipominiabdominoplasty Type III, breast augmentation, and
lipoplasty of the waist.
Classification for Indications of Lipoabdominoplasty
and Its Variations
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A
B
C
D
Figure 11. A, C, Preoperative views of a 45-year-old woman with 3 previous pregnancies, an inferior abdominal scar, excessive skin, and diastasis of
the rectoabdominal muscles. B, D, Postoperative views 1 year after lipoabdominoplasty and associated mastopexy.
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A
B
Figure 12. A, Preoperative view of a 68-year-old woman with 2 previous pregnancies, 7 scars from previous surgery, excessive skin, and diastasis of
the rectoabdominal muscles. B, Postoperative view 16 months after anchor lipoabdominoplasty.
plasty as described previously, the umbilicus was “floated” by cutting it free from the underlying fascial
attachments. Selective upper undermining at the region
of diastasis for the plication was performed, and the
umbilicus was repositioned 2 to 5 cm lower and
sutured20 (Figure 3). Excessive skin at the lower region
was removed by means of a suprapubic elliptical fuse.
This technique could only be used in patients whose
umbilicus position was originally high in relation to the
pubis. Its goal was to treat the light or mild upper abdominal skin flaccidity that might occur after lipoplasty.
Lipominiabdominoplasty III
A lipominiabdominoplasty III was performed in
patients with relevant skin flaccidity at the supra- and
infra-umbilical region who lacked sufficient excess skin
to enable flap traction to the pubic region because of a
high umbilicus position. After lipoplasty, selective undermining at the midline, and partial or total plication, an
Classification for Indications of Lipoabdominoplasty
and Its Variations
extended elliptical resection of suprapubic skin was performed, followed by transposition of the umbilicus and
omphaloplasty. The umbilical orifice was closed, leaving
a 3- to 4-cm scar at the hypogastrium region (Figure 4).
Lipoabdominoplasty
Lipoabdominoplasty was indicated for the patients with
skin flaccidity over the entire abdomen and light to severe
lipodystrophy with or without abdominal muscle diastasis.21 After aspiration of the deep and superficial abdomen
and flanks layer, the umbilicus was isolated and the infraumbilical skin was resected as in a traditional abdominoplasty, preserving Scarpa’s fascia, the venous, arterial, and
lymphatic vessels, and the innervation. Selective undermining at the medial diastasis area was performed close to the
internal rectus abdominis muscle borders, preserving the
abdominal perforating vessels. The partial resection of
Scarpa’s fascia at the mid infra-umbilical line exposed the
aponeurosis for conventional plication of the entire muscle
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A
B
C
D
Figure 13. A, C, Preoperative views of a 42-year-old woman with 3 previous pregnancies and 60-kg weight loss. B, D, Postoperative views 1 year after
lipoabdominoplasty, mastopexy, and lipoplasty of the waist.
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diastasis. The navel was transposed to achieve the “starshaped” omphaloplasty.15,16,23 Closing of the abdomen was
performed in 3 planes: the superficial fat, deep dermis, and
superficial skin (Figure 5). In cases of difficult traction, it
was possible to complete the procedure with a small inverted “T” scar at the lower region.24,25
Lipoabdominoplasty in the atypical abdomen
In patients with atypical abdominal variations related to
the presence of pre-existing scars in the abdomen or to massive weight loss, we adapted the techniques in the previously
described categories to the individual needs of each case.
Table 2. Incidence of the indications
Surgical technique
% of indications
Lipoabdominoplasty
Lipoabdominoplasty in atypical
abdomen
Lipominiabdominoplasty I
Lipominiabdominoplasty III
Lipominiabdominoplasty II
Classic abdominoplasty–herniorrhaphy
79.65
9.95
4.73
2.84
1.89
0.94
Results
Reverse lipoabdominoplasty and anchor or vertical
abdominoplasty
In treating patients who had undergone massive
weight loss, in whom great skin excess and adipose tissue
were present, we performed the lipoabdominoplasty,
using lipoplasty to undermine and thin out the flap,
removing the skin according to the need of each case. A
fuse of Scarpa’s fascia and deep fatty layers may be
removed from the midline. The borders were sutured,
even in those cases when there was no need to expose the
aponeurosis for the plication. In this group of patients,
we found atypical individual variations. Physical examination and abdominal ultrasound may diagnose hernias
and scar adherences in the abdominal wall, which would
contraindicate lipoplasty.
Two hundred eleven patients underwent lipoabdominoplasty, lipominiabdominoplasty, or classical
abdominoplasty between January 2000 and May 2004.
Patient ages ranged from 28 to 69 years; all but one were
female. We observed good results and high patient satisfaction with respect to abdominal profile appearance
(Figures 7-13). Regardless of variations in technique, the
abdomen was better modeled due to the use of lipoplasty
to decrease the thickness of the adipose tissue.
In the lipominiabdominoplasty subgroups Types I and
II there was no incidence of seroma, necrosis, or
hematoma. In the lipominiabdominoplasty subgroup
Type III there was a 1% incidence of necrosis.
Low complication rates for epidermolysis (1.5%),
seroma (1%), hematoma (1%), and necrosis (0.1%)
were noted for patients who underwent lipoabdominoplasty.31 We observed that the final scar is smaller than
with classical abdominoplasty. There was no loss of sensibility in the suprapubic region in any patients. Overall,
patients were able to return to their routine activities
approximately 15 days postoperatively.
We also found a low complication rate among
patients with an atypical abdomen who underwent
lipoabdominoplasty. Seroma was noted in 2% of
patients who underwent reverse lipoabdominoplasty.
Among patients who underwent anchor lipoabdominoplasty, epidermolysis was observed in 1.8% of cases,
seroma in 1%, and hematoma in 0.1%. Among postbariatric patients, complications included epidermolysis
(2.5%), seroma (1%), and hematoma (0.1%) (Table 3).
Abdominoplasty
Discussion
Lipoplasty was contraindicated in the presence of
abdominal wall hernias. In such cases, the traditional flap
undermining, herniorrhaphy, abdominal muscle plication,
and conventional dermolipectomy were performed.28-30
A thorough preoperative evaluation of the abdominal
region is essential to diagnosis, classification, and selection
of the technique most appropriate to each case. The principles and foundations of this classification system are
In patients in whom a high degree of flaccidity of the
inframammary fold was present, the excessive skin was
removed through the inframammary reverse approach
and, if necessary, selective undermining with diastasis
plication was performed.26 It was possible to associate
the suprapubic resection without transposing the
umbilicus in cases of lower region flaccidity, as
described by Avelar,12,13 Hakme,3 and Shestack.11 The
same strategy was used with skin resection in a vertical
or anchor lipoabdominoplasty, 27 depending on the
position and location of the scars, and preserving the
irrigation through the undermining by lipoplasty
(Figure 6).
Postbariatric lipoabdominoplasty
Classification for Indications of Lipoabdominoplasty
and Its Variations
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Table 3. Percentage of complications
Procedure
% Seroma
% Hematoma
% Epidermolysis
% Necrosis
0
0
0
1
2
1
1
0
0
0
0.1
0
0
0.1
0
0
0
1.5
0
1.8
2.5
0
0
1
0.1
0
0.5
0
Lipominiabdominoplasty I
Lipominiabdominoplasty II
Lipominiabdominoplasty III
Lipoabdominoplasty
Reverse lipoabdominoplasty
Anchor lipoabdominoplasty
Postobesity lipoabdominoplasty
based on preservation of the anatomy of the vascular,
lymphatic, and nervous systems of the abdominal wall,
involving the two layers of the adipose tissue and the muscular groups. Through superficial and deep lipoplasty, the
basic lipoabdominoplasty techniques, we can dissect the
two layers of the abdominal fat and reach the abdominal
flap with less trauma compared with dissection using a
bovie, which splits up the perforator vessels emerging
from the rectoabdominal muscles. Currently, this principle
is used in 99.06% of our cases (Table 2). Even in those
cases in which the adipose tissue is thin (4% of cases), we
prefer to perform divulsion with lipoplasty suction cannulas without vacuum for flap undermining.
Selective undermining performed with a bistoury only
in the diastasis region of the rectoabdominal muscle for
plication does not reach the perforator arteries, which
are located 2 cm from the rectoabdominal muscle edge.
Dissection by means of lipoplasty and selective undermining for plication replace the large-scale dissections of
conventional abdominoplasty and lipectomy. 32 Since
2000, when we began using these techniques, we have
found that they result in a broadened vascularized flap
and decrease the incidence of complications, such as
hematoma, epithelioisis, and necrosis.
The preservation of Scarpa’s fascia and of the lower
abdominal deep fat is important for the superior flap
accommodation, and it is another important foundation
of the technique, because anatomically and histologically
speaking, the lymphatic vases are more numerous in this
region.33 We believe that maintenance of the lymphatic
system through this method is the main factor in the
decrease in the incidence of seroma in the patient subgroup treated according to these principles. In those
lipoabdominoplasty cases in which Scarpa’s fascia of the
suprapubic region was removed completely, exposing the
aponeurosis, we encountered seroma and observed a difference in elevation of the lower abdomen in relation to
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the pubis. Another important result was the lack of any
sensibility loss in the lower abdomen in any of the cases.
We routinely associate lipoabdominoplasty and its variations with lipoplasty of the flanks and outer thigh and
lipografting in the gluteal-trocanterian regions, which
allows for global harmonization of the body contour. In
patients who have undergone great weight loss, lipoabdominoplasty enables thinning of the skin flap, prevents wide
undermining, improves the final result, and reduces the
complication rate. We can also apply this technique in
cases of secondary abdominoplasty, when it is necessary
to remove the fatty tissue and remaining excessive skin.
Conclusion
The preoperative evaluation and the correct indication of lipominiabdominoplasty, lipoabdominoplasty,
and variations offer good options for abdominal region
treatment, resulting in a more youthful appearance to the
abdomen with less scarring and a lower incidence of
major complications than traditional abdominal aesthetic surgery.
Resection of adipose tissue through the lipoplasty
cannula, selective undermining, and maintenance of the
scarpa fascia and deep fat permit a better preservation of
the vascular, lymphatic, and nervous systems associated
with the abdomen. The resulting decrease in surgical
trauma is the main factor in the decrease of hematoma
and necrosis rates.
The learning curve is fast because the described procedures utilize techniques and methods already familiar to
most plastic surgeons. ■
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Accepted for publication March 17, 2006.
Presented at the ASAPS/ASERF/ISAPS International Symposium, New
Orleans, Louisiana, May 4, 2005.
Reprint requests: Wilson Novaes Matos Jr, MD, Av. Ana Costa, 151 –
conj.74, Santos, São Paolo 11060, Brazil.
Copyright © 2006 by The American Society for Aesthetic Plastic Surgery,
Inc.
1090-820X/$32.00
doi:10.1016/j.asj.2006.05.003
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Classification for Indications of Lipoabdominoplasty
and Its Variations
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