Abdominoplasty

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Chapter 20 Abdominoplasty

Al Aly, Silvia Cristina Rotemberg, Albert Cram

The modern history of abdominal contouring began in 1899 with Kelly1,2 performing an abdominal apronectomy or dermolipectomy to eliminate a large abdominal pannus. In 1957, Vernon 3 described umbilicus transposition. Gonzalez-Ulloa 4 in 1959 popularized the abdominoplasty technique describe by Somalo 5 in 1946 where he resected a circular skin pattern from the lower abdominal region extending around the waist in a belt lipectomy fashion. In 1967, Pitanguy 6 presented his technique consisting of inconspicuous scars in the lower abdomen and groin, wide superior dissection up to the costal margins and xiphoid, plication of the transverse abdominal rectus muscle and umbilicoplasty. Regnault, 7 in 1972, introduced the concept of abdominoplasty in a ‘W’ pattern, and in subsequent years described modifications of the technique including a fleur-de-lis and modified belt lipectomy. Grazer, 8 in 1973, reported 44 cases of abdominoplasty hiding the incision in the bikini line. The concept of miniabdominoplasty was introduced by Elbaz and Flageul 9 in 1971, and later modified by Glicenstein 10 in 1975. The introduction of liposuction in the late 70s added a significant tool to abdominoplasty and body contouring in general. 11 Matarasso, 12,13 in the late 80s, made a significant contribution by introducing his classification scheme and by describing the incorporation of liposuction with modified abdominoplasty procedures. Lockwood, 14 in 1991, described a new concept – the superficial fascial system (SFS), which is a highly organized collagen structure responsible for anchoring the skin of the body and for supporting the weight of the fat throughout life. In 1995 he introduced a high lateral tension abdominoplasty (HLTA), which was designed to create more lateral abdominal improvement and anterior thigh elevation. 15 Within the past decade Saldanha 16 introduced and popularized ‘lipoabdominoplasty’, which has become fairly popular in South America and Europe. It is a technique that utilizes extensive liposuction of the entire abdomen combined with minimal undermining in the hope of reducing the risks of tissue necrosis and seroma formation.

Summary

1. Abdominoplasty is indicated for skin and subcutaneous tissue excess and/or laxity limited to the anterior abdomen and abdominal wall musculoaponeurotic laxity
2. Contraindications include generalized obesity, excessive intra-abdominal content, circumferential lower truncal excess, smoking, and planned pregnancy in the near future.
3. A subcostal, open cholecystectomy scar is a relitive contraindication for traditional abdominoplasty
4. Lipoabdominoplasty is an alternative technique to traditional abdominoplasty that may be safer and associated with less complications.
5. A high lateral tension abdominoplasty (HLTA) is fundamentally different from the traditional abdominoplasty in that maximum tension is created laterally, rather than centrally and it attempts to not only improve abdominal contour, but also enhance the appearance of the anterior thighs.
6. Regardless of the technique used, vascular territories are interrupted and should be taken into account, especially when upper abdominal scars are present. Zone I is supplied by the deep epigastric arcade and these vessels are almost always interrupted by flap elevation.
7. Many abdominoplasty scar patterns have been introduced over the past five decades to accommodate different clothing patterns and potential improvements in contour.
8. The surgeon has to balance the needs of limiting the width of the scar, eliminating lateral standing cones or dog-ears, and appropriately positioning the mons pubis in the vertical dimension.
9. Postoperatively patients are kept flexed, in ‘beach chair’ position, but are expected to be walking later on the day of surgery bent at the waist. They are not allowed to straighten up for 1 week after surgery.
10. Abdominoplasty is an extensive operation and complications include wound dehiscence, hematoma, wound infection (including toxic shock syndrome), seroma, tissue necrosis, contour irregularity, scarring, umbilical deformity, paresthesia, deep vein thrombosis, and pulmonary embolus.

Introduction

The modern history of abdominal contouring began in 1899 with Kelly1,2 performing an abdominal apronectomy or dermolipectomy to eliminate a large abdominal pannus. In 1957, Vernon3 described umbilicus transposition. Gonzalez-Ulloa4 in 1959 popularized the abdominoplasty technique describe by Somalo5 in 1946 where he resected a circular skin pattern from the lower abdominal region extending around the waist in a belt lipectomy fashion. In 1967, Pitanguy6 presented his technique consisting of inconspicuous scars in the lower abdomen and groin, wide superior dissection up to the costal margins and xiphoid, plication of the transverse abdominal rectus muscle and umbilicoplasty. Regnault,7 in 1972, introduced the concept of abdominoplasty in a ‘W’ pattern, and in subsequent years described modifications of the technique including a fleur-de-lis and modified belt lipectomy. Grazer,8 in 1973, reported 44 cases of abdominoplasty hiding the incision in the bikini line. The concept of miniabdominoplasty was introduced by Elbaz and Flageul9 in 1971, and later modified by Glicenstein10 in 1975. The introduction of liposuction in the late 70s added a significant tool to abdominoplasty and body contouring in general.11 Matarasso,12,13 in the late 80s, made a significant contribution by introducing his classification scheme and by describing the incorporation of liposuction with modified abdominoplasty procedures. Lockwood,14 in 1991, described a new concept – the superficial fascial system (SFS), which is a highly organized collagen structure responsible for anchoring the skin of the body and for supporting the weight of the fat throughout life. In 1995 he introduced a high lateral tension abdominoplasty (HLTA), which was designed to create more lateral abdominal improvement and anterior thigh elevation.15 Within the past decade Saldanha16 introduced and popularized ‘lipoabdominoplasty’, which has become fairly popular in South America and Europe. It is a technique that utilizes extensive liposuction of the entire abdomen combined with minimal undermining in the hope of reducing the risks of tissue necrosis and seroma formation.

Indications

Abdominoplasty

Indications

• Skin and subcutaneous tissue excess and/or laxity limited to the anterior abdomen
• Abdominal wall musculoaponeurotic laxity

Contraindications

• Generalized obesity
• Excessive intra-abdominal content
• Circumferential lower truncal excess (requires circumferential treatment)
• Unrealistic expectations
• Medical or psychiatric instability
• Smoking (considered to be a contraindication by most plastic surgeons)
• Planned pregnancy in the near future

Relative contraindications

• Previous abdominal scars compromising blood supply
• History of diabetes mellitus, chronic obstructive pulmonary disease, cardiovascular disease, thromboembolic events

Mini-abdominoplasty

Indications

• Abdominal laxity restricted to the infraumbilical region

High lateral tension abdominoplasty (HLTA)

• To improve abdominal contour and enhance the appearance of the anterior thighs

Lipoabdominoplasty

• Alternative technique to traditional abdominoplasty but may be safer and associated with less complications

Patients seeking abdominoplasty most often complain of excess skin and subcutaneous tissue in the abdomen and abdominal protrusion due to laxity of abdominal wall caused by previous pregnancy, weight fluctuations and/or aging. Many of these patients will present with lipodystrophy of the hips and lateral thighs as well.17 A traditional abdominoplasty is indicated when the deformities involve both the supra and infraumbilical regions whereas a mini-abdominoplasty is usually indicated if the problems are limited to the infraumbilical region. Although most patients are female, males do present with similar problems, but often complain of adiposity in the flank areas and supraumbilical rectus diastasis.18–20

The ideal candidate for abdominoplasty is a young healthy woman who is a nonsmoker and whose weight is within, or slightly above, the normal range. In many cases, especially in middle-aged and older women, patients present with concomitant lipodystrophy of the hips and lateral thighs, as well as the abdominal deformities. These patients are still amenable to abdominoplasty in combination with liposuction of the areas of lipodystrophy. However, if the deformities involve the lower trunk circumferentially, as in the massive-weight-loss patient or some overweight patients, abdominoplasty can have disappointing results. These patients usually require a circumferential truncal dermatolipectomy to treat their deformities.

Obese patients are not good candidates for abdominoplasty because they have excess intra-abdominal or visceral fat. The intra-abdominal cavity can be thought of as a balloon that fits inside a second external skin balloon. If the internal balloon is overly inflated by visceral fat, it cannot be effectively flattened by musculoaponeurotic plication. Thus it will maintain a convex profile, which is translated to the external balloon and will lead to a convex appearance for the entire abdomen. This defeats the major reason why most patients seek abdominoplasty surgery.

As with any elective plastic surgery procedure patients who have unrealistic expectations of the potential results should either be advised by their surgeon to change their expectations or should not be operated on. Similarly patients who present with unstable psychiatric or medical conditions should be avoided. The question about whether the risk of carrying out an abdominoplasty in an individual who has well-controlled diabetes mellitus is too high is controversial. Many surgeons consider the risk posed by the decreased ability to fight infection, potential vascular compromise, and decreased wound healing ability too high.

Smoking has been implicated in occlusive microvascular thrombosis and delayed wound healing and when associated with a procedure that already compromises the blood supply of the abdominal skin flap, can result in tissue necrosis and jeopardize the outcome. Active smokers are excluded by most surgeons, but some surgeons are willing to operate on them utilizing techniques that reduce abdominal flap elevation to reduce the risk of vascular compromise.21–23

Abdominal wall plication can increase intra-abdominal cavity pressure and this can potentiate certain problems.

• First, the increased intra-abdominal pressure may elevate the diaphragm and compromise pulmonary function, especially in patients who have chronic obstructive pulmonary disease. Thus it is important to work-up these patients and make sure that they can withstand further pulmonary stress prior to contemplating abdominoplasty surgery.
• Second, increased intra-abdominal pressure after abdominoplasty results in decreased venous blood flow through the common iliac vessels, which predisposes patients to deep venous thrombosis (DVT) and pulmonary embolus (PE). Therefore, patients with a history of DVT and/or PE should undergo a thorough evaluation for potential recurrence, and in some, surgery may be contraindicated. A temporary or traditional Greenfield filter may be considered in this instance in conjunction with a vascular surgery consultation.

Although it is always best for women to undergo abdominoplasty after they have had children and when they do not plan any more, many patients do become pregnant and have children after the procedure. Some of the benefits of abdominoplasty may be reduced or eliminated by pregnancy, thus it is wise to postpone the procedure if a pregnancy is anticipated in the near future.

Previous abdominal scars

Patients with previous abdominal scars may require special considerations if abdominoplasty is contemplated.

• McBurney-type appendectomy scars have little effect on surgical planning because they are simply resected during panniculus excision.
• Lower abdominal transverse scars, usually utilized for hysterectomy, are similarly nonproblematic because they are generally resected during abdominoplasty.
• A subcostal, open cholecystectomy scar can contraindicate a traditional abdominoplasty, with its extensive abdominal flap undermining, which reaches up to the costal margins and xiphoid. The only feeding vessels to the elevated abdominal flap in that instance consist of the lateral intercostals, subcostal, and lumbar perforator vessels, which course anteriorly in the fat superficial to Scarpa’s fascia. These vessels are interrupted by a subcostal scar and this can lead to abdominal flap necrosis inferomedial to the scar. Recently created subcostal scars, within the past 2-3 years, usually contraindicate traditional abdominoplasty. Patients who present with old subcostal scars can sometimes undergo an abdominoplasty, but with techniques that limit flap elevation.
• A midline abdominal scar does not usually prevent abdominoplasty surgery. If the scar is limited to the infraumbilical level, it will usually be removed with the abdominal panniculus and should not prevent the procedure from creating the best possible abdominal contour. If the incision is supraumbilical, it usually does not prevent the flap from being advanced appropriately. However in some patients, the scar may be hypertrophic and may restrict abdominal flap advancement during the tailoring process. In these patients resecting the scar only, without the underlying fat layers, will allow the advancement. However, even this maneuver may lead to an increased risk of flap necrosis, because dermal vessels cross over in the midline and can lead to a decrease in blood supply of the inferomedial aspects of the abdominal flap. A less risky way to attain the desired flap advancement is to create multiple small puncture stab incisions along the hypertrophic scar allowing release of the contracted tissues. If a patient desires a revision of the midline scar, it is generally best to perform that in a subsequent procedure after the flap has had enough time to revitalize its blood supply in its new position.

Mini-abdominoplasty

Indications for mini-abdominoplasty are limited to patients who present with abdominal laxity restricted to the infraumbilical region.24 The laxity has to be minimal and may be of the abdominal wall and/ or of the skin/fat envelope. Physical examination of the abdomen in the supine position will demonstrate infraumbilical rectus diastasis, which can be confirmed by the ‘diver’s test’ (see Fig. 20.1). These patients are usually young women who have had one or two pregnancies, have good skin elasticity, and are not overweight. Mini-abdominoplasty, with any of its modifications, is not a procedure that is often employed because it is the unusual patient that will fit its required criteria.

image

Fig. 20.1 The classic ‘diver’s test’. When the patient is flexed at the waist the lower abdominal musculature is relaxed enough to demonstrate laxity in the infraumbilical region.

High lateral tension abdominoplasty

An HLTA15,25 is fundamentally different from the traditional abdominoplasty in the following ways:

• maximum tension is created laterally, rather than centrally as in traditional abdominoplasty;
• HLTA attempts to not only improve abdominal contour, but also enhance the appearance of the anterior thighs by lifting that area and creating a narrowing at the waist as a result of the lateral emphasis;
• tension is maximized laterally, so the defect created by the circumumbilical incision is often not excised;
• the procedure allows for extensive liposuction of the abdominal flap because of the dependence on discontinuous undermining for flap mobilization, which leaves the flap with a more robust blood supply when compared to a traditional abdominoplasty;
• because of the emphasis on lateral tension, HLTA often requires an extension of the scar laterally to accommodate for the more aggressive lateral resection.

Lipoabdominoplasty

Lipoabdominoplasty was introduced and popularized by Saldanha16 from Brazil. This technique, with a variety of its forms, is becoming more popular around the world especially in South America and Europe. For the surgeons who espouse lipoabdominoplasty, it is an alternative technique that accomplishes many of the same goals as traditional abdominoplasty but maybe safer and associated with less complications (Box 20.1). Currently many American plastic surgeons are starting to utilize the technique in its entirety or at least in some of its main aspects. Lipoabdominoplasty has some similarities to HLTA.

Box 20.1 Theoretical advantages of lipoabdominoplasty

• Reduction in seroma rate because of a lack of abdominal wall fascia exposure, which has been implicated in increasing the risk of seromas by some authors. Also, if lymphatic tissues, especially of the femoral region, are left intact, seromas should be less likely.
• Because there is minimal elevation of the supraumbilical abdominal flap, there should be an abundance of remaining abdominal wall muscle perforators intact to supply the abdominal skin and thus decrease the risk of tissue vascular compromise.
• In cases of a thick abdominal flap, liposuction and thinning can be performed safely.

Preoperative Considerations

Preoperative evaluation of potential abdominoplasty patients includes a good history and physical examination, and determination of their primary concerns and expectations. Special attention should be paid to weight fluctuations, any history of pregnancy, diet and exercise regimens, and previous abdominal surgery and/or hernias. A careful medical history should be obtained along with a smoking history.

Physical examination

On physical examination the patient’s weight and height should be determined. The body mass index (BMI), should be calculated based on the formula: weight in kg/(height in m)2. The patient is initially examined circumferentially in the standing position to evaluate the abdominal contour from the rib cage to the mons pubis. However it is also important to pay attention to the surrounding contours of the posterior trunk, thoracic region, and thighs.

Three main components need to be evaluated in the physical examination of the abdomen: the skin, the subcutaneous fat, and the abdominal wall.

Skin

The overall quality of skin, including scars and stretch marks should be noted. The skin should be examined to determine its vertical excess and the extent of its laxity in the different regions of the abdomen. Often multiparous women present with stretch marks that involve the infra and supraumbilical regions.26 The patient needs to understand that infraumbilical skin will most often be removed, but supraumbilical stretch marks will not. These remaining stretch marks are often less unattractive when stretched by the procedure and can be hidden by some bikini patterns because of their transference to the lower abdomen.

Subcutaneous fat

The thickness of the subcutaneous fat of the anterior abdomen and the surrounding lateral and posterior lower truncal regions should be determined.

A protruding abdomen may be caused by a number of factors, alone or in combination.

• In obese patients and some male patients, intra-abdominal fat excess is responsible. In male patients, in particular, who have a fat deposition pattern that predisposes them to large visceral fat deposits, the abdominal panniculus thickness may be minimal despite an extremely protrudent abdomen.18–20 These patients are definitely not good candidates for abdominoplasty.
• Another reason for a protruding abdomen is a thick panniculus, which is often encountered in overweight, obese, or post-massive weight loss patients. If abdominoplasty surgery is contemplated on a patient with a thick panniculus, it is important to choose a technique that allows for thinning of the flap. This usually involves liposuction and limited undermining.

Abdominal wall laxity

A third reason for a protruding abdomen is abdominal wall laxity. It is essential to ascertain the integrity of the abdominal wall, whether there are any hernias present, and the extent of intra-abdominal or visceral fat. The exam is fairly easy in thin patients, but can be more cumbersome and difficult in the overweight or obese patient.

A number of tests can be performed, which alone or in combination, can give the examiner a feel for the degree and extent of any laxity. Initially the patient is asked to stand and relax their abdominal wall completely. For many this is not easy and they must be coaxed into cooperating. An appreciable amount of abdominal protrusion in this position usually indicates significant abdominal wall laxity. To confirm the result of this simple test, the patient is asked to perform the classic ‘diver’s test’ (Fig. 20.1).

To get a more accurate estimation of abdominal wall laxity, the patient is placed in the supine position and asked to lift the head and upper back off the table while the examiner palpates the abdominal wall. The extent of generalized laxity and the separation between the rectus muscles should be noted. Most patients presenting for abdominoplasty will demonstrate at least some degree of rectus diastasis. Men have a propensity toward a supraumbilical diastasis, whereas women most often present with infraumbilical muscle separation.

Abdominal wall laxity can be difficult to examine in patients with thick panniculi. A distinction between subcutaneous and visceral fat must be made because none of the techniques of abdominal contouring are designed to address excess intra-abdominal fat. A helpful test for these patients is to place them in the supine position and observe their abdominal contour. If it dips below the level of the ribs, it is likely that rectus fascia plication will be effective; if not, it can be presumed that there is an excessive amount of intra-abdominal adipose tissue. Attempting to perform an abdominoplasty on a patient with excessive intra-abdominal content most often yields an unfavorable outcome.

Other features

The abdominal physical exam should also include an evaluation of the mons pubis. The amount of excess fat should be determined. Any degree of ptosis should be noted because it should be treated as part of any abdominal contouring procedure. This is especially important in high-BMI patients and those who have experienced appreciable weight fluctuations.

In examining the back, attention should be paid to the waist, hips, localized fat deposits especially in the flank and lateral thigh regions, any deviations in the spine, the depth of lumbar lordosis, and the extent of buttock’s projection.

Counselling

Finally the patient is counseled about the risks, benefits, and alternatives to surgery. He or she should have the opportunity to ask questions and express concerns and doubts. The patient should be well informed about major and minor complications, how they may occur, and how to prevent and treat them, should they occur. A good rapport between patient and surgeon is essential and protects both patient and surgeon when results are unfavorable.

Preoperative photographs

Preoperative photographs are taken in the anterior, posterior, lateral and oblique views to demonstrate the full extent of deformities; they guide surgical planning and serve as an important tool in the post-operative assessment of the results.

Operative Approach

Relevant anatomy

In young, healthy men and women the waist is the narrowest circumference of the torso, usually 2.5 cm cephalad to the umbilicus, which lies on the midline at about the level of the iliac crests. Ideally, the distance from the umbilicus to the anterior vulvar commissure is 18-21 cm, and the pubic hair line is 5-7 cm cephalad to the anterior vulvar commissure.

The anterior abdominal muscle wall may be considered to have two parts:

• an anterolateral portion composed of the external oblique, internal oblique, and transversus abdominis muscles;
• a midline portion composed of the rectus abdominis muscle (Fig. 20.2).
image

Fig. 20.2 Anterior abdominal wall musculature.

The rectus muscle is enclosed in a stout sheath formed by a bilaminar aponeurosis, which passes anteriorly and posteriorly around the muscle, decussating in the midline to form the linea alba. Anteriorly the sheath is made up of the external oblique fascia and the anterior portion of internal oblique fascia. Posteriorly the sheath is made of the posterior portion of the internal oblique fascia and the transversus abdominis muscle fascia. Halfway between the umbilicus and the pubis, the posterior sheath layers pass anteriorly at the arcuate line of Douglas. The lack of support below the line of Douglas leads to a natural tendency toward lower abdominal fullness.

The umbilicus lies in the midline at varying distances between the xiphoid and the pubis symphysis, but usually level with the anterior superior iliac spines (ASIS). It has a dual blood supply, from the deep layer and from the skin, and it is able to survive on either. Caution is warranted in patients with large umbilical hernias and previous transections of the umbilicus.

Subcutaneous abdominal fat is compartmentalized into superficial and deep layers divided by the superficial fascial system, which in this region of the body is called Scarpa’s fascia. In patients who are relatively thin, the two layers of fat are fairly close to each other in thickness. In patients who have a large BMI the superficial fat layer is often much thicker than the deep layer (Fig. 20.3). The superficial fat layer is compact, dense with fat cells contained within well organized fibrous septa, whereas the deep fat is a loose areolar layer.

image

Fig. 20.3 Layers of the abdominal wall.

Vascular zones

Regardless of the technique used when performing abdominoplasty, vascular territories are interrupted and should be taken into account especially when upper abdominal scars are present.27 Thus a thorough knowledge of the blood supply of the abdominal skin and fat is essential. Huger28 studied the blood supply to the abdomen and designated three vascular zones (Fig. 20.4):

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