MUSCULAR ETCHING: ENHANCING MUSCULAR CONTOUR THROUGH DIFFERENTIAL LIPOSUCTION 

MUSCULAR ETCHING: ENHANCING MUSCULAR CONTOUR THROUGH DIFFERENTIAL LIPOSUCTION

Presented at the Texas Society of Plastic Surgeons, Grand Cayman Islands January 1995.

AUTHORS: Henry A. Mentz, III, M.D. , FACS, FICS

AFFILIATIONS:
Associate Clinical Teaching Staff, Division of Plastic Surgery, Baylor College of Medicine Houston , Texas
Associate Clinical Teaching Staff, Division of Plastic Surgery, St. Joseph Hospital Houston , Texas

ABSTRACT:
Abdominal etching is a technique developed to improve the muscular contour of the abdomen in body builders. This technique enhances muscle contour by removing fat with liposuction at specific levels and in specific areas, enhancing the natural landmarks. A modification of this technique has been utilized successfully in less athletic patients to enhance their muscular appearance. Aggressive removal of fatty tissue lateral to the linea semilunaris and at the linea alba defines the rectus muscle contour. Leaving a moderate pad of fat over the rectus muscle augments the muscular bulk and enhances the natural appearance. Patients must be selected with specific attention to individual goals, long-term expectations, percent body fat, and present muscular contour. More than 20 patients have received this modified muscular etching technique with excellent results.

KEY WORDS: Abdominal, differential, etching, liposculpture, liposuction, superficial

INTRODUCTION:
Male and female patients frequently seek consultation for abdominal liposuction to improve abdominal contour. Most patients are interested in reduction of the abdominal fat pad and in achieving a more athletic appearance. Traditional liposuction of the abdomen uses deep liposuction, preserving a subcutaneous pad of fat to minimize irregularities. This technique typically produces a generalized reduction of the abdominal fat pad but also produces a plate-like abdomen that can leave an unnatural or operated appearance.

Abdominal Etching is a technique developed to provide a "washboard" abdomen in body builders. It has been most successful in selected patients with less than 15% body fat, professional body builders, and patients with appropriate long-term expectations. We have not found this technique useful for the "weekend athlete." In these patients with inadequate muscular bulk and fluctuating weight, this technique can leave excess contouring if patients add weight. Secondly, if the patient is not sufficiently muscular, the result may appear artificial. Because of these reasons, the abdominal etching technique has been modified for patients who wish for a muscular, healthy abdomen but are not dedicated athletes committed to lifetime fitness.

Patients must be selected carefully, and preoperative patient marking must be accurate. Modified Abdominal Etching utilizes differential liposuction. Lateral to the rectus muscle, the abdominal fat pad is thinned aggressively, and over the rectus muscle, the fat pad is left thicker, augmenting the patient's natural muscular anatomy. The linea alba above the umbilicus and the lateral edge of the rectus are "etched" to further define the rectus. Special techniques are utilized in the periumbilical area to prevent residual periumbilical fat or a periumbilical "doughnut." The cannulas used are chosen depending on the amount of fibrous tissue present.

PATIENTS AND METHODS:
This study reviewed patients treated with modified abdominal etching. All patients chosen were healthy males and females in good or excellent physical condition who wanted a reduction in their abdominal fat and a more athletic appearance. All patients were thoroughly examined, and the risks and benefits of the operation are discussed in detail.

On the morning of surgery, markings are carefully drawn with the patient in the standing position. Abdominal flexing may be necessary to outline the landmarks. The linea alba, the linea semilunaris, and the liposuction incision points are accurately outlined. These incisions are usually placed in the umbilicus and at the right and left sides of the pubic hair. The abdomen is also marked topographically. If the flanks are also to be reduced, this is marked and incision points are placed just lateral to the anterior superior iliac spine and sometimes posteriorly, low on the buttock.

A #11 blade is used to make small 2 mm punctures. The punctures are stretched with an iris scissor. An infusion pump and 2 mm infusion cannula are utilized to instill the tumescent fluid. The mixture consists of one liter normal saline, one cc of 1:1000 epinephrine, 50 cc of 1% lidocaine, and sometimes one cc of 10 mg/cc Kenalog. The Kenalog is given to provide a speedier reduction of postoperative edema and to reduce postoperative bruising. One to two liters of solution are typically needed with 15 minutes allowed for vasoconstriction. When more areas are treated, the lidocaine component is often reduced to 25 cc of 1% lidocaine to reduce the total lidocaine dose.

At intervals throughout the surgery, the pad thickness should be checked for symmetry and evenness. The intraoperative results closely correlate with the final results. Superficial erythema, especially in the etched areas, is often seen intraoperatively. Horizontal etching at the intertendinous insertions should only be done on patients that fit criteria for the abdominal etching technique. The incisions are left open to drain.

Special bandages are applied with the application of Benzoin. Adhesive foam is applied to these areas and a binding garment is applied. Patients keep the foam in place for one week and shower with the foam in place. The foam is then dried with a towel before placing the garment. The garment is used for at least two weeks, and the foam falls off usually within a week or two. As the foam loosens, the edges can be trimmed. Exercise is allowed five days after surgery.

RESULTS:
More than 20 patients were treated with Abdominal Etching and Modified Abdominal Etching over an 18-month period. Patients had extensive preoperative counseling and consultation discussing short- and long-term expectations. All surgery was done as day surgery, and garments were used from two to six weeks. There were no instances of seroma formation, skin loss, or major complication. Early in the series the periumbilical excess or "doughnut" appeared in patients with moderate reduction of abdominal fat. This was eliminated with vigorous liposuction in this area. Skin laxity, particularly above the umbilicus, did cause postoperative wrinkling in older and sun-damaged patients.

Problems with unevenness were seen below the umbilicus where great care must be observed in evaluating intraoperative thickness. In regard to the abdominal wall thickness, the fat pad overlying the rectus muscle should be left thicker near the xiphoid and gradually thinned toward the pubis. This contributes to the illusion of a flatter lower abdomen relative to the upper abdomen.

DISCUSSION:
Generally, as liposuction is performed, the goal of a smooth, even fatty layer is most important. Contour irregularities on the abdomen are easily created and are readily visible. Problems with the skin excess and wrinkling make the abdomen a more difficult area for liposuction. Many surgeons plan to leave a centimeter of fat pad thickness under the skin to buffer irregularities and prevent skin wrinkling. This technique does not accomplish the goals of many young athletic patients. Furthermore, generalized liposuction can leave the abdomen too flat, revealing an operated or unnatural appearance.

Differential liposuction is another approach to abdominal liposuction. 1 Leaving a thicker fat pad over the rectus muscle with muscular etching at the midline and lateral edges can recreate the athletic abdomen. Differential liposuction is also be used to prevent residual deformities. Residual periumbilical fat is a postoperative complication of generalized liposuction. In moderate and large liposuction, the periumbilical area is an area that occasional is left with a "doughnut" deformity. This can be caused by leaving an even thickness in a conical shaped periumbilical area, and as the surrounding skin flattens, the periumbilical skin and fatty tissue bunch to form a ridge. This bunching eventually leaves an area thicker than the surrounding abdominal fat pad and causes a residual excess of fat surrounding the umbilicus. This can be avoided by excessively thinning the fat pad in a fluted umbilicus to allow skin retraction and prevent bunching.

There are seven important principles of muscular etching:

1) Thorough counseling is necessary to discuss patient expectations and goals. Long-term questions of future weight changes, irregularities, and possible metabolic effects of liposuction are discussed.

2) Preoperative marking is important. The patient is marked with a permanent marker while in a standing position. Intermittent flexing of the abdominal muscles can assist the marking process. The patient is allowed to check the marks in the mirror to confirm the approach.

3) Superficial tumescent or pressurized infusion technique liposuction is used. This technique reduces blood loss, reduces contour irregularities, improves postoperative volume depletion, and reduce s postoperative pain.

4) Cannulas are specifically chosen for each area. Small Mercedes cannulas can be used when the fat aspirates easily. More aggressive open cannulas can be used if the tissue is more fibrous. The etching cannula is most aggressive and should only be used for the areas of linear etching. The etching cannula has beveled edges that cause subdermal trauma when directed toward the skin surface. This internal dermabrasion may assist with skin contraction.

5) Careful and frequent monitoring of tissue thickness by the pinch method helps prevent gouging and dimples. Areas of unevenness can be smoothed by cross-tunneling without suction.

6) Wounds are left open so that serosanguinous fluid can drain. This reduces postoperative

CONCLUSION:
Abdominal Etching was designed specifically for the body builder to enhance highly developed abdominal musculature. The modified muscular etching technique utilizes differential liposuction to create an athletic abdomen in noncompetitive and weekend athletes. The procedure has minimal risks and is performed easily. The surgeon reduces the abdominal fat, creating planned thickness variations in the abdominal fat pad based on the patient's anatomy. The patient's athletic appearance is enhanced by redefining the muscular bulk and edges through modified abdominal etching.

REFERENCES:

. Mentz HA, Gilliland MD, and Patronella CK: "Abdominal Etching: Differential Liposuction to Detail Abdominal Musculature" Aesthetic Plastic Surgery 17:287-290, 1993.

. Lewis CM: "Early Experience of Aspirative Lipoplasty of the Abdomen" Aesthetic Plastic Surgery. 11:33-40, 1987.

. Gilliland MD, Mentz HA, Patronella CK: "Major Liposuction Without Blood Transfusion: A Prospective Study in 122 Patients" Paper Presented to the American Society of Aesthetic Plastic Surgery, Boston , Massachusetts , April 1993.

. Gilliland MD, Mentz HA, Patronella CK: "Major Liposuction Without Blood Transfusion: A Prospective Study in 167 Patients" Presented to the 12th Congress of the International Society of Aesthetic Plastic Surgery. Paris , France . September 1993.

. Gilliland MD, Mentz HA, Patronella CK: "Abdominal Etching: Utilizing Differential Liposuction for Detailed Skin Retraction" Presented to the 11th Annual Meeting of the Lipoplasty Society of North America . New Orleans , Louisiana . September 1993.

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For additional information on this Research article, please contact:

Henry Mentz, MD, FACS, FICS
(713) 799-9999

Source: Henry Mentz III, MD, FACS, FICS
http://www.drmentz.com

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