Introduction

Many surgeons over the last century have increased our understanding of abdominal surgical anatomy, especially with regard to the vascularization and lymphatic drainage of the abdominal wall. These advances have resulted in surgeons able to perform safer, more efficient and faster abdominoplasty procedures with good and consistent results.

Surgeons such as Callia,² Pitanguy,³ Pontes,⁴ Baroudi,⁵ Avelar,⁶ Matarasso,⁷ Lockwood,⁸ Guerrero Santos,⁹ and many others around the world have contributed to the development of surgery in the abdominal area.

Concerning vascularization studies, contributions from El Mrakbey,¹⁰ Boyd and Taylor¹¹ and others have highlighted the associated morbidity related to the extension of the undermining in these procedures.

The classifications of the pathology, according to Pitanguy¹² and Bozola,¹³ allowed more precise and correct surgical indication by choosing the technical options and the extension of each procedure.

Baroudi’s⁵ stitch technique greatly diminished the occurrence of seroma formation by plicating the abdominal flap to the aponeurosis. Seroma formation, together with infection and skin necrosis, are the major complications of this procedure in the postoperative period.

Bozola¹³ described the umbilical position, which can be measured in a geometric proportion of 1 for the infraumbilical portion and 1.5 for the supraumbilical area, giving a harmonic relationship to the abdomen (Fig. 22.1). The umbilical position will be the parameter for our assessment concerning the removal of the infraumbilical flap, so we must be extremely careful with those patients having a high umbilical scar position.

FIG. 22.1 Geometrical position of the umbilical scar described by Bozola.

However, the greatest advancement in the evolution of abdominoplasty was the use of liposuction. The liposuction studies by Illouz,¹⁴ Avelar,⁶ Saldanha,¹⁵ Hunstad¹⁶ and Klein¹⁷ highlighted the safety of this procedure in regular association with traditional abdominoplasty. Liposuction decreases fat thickness and reduces the undermining required. This results in both harmonious and satisfactory outcomes for the patients and their respective surgeons.

In our clinical practice we are in favor of the previous resection of the abdominal flap as proposed by Pontes⁴ since 1964. The ease of the resection, the absolute control of bleeding, scar symmetry, and improved speed and efficiency of the procedure are our critical points to advocate the abdominoplasty with previous flap resection as our routine technique. In addition, improved flap handling is another distinct advantage and further emphasizes our preference for this procedure.

Preoperative Preparation

Once the patients have disclosed their expectations about the surgery, we carefully analyze the deformity to indicate the best technical option for the case. The surgery must be clearly discussed with the patient beforehand so as to avoid any misunderstandings with regards to scarring and the final esthetic results.