Abdominoplasty techniques

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CHAPTER 66 Abdominoplasty techniques

Ronaldo Pontes, Narayana Pauline Serpa

History

This chapter describes the systematization of a technique developed in the early 1960s and presented in 1964. The original technique was extended and formalized in 1971.

The original version of our abdominoplasty procedure is characterized by low incision, cranial undermining of the flap, musculo-aponeurotic treatment, caudal traction, resection, umbilicus transposition and closure of the wound. However, this type of procedure often results in an asymmetric scar due to irregular traction of the flap. On adipose abdomens, this problem is aggravated by the difficulty in supporting an extremely heavy flap during the resection. In these cases, we shift to performing the block resection of the previously demarcated flap, with lateral dissection, which will facilitate the surgery, provide better control over bleeding, besides reducing intervention time.

As we had felt secure and comfortable in the previous resections of tissue in large abdominoplasties, we began to apply this technique as the preferred method in practically all cases.

The technique, besides facilitating surgery, with all the benefits that have been pointed out, further permits association of abdominoplasty with other surgeries, such as face lifting, mammaplasty–face lifting and thigh lifting. Breast reconstruction using the rectus abdominis muscle, even though it has no link with our technique, represents well the block resection that we have idealized. The results have been consistently satisfactory, corroborated by the surgeons who have used this method.

Physical evaluation

The evaluation presupposes a selection for the diverse variants of the block resection. Technique I is obvious and rarely causes doubts. The other variants require careful reflection, which should be discussed with the patients regarding the benefit, extent of the scars and other consequences. Another factor is whether the abdomen is primary or secondary.

• Listening attentively to the complaint and sensing the level of expectation of the patients, the majority female, normally provides a reasonable degree of information regarding the extent of the surgery, its implications and consequences.

• It is important to warn about the existence, location and size of the scars during the physical exam. In order to be more objective, it is helpful to draw the supposed scars on the patient’s abdomen.

• The patient should be examined in a standing position with abdomen exposed. The seated exam should be added when such would provide greater clarity. In this position, the patient has difficulty in contracting the abdominal musculature, which facilitates real knowledge of the shape of the abdomen, showing the situation in its fullest degree.

• After the exam, all the implications of an abdominoplasty are discussed exhaustively: age, fertility, time necessary for recovery, return to his/her normal activities, period of internment, type of anesthetics, dressings, drains, as well as risks arising from the surgery.

• The most frequent complication must be pointed out, namely deep vein thrombosis in the lower limbs, and factors that predispose the patient to this incident should be discussed. It is also opportune, although it may seem premature, to instruct the patient about what measures are necessary for prophylaxis of the DVT.

• It is important to associate an abdominal ultrasonography to the basic exams, so as to detect any pathology that could contraindicate the surgery.

• Women of child-bearing age should be warned that abdominal stretch with future pregnancies would interfere with the quality of the result.

• In secondary abdomens with the presence of marked irregularities and supposition of hernia, it is also appropriate to use magnetic resonance.

• In abdomens with large distension or voluminous incisional hernias, the wearing of a girdle for abdominal containment for around a month prior to surgery is fundamental. Thus, a gradual adaptation will occur after surgical adjustment of the abdominal wall, as the consequent elevation of the diaphragm could entail respiratory dysfunction in the postoperative period.

• It is of great importance to know all the medication normally used, emphasizing the need to suspend those substances that could interfere with coagulation two or three weeks before surgery.

• Smokers represent a serious potential for the flap to incur damage. Even those who affirm that they have given up smoking in time (minimum one month prior to surgery) are considered smokers, requiring the care inherent to this type of situation.

Anatomy of the abdominal wall

The abdomen is the focus of multiple complaints by patients seeking plastic surgery. Due to its evident location, modifications to the form and volume produce, at times, unpleasant alterations to the corporal aesthetics. The abdominal protrusion can be associated to diverse factors such as adiposity, flaccidity of skin and musculature, hernias, increase in intra-abdominal volume, or a combination of these elements.

The anterior abdominal wall presents lines that serve as anatomical references. The medial anterior midline of the abdomen, the linea alba, is a point where the subcutaneous layer is diminished, and is often practically absent in lean patients, with defined musculature. The alba line serves as a reference for the correct positioning of the incisions during surgery of the abdomen. It is formed by the junction of the aponeuroses of the rectus abdominis muscle in the medial line, and extends from the xiphoid process to the pubic symphysis; is broader in the upper portion and suffers alterations with the increase in intra-abdominal volume, as in pregnancy, ascites and obesity. The linea semilunares indicate the lateral edges of the rectus abdominis muscle, and the tendinous inscriptions form transverse folds, three on average.

The disposition of fat varies according to gender. We know that, in females, fat tends to form pockets and maintains a predominant disposition in the infra-umbilical portion of the abdomen, whereas, in men, the distribution is more generalized.

Muscles of the abdominal wall

The muscular complex of the abdominal wall is formed of two muscular groups: one composed of three flat lateral muscles (external oblique, internal oblique and transversalis) and another anterior formed of rectus abdominis muscles and pyramidal muscles.

The rectus abdominis muscles are flat and vertical, and extend from the subcostal angle and costal cartilages to the pubic symphysis. Each muscle forms a band interrupted by aponeurotic digitations strongly adhered to the anterior lamina of its sheath.

The rectus abdominis muscles are enveloped by aponeurotic membranes that form the sheath by the aponeuroses of the lateral muscles joining on the midline known as the linea alba. The anterior lamina, stronger than the posterior, serves as a firm base for the plication of the abdominal wall.

Acting in conjunction, the musculature has the function of increasing intra-abdominal pressure; separately, they move the vertebral column and stabilize the pelvis during deambulation.

Innervation

The anterior abdominal wall is innervated by the intercostal and subcostal nerves T7–T11.

The lower part of the antero-lateral abdominal wall is innervated by the first lumbar nerve by means of the ilio-hipogastric and ilio-inguinal nerves. The anterior cutaneous branches T7–T9 supply the skin above the umbilicus, T10 innerves the umbilical region and T11, T12 and L1, the infra-umbilical region.

Vessels of the abdominal wall

The blood supply is formed of two primary arterial plexuses: a superficial subdermic system and a deep aponeurotic muscle.

Small arteries originate from the anterior and collateral branches of the posterior intercostal arteries of the intercostal spaces 10 and 11 and of the anterior branches of the subcostal arteries to supply the muscles in the antero-lateral region. They are anastomosed with the superior epigastric arteries, with the superior lumbars and among themselves.

The main arteries of the antero-lateral abdominal wall are the lower epigastric and deep circumflex iliac, branches of the external iliac artery, associated to the superior epigastric artery, which is the terminal branch of the internal thoracic artery.

The superficial epigastric and lateral thoracic veins are anastomosed, thereby joining the veins of the upper and lower halves of the body. The three superficial inguinal veins terminate in the magna saphena vein of the lower limb. The upper and lower epigastric vessels run together from the posterior face of the rectus abdominis muscle, inside its sheath.

Lymphatic drainage is carried out by two networks, one superficial and the other deep. The superficial lymphatic vessels from the upper abdominal wall to the umbilicus continue on to the axillary lymph nodes, and the lower drain to the inguinal lymph nodes. The lymph of the musculature is also drained to the deep lumbar and iliac lymph nodes.

The lymphatic drainage necessarily runs to the axillary nodes in the immediate postoperative period of abdominoplasty due to the section of lymphatic canals that drain the inguinal nodes. The systems tend to rebuild themselves as time goes by.

Technical steps

Variants of the block abdominoplasties

The diverse variants are a subdivision of the original in block technique, which is called type I as it represents the starting point of the whole process.

The variants, well-clarified in the respective illustrations, are:

• Type I: Cranial marking of the ellipse glancing across the upper edge of the umbilical scar.

• Type II: Mini – same marking occupying approximately the lower third between the umbilicus and the pubis.

• Type III: Half way between the umbilicus and the pubis, with disinsertion below the umbilical scar.

• Type IV: Generally in secondary abdomen. The flap descends with closure of the original place of the umbilicus.

Other applications are: vertical, high horizontal abdomen and thigh lifting.

Irrespective of the variant indicated, prior marking with the bikini is fundamental, the patient standing, preferably on the eve of surgery. For this maneuver, the patient must wear a bikini with broad side straps in the position that they will be worn in the future (Fig. 66.1). This marking will ensure perfect symmetry of the drawing of the intended resection, as well as the future location of the scar, which should be concealable by this type of clothing.

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Fig. 66.1 Prior marking with bikini on the eve of surgery.

Type I

Type I is an ellipsoidal drawing, in which the cranial arch usually glances past the upper edge of the umbilical scar, descends smoothly to both sides, where it meets the middle of the lateral part of the bikini demarcation. The lower arc, in three segments, two lateral of the cranial concavity, starts from the lateral tips of the upper arc, and meets the suprapubic arc, which has slight caudal concavity and a lower diameter than that of the pubis. This demarcation forms a smooth arc that meets the side strap of the bikini with a greater or shorter length, depending on the amplitude of the problem.

The two lower lateral arcs must be equally curved, with curvature opposite to that of the upper ones (Fig. 66.2A), so that the consequence will be a slightly curved scar, with upper concavity. The pubic segment must be shorter than the diameter of the pubis, whose resulting scar will accompany the trend towards narrower bikinis (Fig. 66.2B). All of this segment is resected in a single block, which is the basis of the technique (Fig. 66.2C). It is important to stress that in closure sutures with greater tension are lateral, to avoid excessive ascension of the pubis.

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Fig. 66.2 Typical scheme for type I block resection.

Surgical sequence 

For pre- and postoperative views, please see Fig. 66.3.

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Fig. 66.3 A, Preoperative view presenting flaccidity, innumerable strias, abdominal distension which are more evident in this position. This demonstrates the importance of the examination and photographic documentation in the seated position. B, Postoperative phase, in the lighter area. It can be observed that the scar is perfectly concealable by the bikini.

The procedure starts with the patient on the table and demarcation of the bikini (Fig. 66.4A). Beginning with a hemispherical marking, the lateral angle lies within the projection of the bikini, the lower lateral curved line meeting the upper, and the marking of the pubis, shorter than the anatomical limit (Fig. 66.4B). We transfer the demarcation from one side to the other, checking with compasses to ensure the correct measurements.

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Fig. 66.4 A, Patient on the table with the demarcation of the bikini. B, The hemispherical marking, noting the lateral angle in the projection of the bikini, the lower lateral curved line meeting the upper, and the marking of the pubis shorter than the anatomical limit. C, Complete demarcation.

After complete demarcation (Fig. 66.4C), infiltration of the entire flap is performed with a solution of lidocaine 20 mL at 2%, adrenalin 1 ampoule 1 : 1000, ropivacaine 20 mL at 0.75% and physiological serum 500 mL, throughout the whole area to be incised and resected.

Scoring of the basic points is realized to avoid erasure during the intervention. The surgery starts with incision and freeing of the umbilical markings. Then the flap is totally incised and removed, starting from the lateral angle and extending as far as the medial part (Fig. 66.5A,B). This maneuver, as well as simplifying the surgery, allows prior hemostasis, thereby minimizing the bleeding.

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Fig. 66.5 A, Flap totally incised. B, Start of the removal of the piece, starting from the lateral angle to the medial part. This maneuver, as well as simplifying the surgery, allows prior hemostasis, decreasing the bleeding. C, Flap completely excised.

After the flap has been completely excised (Fig. 66.5C), the cranial freeing of the flap starts and progresses to the dissection with cautery as far as the xiphoid process. The amplitude of the undermining, as much in the lateral direction as in the cranial, will depend on the case.

Next in sequence is demarcation of the area to be plicated (Fig. 66.6A), and the plication is conducted with Mersilene 3.0 at separate points (Fig. 66.6B), that must take into account overall readjustment of the abdominal wall and redefinition of the waist.

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Fig. 66.6 A, Demarcation of the area to be plicated. B, Plication with Mersilene 3.0 at separate points. C, Start of the assembly gathering the marked sutures. D, Surgery ended with active drainage.

This is followed by triangulation and fixing of the umbilical stump to the aponeurosis. With trunk and legs half-bent, and the flap tractioned in the caudal direction, the new emergence of the umbilicus is located. Incision of the skin and defattening of the cone-shaped passage of the umbilical stump is carried out before making the Baroudi stitches with Vicryl 2.0 that allow fixation of the flap to the aponeurosis, thus reducing the formation of seroma.

Assembly starts by gathering the marked points (Fig. 66.6C). Then sutures are placed in the umbilical stump. The surgery ends with active drainage (Fig. 66.6D), and in the use of prophylaxis for DVT with heparin of low molecular weight.

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Fig. 66.C1 Clinical case 1. A&B, Patient seated, pre- and postoperative phase. C&D, Pre- and postoperative profile. E&F, Position in image view.

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Fig. 66.C2 Clinical case 2. A&B, Patient in image view before and after. Scar following the mark of the bikini. C&D, Patient seated, demonstrating the full definition of all the abdomen as much by the symmetry obtained with the block resection as by the defattening in lamina.

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Fig. 66.C3 Clinical case 3. A, Patient with short trunk, adipose tissue, median infra-umbilical scar and mammary hypertrophy. Line interrupted demarcating the type of block resection. B, Postoperative period of the breast and abdomen with defattening. Note that in patients with large redundancy of tissue there is a tendency towards rectification of the scar, departing from the arcing of the original drawing.

Type II

Type II, also denominated mini-abdominoplasty, is a drawing identical to type I, only smaller, in which the marking occupies approximately the lower third between the umbilicus and the pubis (Fig. 66.7A–C), there being a possibility of disinsertion of the umbilicus or not. It is indicated for patients with a high umbilicus and flaccidity isolated above the pubic region. Despite the small dissection, plication of the rectus abdominis muscles may be carried out, which is a slightly laborious hypothesis, due to the difficulty of access to the supra-umbilical region. One must take extreme care with indication of type II (mini-abdominoplasty), given that the temptation of a smaller scar often leads patients to complain of flaccidity in the epigastric region, above all when seated. We have reoperated in some cases, on our own patients or others, to overcome this dissatisfaction. In this case, the indication of type II is extremely wise, whereas it would be denied when there is significant flaccidity in the epigastric region.

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Fig. 66.7 A–C, Typical scheme for block resection type II.

Type III

Variant type III is indicated exclusively in patients with a high umbilicus (Figs 66.8 & 66.9).

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Fig. 66.8 A–C, Typical scheme for block resection type III. The drawing is identical to that of type I, the difference being the maintenance of an intermediate amplitude between variants I and II.

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Fig. 66.9 A–C, The umbilical scar is sectioned at its base, and after the cranial dissection and plication of the rectus abdominis muscles, it is reinserted below the original point.

Type IV

Type IV is indicated in patients with a high umbilicus, and there is no indication for other variants. Generally, it is utilized in secondary abdominoplasty. The marking is similar to that of type III, though the umbilical scar is incised and its original point is closed longitudinally.

The flap descends normally, the umbilicus is transposed, resembling a typical abdominoplasty (Fig. 66.10A&B).

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Fig. 66.10 A&B, Demarcation and finalization of the block resection type IV.

Postoperative care

The postoperative care varies according to the type of block resection used. Naturally, general measures are common to all variants. In the cases in which there existed reasonable tension of the flap, it is important that the flexion of the thighs on the trunk adopted on the table, to facilitate the closure of the surgical wound, remain in the transfer and position on the gurney. On the bed, besides maintaining the same position of the legs, lifting of the trunk is added with an inclination that is comfortable for the patient. Throughout the period in bed, active and passive movements of the lower limbs are stimulated for prophylaxis of vein thrombosis. Frequently, and with same purpose, we usually use pneumatic leggings in the first 15–20 postoperative hours.

Using a girdle over the dressing, the patient ambulates on the day immediately after surgery.

As we usually provide prophylaxis for DVT, with the use of Enoxaparin for around seven days, there is greater drainage than normal, the drain remaining active for up to a week.

The stitches are removed after 10–12 days, gradually or otherwise, depending on the evolution of each case; at this moment, the application of surgical glue protects and benefits the cicatricial evolution.

Throughout the postoperative period, around 40 days, the wound remains occluded with Micropore tape or glue, it being obligatory to wear a girdle.

It is very important to accompany the cicatricial evolution for a minimum of 2–3 months, when any type of alteration can be detected and treated. It is common to use silicone tape or creams that improve the quality of the scars.

Complications

As in any surgery, abdominal plastic surgery is subject to the most diverse types of complication, which may be local or systemic. The local complications involve: equivocal situations of the block technique or of abdominal plastic surgery in general; necroses; bad cicatricial evolution; hematomas and seromas; irregularities of the abdominal wall; problems with the umbilical scar, infection and bleeding. Dissatisfaction is a type of problem that is inherent to plastic surgery and may assume a grave character of higher importance than an objective situation.

Respiratory restriction and vein thrombosis are serious systemic complications, the latter being the most frequent and acute.

Although it is not common, there are some patients who present with dyspnea in the immediate postoperative period. One must always enter differential diagnosis of the restriction of respiration caused by the plication of the sheath of the rectus abdominis muscles made in the surgery. The treatment is rest, supplementation of oxygen and respiratory physiotherapy.

Deep vein thrombosis and its gravest consequence, pulmonary embolism, is the most feared of the possible complications of abdominoplasty.

Pearls & pitfalls

Pearls

Abdominoplasty – block resection:

• Facilitates surgery.

• Provides better control over bleeding.

• Reduces intervention time.

• Permits association of abdominoplasty with other surgeries, such as face lifting, mammaplasty.

• Provides symmetric scars.

Pitfalls

• Depends on the surgeon’s common sense.

• Depends on the surgeon’s experience to indicate and execute the technique.

• There are complications as in some other surgical procedures.

Summary of steps

1. Demarcation of patient wearing a bikini.

2. Infiltration of the entire flap is performed with a solution of lidocaine, adrenalin, and physiological throughout the whole area to be incised and resected.

3. Surgery starts with incision and freeing of the umbilical scar. Then the flap is totally incised and removed, starting from the lateral angle and extending as far as the medial part.

4. After the flap has been completely excised, the cranial freeing of the flap starts and progresses to the dissection with cautery as far as the xiphoid process. The amplitude of the undermining, as much in the lateral direction as in the cranial, will depend on the case.

5. Next in sequence is demarcation of the area to be plicated.

6. This is followed by triangulation and fixing of the umbilical stump to the aponeurosis.

7. Assembly starts by gathering the marked points.

8. Then stitches are placed in the umbilical stump.

9. The surgery ends with active drainage, and in the use of prophylaxis for DVT with heparin of low molecular weight.

10. The above steps apply to the original block abdominoplasty (type I). There are slight variations in technique for the variants type II (mini: lower third between the umbilicus and the pubis.); type III (half way between the umbilicus and the pubis, with disinsertion below the umbilical scar); and type IV (in secondary abdomen; flap descends with closure of the original place of the umbilicus).

Further reading

Abramo AC, Viola JC, Marques A. The H approach to abdominal muscle aponeurosis for the improvement of body contour. Plast Reconstr Surg. 1990;86(5):1008–1013.

Abs R. Thromboembolism in plastic surgery: review of the literature and proposal of a prophylaxis algorithm. Ann Chir Plast Esthet. 2000;45(6):604–609.

Achauer BM, Eriksson E, Guyuron B, Coleman JJ, III., Russell RC, Vander Kolk CA. Abdominoplasty. In: Guyuron B, ed. Plastic surgery: Indications, operations and outcomes. St. Louis: MO: Mosby; 2000:2783–2821.

Akoz T, Akon M, Yilalirim S. If you continue to smoke, we may have a problem: Smoking’s effects on plastic surgery. Aesthet Plastic Surg. 2002;26(6):477–482.

Baroudi R, Ferreira CAA. Seroma: How to avoid it and how to treat it. Aesthet Surg J. 1998;18:439–441.

Cardoso de Castro C, Daher M. Simultaneous reduction mammaplasty and abdominoplasty. Plast Reconstr Surg. 1974;61:36.

Floros C, Davis PKB. Complications and long term results following abdominoplasty: A retrospective study. Br J Plast Surg. 1991;44:190–194.

Hester TR, Baird W, Bostwick J, III., et al. Abdominoplasty combined with other major surgical procedures: Safe or sorry? Plast Reconstr Surg. 1989;8:997.

Matarasso A. Awareness and avoidance of abdominoplasty complications. Aesthet Plast Surg. 1997;17(4):256–261.

Matarasso A. Minimal-access variations in abdominoplasty. Ann Plast Surg. 1995;34(3):255–263.

Moore KL. Do abdome, Anatomia Orientada para a Clinica, 2nd edn. Rio de Janeiro: Editora Guanabara; 1990.

Nahas FX. Pregnancy after abdominoplasty. Aesthet Plast Surg. 2002;26(4):284–286.

Savage CR. Abdominoplasty combined with other surgical procedures. Plast Reconstr Surg. 1982;70:437.

Sinder R. Cirurgia Plastica do Abdome. Editado pelo autor; 1979.

Tercan M, Bekerecioglu M, Dikensoy O, Kocoglu H. Effects of abdominoplasty on respiratory functions a prospective study. Ann Plast Surg. 2002;49(6):617–620.

Van Uchelen JH, Werker PM, Kon M. Complications of abdominoplasty in 86 patients. Plast Reconstr Surg. 2001;107(7):1869–1873.

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