Introduction

The abdominal wall is one of the regions that most frequently presents with a wide range of anatomical variations. This is due to several factors, which include inadequate diet, pregnancy, sedentary lifestyle, weight loss, and loss of skin elasticity. These can be challenging deformities to address.

Traditional abdominoplasty and mini-abdominoplasty procedures with or without liposuction, usually address most of these problems. However, skin with or without fat excess, especially in the supraumbilical abdominal region, still remains a challenge to most plastic surgeons.

The first description of skin and adipose tissue resection in the upper abdomen was made by Thorek in 1942.¹ However, in 1977 Rebello & Franco described and systematized the approach through the inframammary sulcus for abdominal plastic surgery.² After this period, reverse abdominoplasty was practically forgotten about for many years. This was primarily because it was said to result in poor esthetic results with regards to the inframammary scars.³

However, TRA should be considered a therapeutic option by plastic surgeons, as it is possible, through inframammary incisions, to correct abdominal deformities in the supraumbilical portion.

This chapter proposes a modification of the original technique, based on the upper traction of the flap and its strong fixation to the abdominal aponeurosis, resulting in a tension-free inframammary scar.⁴ The inframammary scar extension and the dissection amplitude are determined by the intensity of the supraumbilical deformities.

This technique should be primarily indicated for patients complaining of skin laxity mainly in the upper abdomen and patients prone to have such excess after liposuction. In these cases, it should be always considered that there is insufficient skin excess for indicating a suprapubic abdominoplasty, and that mini-abdominoplasty would render less than optimal results.

Patients with previous inframammary scars favor this technique, especially if the scars are extensive and are unifying or almost unifying at the midline. Similarly, breasts with wide bases, even without previous incisions, favor the utilization of this technique, as they tend to better hide the resulting scar. On the other hand, this technique is contraindicated to patients with previous history of keloids or hypertrophic scars, especially in cases that require scar unification at the midline.

This technique can also be indicated to patients who had abdominoplasty procedures in the past, but show unsatisfactory results, such as dermal-fat residues or skin excess in the supraumbilical portion.

Preoperative Preparation

Preoperative marking is done preferably in the orthostatic position, by exerting upper traction on the flap towards the breasts and determining the amount of skin to be resected. At this moment, the required extension of the inframammary scar and the eventual need to unify the scars at the midline are defined. This step is extremely important, as the patients are divided into two groups.

FIG. 23.1 Incision (dotted red line) and dissection (grey area) in Group 1.

FIG. 23.2 Incision (dotted red line) and dissection (grey area) in Group 2.

Surgical Technique

The flap to be dissected should be infiltrated with saline solution and epinephrine, at a concentration of 1 : 500 000. Epinephrine (1 mg) is used for each 500 ml of saline. The amount varies depending on the extension of the area to be treated and the patient’s measurements. One liter is needed for the entire abdominal surface, and about 500 ml for just the superior half are usually used. In cases of excessive fat, the procedure begins with a liposuction, which can be limited to the flap region or include the entire abdominal wall.⁵ In both groups, dissection is performed with electrocautery at the anterior aponeurotic plane, resulting in one or two dermal-fat flaps (Fig. 23.3).

FIG. 23.3 Dissected flap showing traction lines and the midline fascia plication markings in methylene blue.

If indicated, supraumbilical plication of the abdominal fascia at the midline is performed, with monofilament nylon threads in two planes. The first aponeurotic suture is done with single interrupted sutures of 2–0 nylon monofilament (Fig. 23.4). The second line of suture is accomplished with a continuous suture of 3–0 nylon monofilament (Fig. 23.5).

FIG. 23.4 Midline fascia plication, first suture with separated stitches.

FIG. 23.5 Complete midline fascia plication.

After performing the dissection and muscle plication based on individual requirements, the principle of progressive and continuous tension sutures is applied towards the inframammary incision (Fig. 23.6).^6,7 The location of traction lines is marked with methylene blue, with each suture intended to perform superior traction on the flap.

FIG. 23.6 Progressive and continuous tension sutures towards the inframammary incision.

In Group 1 patients, upper traction of the flap is performed with three to five lines of parallel sutures, because the dissections are wide and the flaps are usually heavy, requiring strong fixation.

In Group 2 patients, two smaller and lighter flaps are produced. In these cases, two traction lines are usually made in each tunnel. The traction sutures start right above the umbilical scar.

Polygalactine 2–0 threads with a 4 cm needle are used for flap fixation and traction. The surgeon or the assistant should pull the flap towards the incision, in such a way that each stitch determines a superior traction of the flap as a supporting maneuver for flap cranial progression (Fig. 23.7). The suture should include Scarpa’s fascia, but avoid getting close to the dermis as, although the threads are absorbable and the skin depressions will spontaneously disappear, external notches take a long time to fade and can be distressing to patients.

FIG. 23.7 Upper traction of the flap for fixation to the aponeurosis.

In Group 1 patients with larger dissections with a single flap, after flap traction and fixation, the dermal-fat excess is divided at the midline and symmetrically resected (Fig. 23.8).

FIG. 23.8 The dermal-fat excess is cut in two at the midline for symmetric resection.

In Group 2 patients with smaller dissections with two flaps, the fixation with superior oblique traction determines dermal-fat excesses bilaterally, which are resected after precise measurement.

For the sake of preserving the submammary sulcus, it is very important to perform a deep flap fixation using polygalactine 2–0 thread, a second plane of subcutaneous sutures with polygalactine 3–0 thread and a final intradermal suture with polygalactine 4–0 thread (Fig. 23.9). In cases of incision unification at the midline, the scar is M-shaped to minimize risks of hypertrophic scars and scar retractions (Figs 23.10 and 23.11). In cases with persistent skin excess in the lower abdomen, resections can be performed with limited dissection, as done in mini-abdominoplasty. No drain placement is performed.

FIG. 23.9 Reconstruction of the submammary sulcus.

FIG. 23.10 Immediate postoperative result showing M-shaped scar.

FIG. 23.11 M-shaped submammary scar: late postoperative aspect (Group 1).

Optimizing Outcomes

Postoperative Care

After the procedure, the dissected abdominal area is cushioned with dressing pads (cotton wrapped in gauzes), and compression garments should be worn for 4 weeks.

In cases of reverse abdominoplasty with larger dissection or cases of medical or surgical comorbidities, the patient remains hospitalized for 24 hours. In cases of reduced dissection, the patient is discharged from hospital at least 8 hours after the end of the procedure. Early ambulation is encouraged in the first few hours postoperatively.

The patients receive nonsteroidal anti-inflammatory drugs combined with regular analgesics for 4 days if required. All patients receive a dose of antibiotics at anesthesia induction, which is repeated if the procedure lasts for more than 3 hours.

Results are shown in Figs 23.12 and 23.13.

FIG. 23.12 Group 1 patient submitted to TRA associated with liposuction.

(A, C) Preoperative pictures and (B, D) late postoperative results.

FIG. 23.13 Group 2 patient submitted to TRA.

Preoperative pictures (A, C) and late postoperative results (B, D).

Complications and Their Management

In patients requiring incision through the midline (Group 1), there is a risk of skin redundancy in this region, producing an esthetically unpleasant situation, similar to synmastia. It is usually caused by insufficient skin resection at the midline, and these patients should be subsequently treated with excision of the skin excess under local anesthesia.

Double unilateral inframammary sulcus may be present at the final result. This is usually due to an asymmetric resection of the dermal-fat excess, resulting in unilateral skin redundancy, or as asymmetric traction sutures, especially at the stitches closer to the mammary sulcus.

Conclusion

TRA is an efficient and safe technique, which can render good esthetic results in cases of abdominal laxity primarily in the supraumbilical half of the abdomen. The continuous suture offers reduced surgery time and, when following the pre-marked lines of suture, it is possible to determine a better balance in the distribution of tension forces that act on the flap.

This technique should be considered in cases in which conventional abdominoplasty would result in a less than optimal esthetic improvement, and, if carefully indicated, is an important option among the surgical possibilities for treating the abdominal region.