Aesth Plast Surg (2009) 33:366–376 Anesthesia An epidural catheter is inserted in the 11–12 spinal space and connected to a continuous infusion pump. A 15-ml solution of 7.5 mg/ml ropivacaine HCl (Naropin) and 30 mg sufentanil citrate is infused into the epidural space and an analgesic solution is prepared for postoperative administration via the infusion pump (100 mg sufentanil citrate and saline solution 0.9%, 100 ml at 5 ml/h) [23]. Elastic bandages are applied to the legs to prevent throm- bovenous embolism (Fig. 4). Tumescent Inﬁltration and Assisted Liposuction All areas to be lipoaspirated and undermined are inﬁl- trated with a saline solution containing epinephrine at 1:500,000 concentration to avoid excessive bleeding. The patient is put in a prone position and the ﬂank and tro- chanteric areas are manually lipoaspirated with a 3-mm cannula. The patient is then rotated to the supine position and extended liposuction is done to the entire abdomen and epigastric areas. It is important to reach the infra- mammary region and the xiphoid appendix, extending to the condrocostal border, to fully loosen this area. For this maneuver we use an angular cannula, described by Reggazzo (personal communication), to prevent internal perforations. The only region to be avoided is the lateral superior ﬂank in order to avoid damaging the neurovas- cular bundles that give arterial, venous, and neural support to the ﬂap (Fig. 5). Supraumbilical Incision and Epigastric Tunnel Undermining A supraumbilical incision is ﬁrst done and an epigastric tunnel is undermined to the xiphoid appendix (Fig. 6). It is important to preserve the lateral superior ﬂank area and to avoid damage to the neurovascular bundles that support the entire ﬂap. We have already described this [24, 25] and proposed the miniabdominoplasty technique (Fig. 7), stressing the importance of preserving the lateral columns when undermining the long xipho-pubis tunnel and total umbilical stack section. Pull-Down Flap Approach The patient is put in the Fowler position and the ﬂap is pulled down to try to reach the inferior suprapubic line 369 Fig. 7 Lipominiabdominoplasty proposed by the author in 1987, with total amputation of the umbilicus stack and undermining of a long xipho-pubis tunnel, preserving the lateral neurovascular bundles delineated previously and to estimate whether the inferior ﬂap resection can be done en bloc without problems (Fig. 8). This maneuver is critical to determine whether the defect can be closed without stretching. The inferior suprapubic line can then be moved up or down depending on the laxness and elasticity of the skin and patient biotype. Normally, it is approximately 7–8 cm from the labia major vertex. Umbilical Stack Circumcision and Inferior Flap Block Resection After conﬁrming the safety of the pull-down approach, the patient is again placed in the horizontal position and the umbilical stack is trimmed to an elliptical shape. The suprapubic incision is done superﬁcially to avoid damaging the lymphatic vessels and the cutaneous muscle nerves that give the lateral thighs sensibility. We preserve a border of 4–5 cm of the aponeurosis superﬁcialis-scarpa fascia. Then the entire ﬂap is raised en bloc from the abdomen wall (Fig. 9). 123