Introduction

The modern history of abdominal contouring began in 1899 with Kelly^1,2 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

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.

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.

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.

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.

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.

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).

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.

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):

• Zone I is supplied by the deep epigastric arcade. It extends from the xiphoid to the pubis and from one lateral edge of the rectus sheath to the other. The deep superior and inferior epigastric vessels run through the rectus muscle, emitting musculocutaneous perforators to the overlying fat and skin.

• Zone II extends from one ASIS to the other, down to the inguinal creases and pubis. Its blood supply is derived from the superficial branches of the circumflex iliac and external pudendal vessels. Some branches of the deep circumflex iliac vessels, which course above the ASIS course inferiorly into zone II from zone III above as well.

• Zone III provides the blood supply to the anterolateral abdominal wall, extending above the ASIS just lateral to the rectus sheath on either side of zone I. It is supplied by intercostals, subcostal, and lumbar arteries. Because these vessels travel inferomedially in the superficial layer of abdominal fat, they overlap zone I vessels in supplying medial skin.

Fig. 20.4 Blood vessels that supply the abdominal wall. There are three zones of vascularity.

Zone I vessels are almost always interrupted by flap elevation in an abdominoplasty, leaving zone III vessels as the only remaining blood supply. If zone III vessels are interfered with, such as in a subcostal cholycystecomy scar, tissue inferomedial to the interruption may necrose.

Sensory innervation

The sensory innervation of the anterior abdominal wall originates laterally from the 6th to 12th thoracic nerves and 1st lumbar nerve.

The lateral femoral cutaneous nerve ( L2-L3) provides sensation to the anterolateral thigh, is located 1-6 cm medial to the ASIS and can be injured during dissection and closure of an abdominoplasty, resulting in painful neuroma or anterolateral thigh paresthesia.

Iliohypogastric and ilioinguinal nerves supply sensory innervation to the groin and symphysis pubis, proximal portions of the scrotum and labia, and small adjacent area on the inner aspect of the thigh. These nerves can be entrapped during plication of the anterior rectus sheath in the lower abdomen.29,30

Fascial attachments

The lower trunk has fascial attachments between the skin and underlying muscle fascia that act as anchoring points or zones of adherence³¹ (Fig. 20.5), which tether the overlying skin to the underlying musculoskeletal anatomy, not allowing either descent or elevation with aging, weight fluctuation, or surgical manipulation.

• Posteriorly the midline has a zone of adherence that overlies the spine.

• The anterior midline of the abdomen has a less defined zone of adherence overlying the linea alba.

• There are three horizontal zones of adherence in the inferior aspect of the lower trunk, which are responsible for the fact that abdominoplasty scars do not end up in much higher positions because they prevent unrestricted superior movement. The first is bilaterally located at the inguinal ligament extending towards the ASIS. The second is located just above the mons pubis, and though this particular zone of adherence may occasionally not be vigorously adherent, it is usually a strong zone of adherence. The third is located bilaterally between the hip and lateral thigh fat deposits.

Fig. 20.5 Zones of adherence of the upper and lower trunk. A-C, The anterior midline of the abdomen has a less defined zone of adherence overlying the linea alba. Posteriorly the midline has a zone of adherence that overlies the spine. There are three horizontal zones of adherence in the inferior aspect of the lower trunk: bilaterally at the inguinal ligament extending towards the ASIS; just above the mons pubis, and bilaterally between the hip and lateral thigh fat deposits.

Truncal tissues become lax due to aging, pregnancy, and/or massive weight loss. They descend the greatest distance laterally, caused by a combination of tissue laxity and central tethering of the midline zones of adherence. As tissues descend around the pelvis they also migrate centrally.

Operative techniques

Plastic surgeons vary in their approaches to any surgical procedure and abdominoplasty is no exception. We present our preferred technique, though we tend to vary the technique depending on the patient and his or her particular desires.

Markings

Many abdominoplasty scar patterns have been introduced over the past five decades. They have evolved over time to accommodate different clothing patterns and potential improvements in contour. We prefer a ‘French Bikini’ pattern because it places the scar at the natural junction between the abdominal and thigh units. However, because of recent fashion trends we often utilize lower patterns to accommodate patient wishes.

Preoperative markings are performed 1-2 two days prior to the procedure to allow photography of the markings and evaluation of any need for adjustments. However, some surgeons perform the markings immediately prior to surgery or in the operating room.

In abdominoplasty 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. The inferior aspect of the elliptical excision is generally longer than the superior aspect creating a mismatch, which can lead to the dog-ears. Patients who present in the lower BMI range generally do not cause as much difficulty with dog-ears as the patients who have a larger BMI. Patients who have relatively inferiorly positioned umbilici are also less troublesome with respect to dog-ears compared to those who have fairly high umbilici.

To eliminate dog-ears three general approaches, individually or in combination, can be utilized.

• First, the excision and scar can simply be extended laterally.

• Second, the lateral aspect can be closed first to create a flat surface and subsequently the abdominal flap is cheated medially.

• Third, in cases of a superiorly located umbilicus, the umbilical defect created by the circumumbilical incision can be closed on itself leaving behind a vertical scar in varying positions. This will reduce the vertical distance resected thus leading to less lateral fullness.

The marking process begins by delineating the midline from the xiphoid to the mons pubis. Centrally, the proposed lower abdominal incision is marked in the natural suprapubic crease in most patients who are within the normal weight range. For most patients undergoing abdominoplasty the superior pubic hairline coincides with the natural crease, but if there is no natural crease present then the mark can usually be placed at the edge of the hairline. In massive-weight-loss patients, and occasionally in fairly lax non-massive-weight-loss patients, the mons pubis is ptotic and it is necessary to place the incision a few centimeters within the hair-bearing pubic skin. A good guide for most patients is a 7 cm distance from the top of the fourchette or penis to the incision line.

It is obviously important to control final scar position in abdominoplasty, and it is therefore helpful to think of an abdominoplasty closure in the same way as the closure of any elliptical defect. The greatest tension and tissue distortion occurs centrally, with minimal to no tension or distortion laterally (Fig. 20.6).

Fig. 20.6 Tension created by abdominoplasty across the abdomen. Note that tension is significant centrally and essentially goes to zero laterally.

In abdominoplasty the final position of the central scar, between the lateral edges of the mons pubis, is a result of the balance of the upward pull of the tailored abdominal flap and the opposing inferior pull down of the zone of adherence at the suprapubic crease. A great deal of attention should be paid to how this central area of greatest tension will be manipulated to allow for the resection of the appropriate amount of vertical excess without lifting the mons pubis to an unnatural superior position. Once central tension is set, which actually takes place at the time of surgical resection, scar position lateral to the mons pubis is much easier to predict because there is little tension on either a superior or inferior direction by the lateral aspects of the resected ellipse. Thus to complete the inferior aspect of the abdominoplasty ellipse the marking is extended laterally, based on the desired pattern of the final scar. In a French-bikini pattern the extension is made towards the ASIS. If a flatter scar is desired, the mark is angulated at the desired level. In general the scar will end up 1-2 cm above the initial inferior incision in the area lateral to the mons pubis.

To approximate the superior extent of the ellipse, the patient is placed supine and flexed at the waist, and the ‘pinch technique’ is utilized to approximate the superior extent of the incision. Ideally the patient should have enough excess skin to allow for excision of the skin from above the umbilicus to the inferior mark. Lipodystrophy of any surrounding regions such as the flanks, hips, and lateral thighs is also marked for liposuction.

Abdominoplasty

• In the operating room, the patient is placed in the supine position, intermittent compression devices are applied to the lower extremities, and a dose of perioperative antibiotic is given.

• Most plastic surgeons prefer to perform abdominoplasty under general anesthesia because it allows complete muscle relaxation, which is helpful during abdominal wall plication.

• If the procedure is going to require a long operative time, which can occur when multiple other procedures are planned, an indwelling urinary bladder catheter is placed.

• After the patient is prepped and draped, the operation begins by circumferentially incising around the umbilicus. To facilitate the incision and the subsequent creation of a neoumbilicus, retraction sutures are placed at 12 and 6 o’clock (Fig. 20.7).

• A periumbilical dissection down to the level of the surrounding rectus fascia is then performed making sure that a generous amount of fat is left attached to the umbilicus to preserve its blood supply.

• Next, the inferior mark of the proposed elliptical excision is incised and abdominal flap elevation is performed. In traditional abdominoplasty, an abdominal flap is elevated at the level of the underlying muscle fascia, around the umbilicus, and up to the xiphoid and costal margins. This type of wide undermining allows the greatest amount of inferior abdominal flap advancement at the time of flap tailoring, but it also compromises the greatest number of muscle wall perforating vessels that directly supply the overlying fat and skin. We, like many plastic surgeons, prefer to leave the subscarpal fat down in the femoral region during abdominal flap elevation in the hope of maintaining the prominent lymphatics of that region to help reduce postoperative seroma formation (Fig. 20.8).

• Some surgeons prefer not to liposuction an extensively elevated abdominal flap in fear of injuring its remaining blood supply – the intercostal, subcostal, and lumbar vessels, which run in the fat superficial to Scarpa’s fascia. Others liposuction the flap only if they limit their elevation to either side of the midline, which is only wide enough to allow for the needed plication (Fig. 20.9). This conservative central elevation maximizes the number of intact muscle perforator vessels to supply the tailored abdominal flap. As a general rule, flap elevation should be restricted to just what will allow both appropriate abdominal wall plication and adequate flap advancement. Thus no matter which type of flap elevation is contemplated in any particular patient, it is usually best to limit the elevation initially and then release the tissues incrementally to allow for appropriate plication and contour.

• Next, the patient is flexed at the waist, abdominal wall laxity is examined, and a vertical elliptical plication is marked from the xiphoid to the symphysis pubis (Fig. 20.10).

• Often the anesthesiologist is asked to relax the patient prior to starting the plication, especially in patients who seem to have tense abdominal walls. If there are any concerns about excessive gastric air content, nasogastric tube aspiration should also be performed. The authors prefer a two-layer vertical plication. The first layer is performed utilizing interrupted permanent braided suture and the second layer is performed with permanent monofilament running suture (Fig. 20.11).

• In some patients vertical laxity may persist after the two-layer plication is completed. In these instances, one or two rows of horizontal plications can be performed to further flatten the abdominal wall.

• With the plication accomplished, the patient is maintained in the flexed position. The abdominal flap is advanced inferiorly to facilitate the process of flap tailoring (Fig. 20.12). The tailoring process must be a balance between eliminating vertical abdominal flap excess, not elevating the mons pubis too high, and limiting scar width. Often, however, it is necessary to make adjustments to accommodate all three desires. For example if eliminating the umbilical defect will lead to an abnormally high mons pubis, the defect can be left as part of the remaining flap and closed on itself leading to a midline vertical scar located at varying distances between the newly created umbilicus and the horizontal abdominal scar. If the mons pubis is overly thick, it can be defatted by reducing subscarpal fat to balance its proportions in relation to the new abdominal contour. If the mons pubis appears to rise too high, its superficial fascial layer may be anchored to the underlying muscle fascia to hold it in the appropriate position. The abdominal flap is then tailored based on that position.

• To aggressively improve waist definition and elevate the anterior thighs, proponents of the HLTA technique place a great deal of tension laterally, from the lateral border of the mons to the ASIS.15,25 This method of abdominal flap tailoring decreases central tension on the mons pubis. However, it often necessitate a lateral extension of the scar to eliminate the dog-ears created by the lateral tension. Conversely limiting scar width, and thus lateral tension, will lead to less aggressive improvements in waist definition and anterior thigh elevation. We tend not to choose a particular method to use on all patients, but rather adjust the resection to the particular patient’s condition and desires, at the time of surgery.

Fig. 20.7 Traction sutures. These put traction on the umbilicus to facilitate the circumumbilical incision.

Fig. 20.8 Abdominal flap dissection is performed at the level of Scarpa’s fascia, or just deep to it, in the femoral regions bilaterally. This leaves behind important lymphatic channels to help drain the lower abdominal region and presumably reduce seroma formation.

Fig. 20.9 Extent of abdominal flap dissection in the supraumbilical region, if abdominal flap liposuction is to be performed.

Fig. 20.10 First layer of plication.

Fig. 20.11 Second layer of plication. This is completed infraumbilically, and partially completed in the supraumbilical region.

Fig. 20.12 Abdominal flap after being advanced. The amount to be resected is determined at key points.

Our preferred method of umbilicoplasty

• With the abdominal flap tailored and temporarily tacked in place, the position of the underlying umbilicus is marked in preparation for umbilicoplasty. The particular method of umbilicoplasty is quite variable from surgeon to surgeon. As a general rule however, the neoumbilicus should be fairly small, vertically oriented, inverted, and its suture line should be buried within the cone shaped structure. We describe our preferred method because of its simplicity and the results it produces.

• A 1.5-2.0-cm vertical incision is made in the midline overlying the buried umbilicus and a path is created by bluntly dissecting a passageway for the stalk to be brought through to surface.

• We prefer not to de-fat this area to avoid possible vascular compromise of the abdominal flap and because the desired inversion can be accomplished by the suture technique we describe here.

• At 3, 6, and 9 o’clock, three point fixation sutures are placed from the surrounding abdominal wall fascia, to the subcuticular level of the umbilicus, and through the subcuticular level of the abdominal flap (Fig. 20.13). As these sutures are tied, the neoumbilicus is inverted. The remainder of the closure is accomplished with simple inverted, subcuticular, nonpermanent sutures from the abdominal flap to the umbilicus.

Fig. 20.13 Three point fixation sutures at 3, 6, and 9 o’clock are placed from the subcuticular level of the abdominal flap to the subcuticular level of the umbilicus and through the fascia of the surrounding abdominal wall. These sutures allow inversion of the neoumbilicus without having to de-fat the surrounding tissues.

Closure of the abdominal wound

• Prior to beginning closure of the abdominal wound two closed-suction drains are placed through the hair-bearing skin of the mons pubis.

• Closure is accomplished in multiple layers, with the most important layer being the superficial fascial system, or Scarpa’s fascia.¹⁴ It is assumed that reapproximating this layer reduces the significant tension on skin that can be generated in an abdominoplasty. It also prevents acute wound dehiscence and reduces scar widening in the long run. Traditionally it has been accomplished with a 0- or #1-sized permanent braided suture. We, however, have abandoned permanent sutures and currently utilize a longlasting non-permanent, non-braided, 0 suture, with no discernible decrease in the quality of the scars.

• The skin is closed with either interrupted or a running subcuticular layer of 2-0 to 3-0 non-permanent, non-braided, suture followed by an overlying layer of medical grade skin glue.

• Recently, we have started utilizing an indwelling pain pump catheter that drips local anesthetic in the operative field, which helps decrease pain over the first 3-4 days after surgery. Some surgeons

• We use an epidural infusion for postoperative pain management for patients who are going to be admitted to the hospital.

• An abdominal binder is applied to the patient’s abdomen at the end of the surgical procedure and is utilized for a few weeks after surgery.

Mini-abdominoplasty

• Preoperative markings are performed 1 or 2 days prior to the procedure in the office. The midline from the xiphoid to the umbilicus and midline of the mons pubis is marked. A lower abdominal incision in the natural suprapubic crease is marked and often can be limited to the width of the pubic hair or just beyond its lateral borders.

• In the operating room intermittent compression devices are applied to the lower extremities, a dose of perioperative antibiotic is given, and general anesthesia is induced.

• The operation begins with the lower abdominal incision. The abdominal flap is raised to the level of the umbilicus. The patient is flexed at the waist and abdominal muscle wall laxity is examined. The rectus abdominis muscle fascia is vertically plicated from the umbilicus to the pubis (Fig. 20.14).

• The abdominal flap is then advanced inferiorly and tailored to remove the excess skin and fat. This advancement will usually pull the umbilicus down 1-3 cm, and should be taken into consideration if the patient has a low umbilicus preoperatively.

• A closed suction drain is placed through a separate stab incision.

• The incision is closed in layers, with interrupted 0-sized longlasting nonpermanent monofilament suture used to reapproximate the superficial fascial system, followed by interrupted, inverted 2-0 to 3-0 monofilament nonpermanent suture and an overlying layer of medical grade skin glue.

Fig. 20.14 Mini-abdominoplasty. The extent of flap dissection and abdominal wall plication is shown.

Modifications

A modification of this technique can be applied to patients who present with minimal lower abdominal skin and subcutaneous tissue excess, but have both supra and infraumbilical abdominal muscle wall laxity.

• In order to obtain access to the supraumbilical rectus diastasis, the umbilical base is amputated as the abdominal flap is elevated from pubis to xiphoid and the umbilicus is ‘floated’ with the abdominal flap.

• The supraumbilical flap elevation is limited to a distance on either side of the midline that allows for the planned plication. The muscle diastasis is repaired from the xiphoid to the pubis in a similar manner to a routine abdominoplasty.

• The abdominal flap is then advanced inferiorly and tailored; the umbilical stalk is resutured to the plication at its more inferiorly positioned final level.

In a variation of this technique, a superior periumbilical incision is made and an endoscopic elevation of the abdominal flap, from umbilicus to xiphoid, on either side of the midline is performed to allow for rectus fascia plication. The inferior abdominal flap is tailored in a similar manner to a more traditional mini-abdominoplasty with the umbilicus inferiorly advanced a few centimeters.

High lateral tension abdominoplasty

• Preoperative markings are performed in the office a day or two prior to surgery. First, the final location of the scar is determined with the patient in standing position. This is accomplished by marking a horizontal line 7 cm superior to the anterior vulvar commissure (or base of the penis) and two lateral marks at either ASIS. These three marks are then connected to create the proposed final scar position in the shape of ‘French bikini’ pattern. However, the proposed final scar shape can be manipulated to fit beneath any preferred underwear pattern by altering the position of the lateral marks.

• Next, the inferior margin of excision is marked. This is accomplished by holding the marking pen at the level of the previously made central mark and displacing the central abdominal tissues superiorly to the extent that the appropriate mons pubis contour is created. A mark is made on the elevated skin at the level where the pen has been steadily held in position. This maneuver is repeated all along the path from the central mark to the lateral marks creating multiple points that are connected and thus form the lower proposed incision.

• Next, the superior proposed incision line is marked utilizing the pinch technique, with the thumb placed on the inferior proposed incision, pinching, and then observing that the appropriate abdominal contour is created by the pinch. As previously mentioned, the central aspect of the superior proposed incision often does not reach the level of the umbilicus because the emphasis of maximal resection and tension in a HLTA is lateral.

• In the operating room intermittent compression devices are applied to the lower extremities and a dose of perioperative antibiotic is given. General anesthesia is induced and an indwelling urinary catheter is placed if required.

• The umbilicus is circum-incised and left attached by a generous subcutaneous pedicle.

• The lower reference line is incised and the abdominal flap is elevated off the rectus fascia up to the umbilicus.

• Above the level of the umbilicus, undermining is limited to a narrow strip around the midline centrally, just enough to allow the desired supraumbilical plication. This type of central undermining preserves more rectus muscle perforators, which allows the surgeon to liposuction the flap if it is deemed too thick.

• Vertical plication of the abdominal wall fascia is accomplished in a similar manner to the traditional abdominoplasty.

• Next the abdominal flap is advanced inferiorly to start the tailoring process. Whether the abdominal flap has been liposuctioned or not, at this point in the operation, the attachments of the abdominal flap to the underlying muscle fascia can be discontinuously undermined using large scissors that are opened parallel to the path of the remaining vessels. This maneuver allows for further abdominal flap inferior advancement.

• The actual tailoring process is begun by pulling on the abdominal flap laterally and inferiorly, thus placing the greatest tension laterally. The excess tissue is then tailored appropriately.

• Often the incision has to be extended laterally to eliminate dog-ears.

• With the abdominal flap tacked to the inferior incision, the neoumbilicus position is determined. The performance of the umbilicoplasty and the closure are similar to that described in the more traditional abdominoplasty technique.

Lipoabdominoplasty

• The markings can be performed in a similar manner to the more traditional abdominoplasty or the HLTA pattern.

• The operation begins by tumescent infiltration of the entire abdomen.

• Both infra and supraumbilical regions are liposuctioned, superficial and deep to Scarpa’s fascia.

• Realistically, most of the liposuction occurs superficial to the fascia because subscarpal fat is often fairly thin and would be difficult to significantly reduce in thickness without injuring abdominal muscle wall fascia. Some surgeons aggressively liposuction the infraumbilical fat, and so when it is time to tailor the flap the skin will essentially just peel off the underlying liposuctioned tissue, which should contain a large component of the lymphatic system. Other surgeons, including us, aggressively liposuction the supraumbilical region and then raise the infraumbilical abdominal flap at, or just below Scarpa’s fascia. In either case the intent is to leave some fat behind to maintain lymphatic tissues, which theoretically reduces the risk of seromas.

• Supraumbilically a narrow swath of central elevation is performed on either side of the midline to allow for plication.

• In the infraumbilical region a small strip of fat is resected or elevated from either side of the midline to allow for plication.

• Plication is performed in a similar manner to any other abdominoplasty technique.

• Although there is minimal elevation of the flap, flap advancement is possible due to the indirect undermining caused by the liposuction aspect of the procedure. If more advancement is required further blunt dissection can be performed, as in a HLTA, to allow for release of the flap.

• Umbilicoplasty and flap tailoring are similar to the other techniques. Some surgeons do not utilize any drains with this technique, especially if they use quilting sutures from the abdominal flap to the underlying tissues.

Optimizing outcomes

• Avoid patients who have excessive intra-abdominal fat content because the results of abdominoplasty will be unsatisfactory.

• Patients best suited for abdominoplasty surgery present with lower truncal excess limited to the anterior abdomen.

• Evaluate and treat areas surrounding the abdomen, usually with concomitant liposuction, to attain better overall lower truncal contour.

• The extent of flap elevation in abdominoplasty, no matter which technique is utilized, should be as minimal as possible to reduce vascular compromise and accomplish the desired contour.

• If liposuctioning of the abdominal flap is contemplated, supraumbilical flap undermining should be only wide enough to allow for the needed plication, thus reducing the risk of flap necrosis.

• Wide undermining in smokers, diabetics, hypertensives, and if there are pre-existing scars in the upper abdomen should be auoided.

• During flap tailoring the mons pubis should not be elevated to an aesthetically unappealing level.

• Most lateral dog-ears should be taken care of at the time of surgery by either extending the scars or cheating the abdominal flap medially.

• Reapproximation of the superficial fascial system is essential to obtain a high-quality fine-line scar.

• The neoumbilicus should be small, vertically oriented, and superiorly hooded, with a slight hollow around it.

• Patients who present with a high BMI greater than or equal to 30 have a greater complication rate.

• Use of sequential compression devices, early ambulation, vigorous pulmonary toilet, appropriate hydration, discontinuing nicotine, birth control pills, and hormone replacement therapy, and avoiding lengthy operations improve outcome.

• The technique utilized in any particular patient sould be individualized to accommodate the patient’s anatomy and desires.

Complications

Abdominoplasty is an extensive operation with potential risks and complications that need to be considered by both the patient and plastic surgeon.^21,32–38 Abdominoplasty, alone or in combination with other procedures, carries the highest risk among body contouring procedures. As a general rule complications are more common in higher BMI patients and because many patients that present for abdominoplasty may be in the overweight-to-obese range, they need to be approached with caution and full disclosure.

Contour irregularity

Contour irregularity is not an uncommon complication after abdominoplasty.

Epigastric bulging after abdominoplasty results from inadequate plication of the superior abdominal wall superiorly, near the xiphoid. To avoid this problem, appropriate midline undermining of the flap up to the xiphoid must be performed, to allow complete access for the full extent of superior plication.

Box 20.2 Inverted ‘T’ or fleur-de-lis abdominoplasty

Some plastic surgeons prefer to utilize inverted ‘T’ or fleur-de-lis³⁹-pattern procedures in patients that present with circumferential lower truncal excess, especially if the patient presents with a midline abdominal scar. We have almost abandoned this pattern as a primary procedure, especially since circumferential dermatolipectomy procedures have become main stream in plastic surgery as a reaction to the frequent presentation of the massive-weight-loss patient. The theoretical advantage of utilizing this technique is that it can eliminate horizontal as well as vertical excess and create waist narrowing by pulling the lateral tissues centrally. It is important to note that to safely utilize this technique it must not be thought of as a traditional abdominoplasty with a simple addition of a vertical wedge.

Disadvantages

It is dangerous to combine extensive undermining of the abdominal flap up to the xiphoid and costal margins with vertical midline resection because it further compromises the blood supply of the flap, and combined with a great deal of tension on the closure can lead to an increased risk of flap necrosis, especially at the T intersection. Thus if a T-type resection is contemplated, it is wise to not undermine any of the vertical pillars on either side of the vertical resection, and limit the dissection to only what is required to accomplish the central plication.

Other disadvantages of a T-type resection are:

• in eliminating the central vertical wedge, the epigastric region can be left with fullness secondary to a ‘dog-ear’ and attempts to eliminate the fullness by extending the incision may lead to a scar that is carried onto the sternal region;

• if the vertical component of the T is overly aggressive in one region versus the other, the resultant contour can create a bizarre shape to the abdominal wall (Fig. 20.15A-F);

• if the umbilicus is not intentionally made small, then it will eventually widen due to the lateral tension created by the vertical excision;

• no matter how expertly the T resection is performed, it does not adequately address problems with the lateral thighs, buttocks, and back; all problems that are much better addressed by a circumferential procedure.

Fig. 20.15 A poorly performed T-type abdominoplasty. A-F, These photographs demonstrate resultant epigastric fullness, asymmetries, and a bizarre-appearing pubic region.

Lateral dog-ears can occur, especially in patients with a larger BMI, and are best managed at the time of the actual procedure, though some fairly small dog-ears will disappear over time without formal treatment. Intraoperatively, one way to avoid dog-ears is to start out with the lateral closure first, creating perfect contour there, and then adjusting the remainder of the incision accordingly. A second method is to extend the incision laterally, with or without de-fatting the lateral soft tissues to allow for a straight-line closure.

The position of the mons pubis can be altered for better or worse after abdominoplasty. If the mons is ptotic prior to surgery, it should be lifted, which is easy to accomplish because of the tension created by the resection of an abdominoplasty. It is more difficult, however, to keep the mons pubis from ending up too high, especially in patients who have a highly positioned umbilicus. To avoid this problem it best to place the mons pubis where it is felt to be most ideal and then tailor the abdominal flap based on that position. This may necessitate leaving the umbilical defect behind as a vertical scar either as part of a midline T-shaped closure or a vertical scar between the neoumbilicus and the mons. If such scars are contemplated, it is imperative that the patient is warned about the possibility prior to surgery with an explanation of why this may be necessary. To further hold the position of the mons in its ideal position, its underlying Scarpa’s fascia can be sutured to the underlying muscle fascia to prevent superior migration.

Scar symmetry can often be accomplished by a careful marking process; however, some patients have intrinsic musculoskeletal asymmetries that are not amenable to surgical manipulation. It is best to warn the patient about this problem prior to surgery to avoid post-operative difficulties.

Postoperative Care

Abdominoplasty

Intravenous fluids and antibiotics are given for 24 hours. Patients are kept flexed, in ‘beach chair’ position. Intermittent compression devices continue to be used until full ambulation is obtained. A clear liquid diet is started and advanced to regular as tolerated. Postoperative pain is controlled with narcotic analgesics and a pain pump. The pain pump is turned on before leaving the operating room.

Patients 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, and then they are instructed on exercises that will allow them to straighten to full extension. The exercises entail the patients straightening until they feel tension and holding that position for 30 s, then releasing the tension by re-bending at the waist. This is repeated 20-30 times during the day, and most patients are able to get to a fully erect position in 2-3 days.

Abdominoplasty can be performed as an outpatient procedure, but we usually keep our patients overnight. They are discharged home with drains and instructed to record their output daily. Each drain is removed when its output is less than 40 mL/24 hours. Showering, but no bathing, is allowed while drains are in place.

The abdominal binder is kept on for the first week and then the patients are instructed to wear a tight garment that is more comfortable, for as long as they can tolerate wearing it.

Patients are instructed not to apply heating pads to the abdomen, take hot showers, or sunbathe until they regain sensation in the abdominal skin to avoid potential burns.

Driving is allowed when narcotic pain medication is no longer required and the patient can perform emergency driving maneuvers without the fear of pain from the surgical sight.

Light, lower extremity exercises, like walking or stationary biking, can be resumed 2-3 weeks after surgery. Abdominal muscle exercises are discouraged for 3 months after surgery to protect the abdominal wall plication suture.

Photographs before and after abdominoplasty performed on three different categories of patient are shown in Fig. 20.16A-F, Fig. 20.17A-F and Fig. 20.18A-F.

Fig. 20.16 Before and after abdominoplasty. A-C, White woman in her late 20s who presented with complaints of a protrudent lower abdomen after having two children. D-F, The postoperative photographs demonstrate a French-bikini-pattern scar 6 months after surgery.

Fig. 20.17 Before and after abdominoplasty. A-C, A 32-year-old woman patient who underwent an abdominoplasty with liposuction of the hips and lateral thighs. She desired her scar to fit under a fairly low underwear line. D-F, 7 weeks after surgery. Note the swelling above the incision line, which typically resolves over a few months. (Note: this patient is shown on the accompanying video.)

Fig. 20.18 Before and after abdominoplasty. A-C, Preoperative markings of an abdominoplasty on a 65-year-old female. She is atypical because of her older age and how it appears that she might have too much intra-abdominal content prior to surgery. Her abdomen became scaphoid in the supine position during her preoperative exam, which confirmed that she would benefit from the surgery. D-F, 1 year postoperatively.

Conclusion

Patients best suited for abdominoplasty surgery present with lower truncal excess limited to the anterior abdomen. Those with a high BMI greater than or equal to 30 have a greater complication rate. The technique used in any particular patient should be individualized to accommodate the patient’s anatomy and desires, but the extent of flap should be minimal to reduce vascular compromise. Complications are minimized by use of sequential compression devices, early ambulation, vigorous pulmonary toilet, appropriate hydration, discontinuing nicotine, birth control pills, and hormone replacement therapy, and avoiding lengthy operations.