Reverse abdominoplasty

Published on 23/05/2015 by admin

Filed under Plastic Reconstructive Surgery

Last modified 22/04/2025

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Chapter 23 Reverse abdominoplasty

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.

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).

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).

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.

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.

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).

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.

Optimizing Outcomes

We use the navel as the inferior limit of dissection in almost all cases. Even so, due to intense upper traction of the flap, it is possible to observe reduced skin redundancy in the infraumbilical segment as well. Nevertheless, the inferior dissection can be carried further down, releasing the umbilical scar and enabling midline plication along the whole extension of the abdominal fascia, as originally proposed by Rebello and Franco.2 This procedure is considered safe, once vascularization will be kept by preserved lateral perforating and inferior epigastric arteries.

We prefer a modification of the tension suture method – continuous and with guiding lines. Continuous sutures make the procedure easier and faster, but we understand that the technique can also be performed with separated stitches, without affecting the final result.

In Group 2, when performing resections with limited mammary sulcus incisions, we frequently need to associate TRA with mini-abdominoplasty to have good esthetic results. In this way, TRA performs upper traction of the abdominal wall and mini-abdominoplasty performs lower traction towards the pubis.

The adequate reconstruction of the inframammary sulcus is extremely important for the final result. The incision is sutured in three planes, with the deeper sutures fixed to the aponeurosis for a better definition of the mammary sulcus position. When performed as described above, the flap is fixed to the abdominal wall and does not tend to displace caudally to its initial position. This procedure minimizes the tension on the resulting scar and prevents the inframammary sulcus or breasts displacement. We always try to keep the inframammary sulcus at its original position.