Primary Vessels Causing Hemorrhage in Abdominoplasty
The primary sources of hemorrhage in abdominoplasty are the perforating vessels of the rectus abdominis muscle, particularly the superficial inferior epigastric arteries and the deep inferior epigastric arteries.
Anatomical Considerations
Major Vessels at Risk
Superficial Inferior Epigastric Arteries (SIEA)
- These vessels run superficially in the subcutaneous tissue
- They form a central superficial system that communicates with the subdermal plexus of the anterior abdominal wall 1
- Division of these vessels during abdominoplasty significantly reduces perfusion to the abdominal flap
Deep Inferior Epigastric Arteries (DIEA)
- These vessels run deep within the rectus sheath
- They provide perforating branches that supply the overlying skin and subcutaneous tissue
- Division of these perforators during flap undermining is a major source of bleeding
Peripheral Contributory Vessels
- Superficial circumflex iliac arteries
- Deep circumflex iliac arteries
- External oblique perforators 1
Mechanism of Hemorrhage
During abdominoplasty, significant vascular disruption occurs through:
Extensive Undermining
- Traditional abdominoplasty involves division of the main perforating vessels
- This causes profound devascularization of the abdominal flap
- Quantitative studies show that perfusion in the region between the umbilicus and transverse scar is reduced to only 17.2% of normal tissue perfusion 2
Vessel Transection Points
- Along the incision line at the lower abdomen
- During umbilical transposition
- At the lateral edges of the flap where the superficial circumflex iliac vessels may be encountered
Clinical Implications and Complications
Hemorrhage-Related Complications
- Hematoma formation: Occurs in approximately 12% of patients 3
- Postoperative bleeding: Reported in about 8% of cases 3
- Seroma: Most common complication (36% of patients) 3
- Skin flap necrosis: Result of compromised blood supply following vessel division
Risk Factors for Hemorrhage
- Previous abdominal surgeries (altered vascular anatomy)
- Massive weight loss patients (increased vascularity)
- Extended undermining techniques
- Combined procedures
Management Considerations
Preventive Measures
- Meticulous hemostasis during surgery
- Careful identification and ligation of perforating vessels
- Judicious use of electrocautery
- Consideration of staged procedures in high-risk patients
Thromboprophylaxis Considerations
- Abdominoplasty carries a significant risk of venous thromboembolism (VTE)
- Pharmacological thromboprophylaxis must be balanced against bleeding risk
- Studies show increased hematoma rates (29.6%) with anticoagulant use 4
- Consider mechanical prophylaxis as it is not associated with increased bleeding complications 5
Conclusion
Understanding the vascular anatomy of the anterior abdominal wall is crucial for preventing hemorrhage during abdominoplasty. The division of superficial and deep epigastric vessels and their perforators represents the primary source of bleeding in this procedure. Careful surgical technique with meticulous attention to these vessels can help reduce the risk of hemorrhagic complications.