The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

The patient is instructed to maintain the flexed position for 1 week. At the end of
the week the patient is instructed to practice slow straightening exercises. Most pa-
tients will be able to stand up fairly straight by 10 to 14 days after surgery. Drain
management for any surgical procedure is widely variable and depends on the sur-
geon’s philosophy and experience. Belt lipectomy is no exception, but drain man-
agement is particularly important because of the relatively high incidence of sero-
mas, especially in massive-weight-loss patients who have high BMIs. We do not think
that any particular protocol of drain management will actually decrease the rate of
seroma formation, but a reasonable approach is to start removing drains that reach
the criterion of less than 40 ml of drainage per 24 hours, starting the third day af-
ter surgery. In most cases the anterior drains will reach this criterion within the first
7 to 10 days. The posterior drains will usually be the slowest to reach this criterion,
and in some patients they will not have reached it at 14 days. In this instance, a scle-
rosing agent is injected through the drain every 2 to 3 days in an attempt to decrease
the size of the pocket. We prefer to use doxycycline as the sclerosing agent. Once the
drainage drops to approximately 80 ml per day, the drain is removed and the possi-
ble seroma is dealt with through serial aspirations. Early in the postoperative period
the use of compression garments should be individualized to the patient, because
circumferential compression in this group of patients can potentially cause skin necro-
sis of the lower abdominal flap. We use compression garments after concerns about
flap vascularity have passed, usually 4 to 5 days after surgery. Patients are instructed
to keep the garment on as much as they can tolerate for up to 6 months.
Patients can usually return to normal, nonvigorous activity after 4 to 6 weeks. They
are advised to slowly increase their activity level, depending on how they feel, with
really strenuous exercise discouraged for at least 3 months. Swelling superior to the
scar, especially anteriorly, will be significant and apparent for at least 3 months.
Overall truncal contour will start to stabilize in appearance at about 1 year but can
continue to improve for years, especially if the patient loses more weight.
Complications
We evaluated 70 consecutive belt lipectomy patients; 85% were women and 15%
were men. Fifty-six percent had at least one complication, 21% had more than one
complication, 44% had no complications at all, and no deaths occurred in the se-
ries. Complications occurred in 55% of women and 56% of men. When complica-
tions were stratified according to BMI, it was noted that the rate of complications
increased as the BMI increased. Seromas were the most frequent complication, oc-
curring in 30% of patients, with an increase in frequency as the BMI rose. The fairly
large number of seromas can be attributed to the very large area of dissection, with
most of these fluid collections occurring in the back (back dissections are associated
with seromas in general). Small wound separations occurred in 20% of the patients,
2920
Part XII  Body Contouring

2921
Chapter 82  Body Lift: Belt Lipectomy
with a few fascial dehiscences requiring surgical intervention. Dehiscences were caused
by mechanical stress on the wounds, which mostly occurred within the first 24 hours
after surgery.
Preventing patients from moving until they are completely awake and instructing
them to guide their own ambulation are very helpful in reducing this problem. The
other cause of dehiscence is large seromas that cause breakdown at the wound edge
to allow drainage. Detection and frequent aspiration of seromas will help reduce that
risk. Infections occurred in 4.3% of the patients and were almost always associated
with seromas. They were controlled through appropriate seroma drainage and an-
tibiotic therapy. Pulmonary emboli occurred in 2.9% of the patients. To prevent this
serious complication, all patients were required to wear sequential compression gar-
ments intraoperatively and while in their hospital bed. They were also ambulated as
soon as possible after surgery.
Despite such efforts, these problems can still occur, and any suggestive symptoms
should be investigated. Since this study was conducted, we have used postoperative
epidural analgesia, and the rate of DVT/PE has dropped to zero.
Lower midline abdominal flap skin or fat necrosis occurred in 4.3% of the patients.
In two patients, the lateral abdominal flap was tailored at an acute angle to match
an acute angulation of the inferior line of resection that traversed from the lateral
mons pubis to the ASIS. This was done to create a high French bikini line–shaped
scar. This is believed to have led to a reduction of the number of lateral perforators
reaching the inferior midline of the abdominal flap. Thus it is wise to avoid extreme
angulation of the lateral abdominal flap. Another cause of abdominal flap necrosis
was encountered in two patients who had a midline supraumbilical scar that had to
be resected to allow advancement of the abdominal flap at closure. When the ab-
dominal flap is incised in the midline, there is a reduction of the blood supply at the
level of the subdermal plexus to the inferior medial edge of the skin on each side. If
this is combined with aggressive resection of the abdominal flap in the vertical di-
rection, leading to significant tension at closure, vascular compromise may occur.
Thus, as previously mentioned, we have abandoned the practice of resecting teth-
ered midline scars and replaced that with serial stab incisions to release the flap.
Outcomes
In properly selected patients who undergo belt lipectomy, significant improvements
in their inferior truncal contour can be achieved. The outcomes of surgery can be
categorized into two main groups: massive-weight-loss patients and non–massive-
weight-loss patients. Each group can be further divided into subgroups that can help
the surgeon better predict the possible outcome for a particular patient. The classi-

fication of patients discussed here, which is based on weight at presentation, is help-
ful in predicting outcome. However, it is not the only telling factor, because the pa-
tient’s fat distribution pattern and the absolute decrease in BMI from the greatest to
the lowest weight are also important.
Massive-Weight-Loss Patients
This group of patients is defined as any patient whose weight at one time was in the
obese range (a BMI of 30 or above) and subsequently lost a significant amount of
weight. Although generally that amount is often felt to be at least 45 kg (100 pounds),
patients who are small in stature can lose less weight and still qualify as massive-
weight-loss patients. The results that can be expected from this group of patients are
divided into clinically relevant subgroups according to the weight at which they sta-
bilized before surgery. As a general trend, the lower a patient’s BMI at presentation,
the closer to normal his or her body contour will be after surgery.
Still Significantly Obese With a BMI of 35 or More
The subgroup of patients who still have a BMI above 35 will achieve significant im-
provement in their inferior truncal contour through belt lipectomy, but generally they
do not attain what is considered normal for the overall population. They often have
other body areas, especially the thighs, where a significant amount of fat is still re-
tained, preventing an appearance of normality. They have a very significant increased
risk of complications, seromas being the most common problem. Often they will re-
quire treatment of other areas of the body to reach the norm for the population.
Near Ideal Body Weight With a BMI of 28 or Less
The closer a patient is to ideal weight at presentation, the better the final contour af-
ter belt lipectomy. Commonly the subcutaneous fat layer encountered in this sub-
group of patients allows the overlying skin to move freely over the underlying mus-
cular framework. This permits the surgeon to resect larger amounts of excess skin
and to transmit the effects of the pull on tissues located far from the areas of the re-
section. This subgroup of patients generally achieves a remarkable improvement that
will place them in the normal range of body contour; some even attain ideal body
contour. Their complication rate is relatively low, especially when compared with
the still-obese subgroup of patients previously discussed.
Intermediate Weight Level With a BMI of 29 to 34
Patients in this intermediate subgroup generally attain results that are intermediate
between the two subgroups discussed previously and would be considered on a con-
tinuum between them. They will attain a significant improvement in their inferior
truncal contour and would generally be considered to have body contours within
2922
Part XII  Body Contouring

the norm for the overall population. Their results are similar to the group that is 20
to 30 pounds overweight discussed below. Their complication rate is intermediate
between the two subgroups mentioned previously.
Massive-Weight-Loss Patients Who Have Undergone
Anterior Resection
This subgroup is composed of massive-weight-loss patients who have had derma-
tolipectomy procedures limited to the anterior abdomen. They are grouped separately
because they have distinct complaints; this group is growing in increasing in num-
bers. Typical patients in this group are initially seen with the complaint that before
their previous surgery they were told that they needed only an abdominoplasty or
panniculectomy. After that surgery was performed, these patients are often disap-
pointed with the increased lateral prominence caused by the limited anterior resec-
tion’s dog-ears and the lack of improvement of the waist, hips, back, and buttocks.
Depending on the patient’s contour at presentation, a partial, modified, or full belt
lipectomy will be appropriate. The results can be predicted based on the BMI cate-
gories described previously.
Non–Massive-Weight-Loss Patients
Patients 20 to 30 Pounds Overweight With a BMI of 26 to 29
This subgroup comprises patients who are 9 to 14 kg (20 to 30 pounds) overweight,
have not been able to lose the weight despite real attempts, and have never been ap-
preciably heavier. A significant improvement in their inferior truncal contour is gen-
erally attained with surgery. They start out with contours that are within the norm
for the general population and will attain significant improvement toward an at-
tractive contour with belt lipectomy. Results in this subgroup are similar to those of
the intermediate subgroup in the massive-weight-loss group discussed earlier. Their
complication rate is also similar.
Normal-Body-Weight Patients
Patients who are at or near their ideal body weight may have abdominal wall laxity
and/or skin excess amenable to abdominoplasty; they also usually have different de-
grees of isolated fat deposits amenable to liposuction. However, they will specifically
desire remarkable elevation and definition of their buttocks contour, and some pa-
tients will request more waist definition. The postoperative abdominal and lateral
truncal contour in this subgroup of patients usually demonstrates the typical effects
attained by abdominoplasty, in addition to remarkable improvement in buttocks con-
tour that would not be attainable by liposuction alone. These patients present within
the norm of the general population and should have a remarkable improvement in
their inferior truncal contour after belt lipectomy.
2923
Chapter 82  Body Lift: Belt Lipectomy

2924
Part XII  Body Contouring
Results
The following patient examples demonstrate the results attainable in the patient cat-
egories that have been discussed. These cases show variations of technique and de-
formities and help to delineate the limitations of belt lipectomy.
This 33-year-old woman reached her highest weight at a BMI of 45. She lost 45 kg
(100 pounds) after bariatric surgery and presented with stabilized weight at a BMI of
29. She is shown before and after undergoing a belt lipectomy. Her postoperative
photographs demonstrate an excellent improvement in her inferior truncal contour
with elimination of the pannus, flattening of the belly, elevation of her mons pubis,
creation of waist definition, and elevation and definition of the buttocks. Although
her lower back rolls were eliminated, the upper truncal deformities were minimally
affected and more outlined after belt lipectomy. The same can be observed in her
thigh region. Thus both the superior truncal subunit and the thighs will need fur-
ther surgical intervention.

This 52-year-old woman’s BMI at her greatest weight was 49. She subsequently un-
derwent a gastric bypass procedure and lost 36 kg (80 pounds) before stabilizing at
a BMI of 37. She is shown before and after undergoing a belt lipectomy. She presented
with a preoperative circumferential inferior truncal excess of skin and fat, mons pu-
bis ptosis, abdominal wall laxity, and a fairly unique pattern of hip lipodystrophy.
The pattern of posterior resection used in this patient was adjusted inferiorly to ad-
dress the prominent hip roll. After a belt lipectomy, her abdomen is flat, the mons
pubis is partially elevated, and the extra hip roll is eliminated. Because her present-
ing BMI was still in the morbidly obese range, her improvements, although signifi-
cant and very much appreciated by the patient, are tempered by the fact that she still
has an overall body contour that would not be considered within the norm for the
whole population. Her fat deposition pattern dictates that her lower extremity has
persistent lipodystrophy after significant weight loss, which contributes to the less
than ideal body contour. Patients in her weight range often have a thick subcuta-
neous fat layer that reduces the mobility of the skin-fat envelope over the underly-
ing muscle fascia. This prevents improvement of anatomic contour located at a dis-
tance from the actual dermatolipectomy resection, such as the infrabuttocks creases.
2925
Chapter 82  Body Lift: Belt Lipectomy

This 31-year-old woman who had triplets and then another child reached her high-
est weight at a BMI of 41. She subsequently lost 26 kg (60 pounds) as a result of
lifestyle changes, reaching a BMI of 30. She is shown before and 14 months after
surgery. She presented with significant abdominal wall laxity, a single roll pannus,
mons pubis ptosis, and a lack of waist definition. Her buttocks appeared long verti-
cally and lacked definition but were not overprojected. The surgical technique we
employed had a more superiorly positioned posterior excision, because she did not
need a reduction of her posterior buttocks projection. Placement of the scar in the
posterior vertical position chosen allowed the surgeon to create the desired depres-
sion in contour at the junction of the back with the buttocks. This was accomplished
by thinning the inferior advanced flap. If the scar had been placed lower, onto the
buttocks proper, this maneuver would not have been possible, because it would have
created a depression in the superior buttocks area.
Postoperatively, the patient has a flattened abdominal contour and an elevated mons
pubis, and an attractive waistline has been created. Her buttocks are better defined
and appear shorter in the vertical dimension. Note that this patient does not need
surgery to the upper truncal subunit or the lower extremity, which correlates with
her range of BMI.
2926
Part XII  Body Contouring

This 38-year-old woman had reached a BMI of 42 before losing 45 kg (100 pounds)
through diet and exercise. At presentation, her BMI was 25 for a total drop of 17 in
BMI. She is shown before and 1 year after surgery. Postoperative photographs reveal
elimination of her hanging skin, flattening of the abdomen, elevation of the mons
pubis, increased soft tissue cover over the coccyx, increased buttocks definition, and
improvement in the redundancy below the infrabuttocks creases. Because she had a
relatively significant drop in her BMI, she presented with a small amount of subcu-
taneous fat. This allowed the surgeon to “translate the pull” to greater distances from
the line of resection, especially compared with patients who have a much thicker
subcutaneous fat layer. Thus the significant improvement of the infrabuttocks creases
and the moderate improvement of the anterior thighs can be attributed to her thin
subcutaneous fat layer. Patients in this range of BMI will often attain a near-ideal
body contour after surgery.
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Chapter 82  Body Lift: Belt Lipectomy

This 44-year-old woman originally reached a BMI of 72. She lost more than 91 kg
(200 pounds) after gastric bypass surgery and stabilized at a BMI of 33. She is shown
before and after undergoing a subsequent belt lipectomy. The procedure was adapted
to her open cholecystectomy scar, which required a reverse approach to the abdom-
inal resection. Thus her abdominal superior incision was made first during the an-
terior resection, at the level of the cholecystectomy scar, and the inferior flap was ad-
justed to the superior flap. This resulted in a more superiorly positioned anterior
abdominal scar.
Excellent contour was achieved through the surgery, but she continued to lose weight,
reaching a BMI of 25 at the time the postoperative photographs were taken 1 year
after surgery. However, she did not feel well at that weight and intentionally gained
weight to reach a BMI of 26.6. It is unusual for a stabilized weight-loss patient to
lose the remarkable amount of weight this patient did. Her BMI of 33 at presenta-
tion would ordinarily predict less improvement than she actually has attained. The
better-than-expected improvement is the result of the very large drop in BMI, which
led to greater elasticity and redundancy of the skin-fat envelope and thus provided
the surgeon a greater ability to resect the excess.
Overall, she has a remarkable improvement in her circumferential inferior truncal
contour. Her pannus was eliminated and a flat abdominal contour achieved, her
mons pubis was elevated, her waist was defined, and her lower back rolls were elim-
inated. Her buttocks contour at a BMI of 25 was too deflated and improved with
her weight gain to a BMI of 26.6, but her lateral thighs increased in prominence be-
cause of her genetically controlled fat deposition pattern. The upper truncal subunit
contour was unaffected by the belt lipectomy; she will need an upper body lift to at-
tain maximal improvement in those areas.
2928
Part XII  Body Contouring
Preoperative
2 years postoperatively
1 year postoperatively

2929
Chapter 82  Body Lift: Belt Lipectomy
Preoperative
2 years postoperatively
1 year postoperatively

This 46-year-old patient is shown before and 21⁄2 years after belt lipectomy. At pre -
sentation, she was 18 kg (40 pounds) overweight with a BMI of 31.2. She was not
able to lose the weight despite multiple serious attempts over a number of years. Her
complaints were concentrated on the lower truncal subunit and included abdomi-
nal wall laxity, excess abdominal skin and fat, lack of waist definition, lipodystro-
phy of the hips and lower back region, and ill-defined buttocks that appeared long
in the vertical dimension. She was offered a traditional abdominoplasty and lipo-
suction but was warned that her lateral excess might not be eliminated. She refused
that approach and underwent a belt lipectomy. Postoperative photographs demon-
strate a flat abdomen, a well-defined waist, elimination of the lower back rolls, and
well-defined buttocks that appear shorter in the vertical dimension. This patient is
fairly representative of patients who are 14 to 23 kg (30 to 50 pounds) overweight.
2930
Part XII  Body Contouring

This 44-year-old woman presented with a BMI of 23. She requested improvement in
abdominal contour, elimination of her right lower quadrant scarring, and reduction
of her hip and lateral thigh lipodystrophy. She was offered an abdominoplasty and
liposuction to the hips and lateral thighs, but elected to undergo a belt lipectomy be-
cause of her specific desire to lift and improve her buttocks contour. She is shown
before surgery, 1 year after surgery, and 4 years after surgery.
After 1 year there is improved abdominal contour and an outstanding improvement
in buttocks contour. Four years after surgery, she is shown after a 9 kg (20-pound)
weight gain despite a continued good exercise regimen. Although she has retained
benefits from the surgery, it is apparent that a rise in BMI from 23 to 27 has led to a
return of some of her original fat deposition pattern.
2931
Chapter 82  Body Lift: Belt Lipectomy
Preoperative
4 years postoperatively
1 year postoperatively

Clinical Caveats
 Patients with excessive intraabdominal content are not good candidates for belt
lipectomy.
 The goal of belt lipectomy surgery is to create proper contour of the inferior sub-
unit of the trunk and to place the resultant scar in natural junctions.
 There are many types of patients who can benefit from belt lipectomy, the most
prevalent being massive-weight-loss patients.
 Multiple factors contribute to the widely variable presentation of massive-weight-
loss patients, including the BMI at presentation, the difference between the high-
est and lowest BMI, and the genetically controlled fat deposition pattern.
 The anterior abdominal contouring aspect of belt lipectomy should be emphasized
over the back resection. The lateral resection should be maximized to create the
best possible lateral contour.
 Belt lipectomy should be thought of as a circular excision of the lower trunk, in
the shape of a “boxing championship belt,” wide anteriorly and narrow posteri-
orly.
 Since dehiscence is of major concern in the postoperative period, the extent of the
midline back excision is marked with the patient flexed at the waist to approxi-
mate the flexed position that the patient will be in after the anterior resection.
 Upper arm excess in massive-weight-loss patients crosses the axilla onto the lat-
eral chest wall and to treat that deformity, the brachioplasty technique used needs
to cross the axilla.
 In a massive-weight-loss patient the thorax, or the superior truncal subunit, will
often have deformities that may require a combination of procedures called an up-
per body lift to normalize the appearance of that subunit.
 The postoperative recovery from belt lipectomy, especially in a massive-weight-
loss patient, is a long and difficult process and should not be taken lightly by the
patient or the surgeon.
 As a general rule, especially in massive-weight-loss patients, the lower the patient’s
BMI before surgery, the better the results and the lower the complication rate.
 Seromas and small wound separations are the most common complications asso-
ciated with belt lipectomy surgery.
 Overall, complications are not uncommon with belt lipectomy surgery; the higher
the patient’s BMI before surgery, the higher their risk for complications.
2932
Part XII  Body Contouring

Annotated Bibliography
Aly A, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess: the Uni-
versity of Iowa experience. Plast Reconstr Surg 111:398-413, 2003.
This review article critically evaluates a large series of belt lipectomy patients. The au-
thors delineate guidelines for patient selection, introduce a classification scheme for pa-
tients undergoing belt lipectomy, define the truncal deformities encountered in their pa-
tient population, evaluate the effects of surgery on different groups of patients, and
quantitatively report on their complications.
Hamra ST. Circumferential body lift. Aesthet Surg J 19:244-250, 1999.
The author describes the use of circumferential dermatolipectomy on a series of non-
massive-weight-loss patients.
Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept.
Plast Reconstr Surg 87:1009-1018, 1991.
The author defines the superficial fascial system and how it is to be used in body con-
touring.
Van Geertruyden JP, Vandeweyer E, de Fontaine S, et al. Circumferential torsoplasty. Br J
Plast Surg 52:623-628, 1999.
This article describes a series of massive-weight-loss patients who have undergone cir-
cumferential torsoplasty.
Suggested Readings
Baroudi R. Body contouring surgery in the 90s. In Advances in Plastic and Reconstructive
Surgery, vol 9. St Louis: Mosby–Year Book, 1992.
Burget G, Menick F. Aesthetic Reconstruction of the Nose. St Louis: Mosby–Year Book, 1994.
Carwell R, Horton CE Sr. Circumferential torsoplasty. Ann Plast Surg 38:213-216, 1997.
Dardour JC, Vilain R. Alternatives to the classic abdominoplasty. Ann Plast Surg 17:247-
258, 1986.
Delay E, Gounot N, Bouillot A, et al. Autologous latissimus breast reconstruction: a 3-year
clinical experience with 100 patients. Plast Reconstr Surg 102:1461-1478, 1998.
González-Ulloa M. Belt lipectomy. Br J Plast Surg 13:179-186, 1961.
Hunstad JP. Body contouring in the obese patient. Clin Plast Surg 23:647-670, 1996.
Lockwood TE. Lower-body lift. Aesthet Surg J 21:355-370, 2001.
Millard DR Jr. Principalization of Plastic Surgery. Boston: Little Brown, 1986.
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Abdominoplasty

GILBERT P. GRADINGER,
LORNE K. ROSENFIELD, FARZAD R. NAHAI
CHAPTER 83

A
bdominoplasty is performed to correct soft tissue abnormalities of the ante-
rior trunk, from the lower border of the ribcage to the inguinal and pubic ar-
eas. Body contour problems involving the fat and skin of the lateral and posterior
truncal regions are treated with liposuction and extended dermolipectomy.
Plastic surgeons who perform abdominoplasty have recognized that variations in ab-
dominal contour require modifications in surgical procedure. Newer techniques re-
quire shorter incisions and eliminate umbilical circumscription. In the past, patients
who sought contour reduction had only one choice—abdominoplasty. Today supe-
rior aesthetic results can be achieved in many patients with liposuction alone. Lipo-
suction combined with abdominoplasty has enhanced our ability to achieve better re-
sults. Small fat deposits, which cannot be treated with abdominoplasty, are ideal for
liposuction, which is associated with insignificant scarring, minimal inconvenience,
and negligible morbidity. On the other hand, treatment of a massive-weight-loss pa-
tient mandates more aggressive and advanced techniques to repair this multifaceted
deformity.
Plastic surgeons now have a much wider range of choices for operative correction
of the many abdominal deformities, including the following:
 Liposuction alone
 Complete abdominoplasty with or without umbilical translocation
 Lower abdominoplasty
 High lateral tension abdominoplasty
 Fleur-de-lis abdominoplasty
 Reverse abdominoplasty
Surgery may involve one option, a variation on an option, or a combination of options.
Indications and Contraindications
The typical abdominoplasty patient is a woman (although increasingly men are also
seeking treatment) who has had one or more full-term pregnancies and a subsequent
loss of youthful abdominal contour. Most of these women have tried exercise and
dieting but have been unable to regain their prior shape. Obesity may or may not be
2936
Part XII  Body Contouring

a factor. Usually an excess of fat is present. The skin of the abdomen is stretched from
pregnancy weight gain and subsequent weight loss. Dermal breakdown, as evidenced
by stretch marks, is often present. The quality of the lower abdominal skin often de-
termines the relative roles of surgical lipectomy versus liposuction. The status of the
underlying fascia and abdominal wall muscles also dictates which surgical approach
is indicated.
The patient criteria to be considered must be exhaustive if the surgeon is to avoid
major complications and patient dissatisfaction. The elements of a successful ab-
dominoplasty include the following:
 Weight: Stable for more than 6 months and not grossly overweight (BMI less
than 30)
 Medical condition: No major medical issues such as labile hypertension, dia-
betes, or coronary artery disease
 Psychological state: Well motivated and realistic (for example, postpregnancy or
gastric bypass patients)
 Habits: Regular exercise, reasonable diet, and no smoking or excess alcohol
consumption
 Anatomy: Absence of multiple abdominal scars and no extreme abdominal
protrusion (secondary to intraabdominal fat accumulation)
Pertinent Anatomy
FARZAD R. NAHAI
When considering aesthetic procedures of the abdomen, the surgeon must be thor-
oughly familiar with the anatomy of the abdominal wall. A clear understanding of
the blood supply and soft tissue layers is critical when planning incisions, determin-
ing the amount of tissue to be resected, and deciding whether concomitant liposuc-
tion or lipectomy is indicated. It is also important when managing the umbilicus and
calculating the degree of flap elevation, especially in patients who have had prior ab-
dominal procedures. The specific anatomy most relevant to the understanding and
application of these complementary techniques includes the zones of adherence, the
superficial fascial system, and the blood supply remaining after each approach.
2937
Chapter 83  Abdominoplasty

2938
Part XII  Body Contouring
Soft Tissue Layers of the Abdominal Wall
Peritoneum
Anterior rectus sheath
External
oblique muscle
Rectus abdominis
muscle
Internal
oblique muscle
Transversalis
muscle
The abdominal wall is composed of six distinct soft tissue layers: skin, subcutaneous
fat, subscarpal fat, anterior rectus sheath, muscle, and a posterior rectus fascia. It
spans the area between the costal margin, midaxillary line, iliac crest, and sym phy -
sis pubis—a sort of elongated hexagon. The layers of the abdominal wall are con-
sistent in their relationship to each other; the variability occurs with regard to the
quality of the tissues and amount of fat present.
Skin
The skin of the abdomen receives its blood supply from multiple muscle and fascial
perforating vessels that feed a subdermal vascular plexus. Depending on multiple pa-
tient characteristics (such as age, BMI, and number of full-term pregnancies), the
skin of the abdomen can have differing degrees of elasticity. Often, the skin of the
patient being considered for abdominoplasty is stretched, demonstrating poor elas-
ticity and multiple striae. These striae are surface evidence of attenuated or absent
underlying dermis. The location and extent of striae should be considered when plan-
ning skin incisions, because at the time of closure these areas of poor or absent der-
mis are more difficult to close and are at risk for separation. The surgeon should at-
tempt to place skin incisions on the abdomen in such a way that the resultant scars
will be covered by the patient’s choice of undergarments.

2939
Chapter 83  Abdominoplasty
Intramuscular perforator
Subdermal plexus
Scarpa’s fascia
Subscarpal fat
The adipose layer of the abdominal wall can be divided into two layers—superficial
and deep—based on Scarpa’s fascia. The superficial fat layer has a more robust blood
supply, is usually thicker, and has a more dense and durable type of fat. Its vascular
supply is from both the subdermal plexus and the underlying musculocutaneous per-
forators. The deeper layer of fat is typically less dense and receives most of its blood
flow from underlying muscle, making it more prone to ischemia during abdomino-
plasty. This difference in blood supply to the superficial and deep layers of fat is an im-
portant factor to consider during lipectomy of the abdominal flap. Because the an-
terior abdominal wall fat deep to Scarpa’s fascia is not involved in supplying
circulation to the skin, it may be excised during an abdominoplasty. Conversely,
preservation of subcutaneous fat superficial to Scarpa’s fascia is crucial to survival
of the overlying skin.
Muscle and Fascia
There are four principal paired muscle groups of the abdominal wall: the rectus ab-
dominis, external oblique, internal oblique, and transversalis. The common purpose
of these muscle groups is to support the abdominal contents, assist in breathing, and
permit the flexion/rotation of the thorax and pelvis. The external oblique, internal
oblique, and transversalis muscles form the anterolateral wall of the abdomen, span-
ning the costal margin to the midline. The rectus abdominis originates on the anterior
surface at the lower midline of the rib cage and inserts on the symphysis pubis. The
aponeurotic portions of the oblique and transversalis muscles envelope the rectus
abdominis and blend in the midline to form the linea alba, a dense confluence of fas-
cia that separates the left and right rectus muscles. The arcuate line is a transition
point above which the external oblique and a superficial division of the internal
oblique form the anterior rectus sheath, while the deep division of the internal oblique
and the transversalis composes the posterior rectus sheath. Below the arcuate line,
approximately midway between the umbilicus and symphysis pubis, the transver-
salis aponeurosis, along with the deep division of the internal oblique muscles, pro-
gressively transfers to the anterior fascial layer, leaving only the preperitoneal fat be-
tween the rectus muscle and the underlying peritoneum.
Fat

2940
Part XII  Body Contouring
Superficial
epigastric artery
Deep inferior
epigastric artery
Superior
epigastric artery
Subcostal artery
Ascending branch of
deep circumflex artery
Lumbar branches
The blood supply to the muscles, skin, and fat of the abdominal wall comes from
numerous major arteries of the thorax and pelvic region. These arteries exhibit many
anastomotic interconnections that are important for abdominoplasty. Understand-
ing their origins and routes is essential to avoiding ischemic complications.
For the purposes of this discussion, it is helpful to consider the blood supply to the
abdominal wall from two areas: one that is superolateral in origin and the other that
is inferior in origin. Superiorly, the superior epigastric artery, a branch of the inter-
nal thoracic artery, enters the posterior rectus sheath on its way into the rectus ab-
dominis muscle as it emerges from the costal margin immediately lateral to the ster-
num. As it enters the rectus, it is situated medially in the muscle. It then perforates
the rectus abdominis muscle, branching as it descends within the muscle until it anas-
tomoses with the deep inferior epigastric artery. Perforators through the anterior rec-
tus sheath, more densely present in the periumbilical area, supply the abdominal
skin and fat overlying the muscle.
The other terminal branch of the internal thoracic artery is the musculophrenic ar-
tery, which passes inferolaterally deep to the ribs at the costal margin where it anas-
tomoses with the lower and posterior intercostal vessels (direct branches of the aorta)
at the last intercostal space. These posterior intercostal vessels travel between the
transversalis and internal oblique muscles and have collateral, muscular, and cuta-
neous branches. Caudal to these are the subcostal and lumbar arteries, both dorsal
branches of the thoracic aorta, which contribute to this anastomotic network of ves-
sels that course between the transversalis and internal oblique muscles.
Blood Supply

2941
Chapter 83  Abdominoplasty
Deep inferior
epigastric artery
Superior
epigastric artery
Large ascending
branch from deep
inferior epigastric artery
Arcuate line
Flow along
ligamentum teres
Subdermal
vascular plexus
Small perforators
from deep inferior
epigastric artery
Flow along
median umbilical
ligament
It is within this intermuscular space that one of the anastomoses between the su-
perolaterally based vasculature and inferiorly based vasculature exists. The ascending
branch of the deep circumflex artery, a branch of the external iliac artery, originates
from the iliac crest and ascends to the aforementioned anastomotic network. The
two other principal inferiorly based vessels are the paired deep inferior epigastric ar-
teries (DIEAs), a branch of the external iliac artery, and the superficial epigastric ar-
teries, a branch of the femoral artery. The DIEA travels superomedially from its ori-
gin, pierces the transversalis fascia, and runs along the posterior border of the rectus
abdominis muscle before entering it. Once in the muscle, it branches on its way cepha-
lad to anastomose with the branches of the superior epigastric artery. The principal
perforators to the skin, on average five per side, emerge through the anterior rectus
sheath more densely in the periumbilical region. These perforators receive more inflow
from the DIEA than the superior epigastric artery. The superficial epigastric artery
arises from the common femoral artery, 1 cm distal to the inguinal ligament at its
midline, and ascends within the superficial abdominal fascia and fat toward the um-
bilicus. It often arises as a common trunk with the superficial circumflex iliac artery,
superficial external pudendal artery, and deep circumflex iliac artery.
The Umbilicus
The umbilicus is an aesthetically important surface structure of the abdomen. It is
typically situated approximately 14 cm above the symphysis pubis in the midline, or
10 cm above the pubic hair (at the level of the iliac crest). The aesthetically pleasing
umbilicus is shallow, has a thin superior skin hood, and is round or elliptoid in shape.
Blood flow to the umbilicus is from the subdermal plexus, in addition to three dis-
tinct sources: the principal supply is from branches of the right and left DIEAs; ad-
ditional flow is from the ligamentum teres and the median umbilical ligament. Mul-
tiple branches of the DIEA ascend between the rectus muscle and the posterior rectus
sheath on their way to the umbilicus. In a morbidly obese patient, the stretching and

2942
Part XII  Body Contouring
descent of the tissues distorts the vascular anatomy and the umbilicus is elongated.
Extra caution should be exercised when dissecting the umbilicus in these cases. The
fascia around the umbilicus can be weak with a resultant umbilical hernia. Care
should also be taken to dissect around the hernia sac to avoid bowel injury.
Nerves
Cutaneous sensation of the abdomen is derived from the lateral cutaneous and an-
terior cutaneous branches of intercostal nerves T7 through T12. The lateral cuta-
neous branches perforate the intercostal muscles at the midaxillary line to travel
within the subcutaneous plane. The anterior cutaneous branches travel between the
transverse and internal oblique muscles to penetrate the posterior rectus sheath lat-
eral to the rectus muscle before entering the rectus muscle on their way to the over-
lying fascia and skin.
Le Louarn and Mustoe published favorable results demonstrating that preservation
of the suprafascial network of lymphatics (in addition to use of a quilting suture, in
Le Louarn’s case) diminishes time with a drain, and both stated that postoperative
serous drain output, seromas, and abdominal flap swelling is diminished.
The anatomy of the lymphatic system of the ab-
dominal wall is important, because it is clinically
related to the occurrence of serous fluid accu-
mulation and edema after abdominoplasty. A
plexus of lymphatic vessels resides within the
subscarpal fat layer just superficial to the ante-
rior rectus sheath. Below the umbilicus, the lym-
phatic system drains inferiorly via the femoral
route. Above the umbilicus, this system drains
cephalad in the superficial plane to the axilla on
its way to the thoracic duct.

2943
Chapter 83  Abdominoplasty
Preoperative Assessment
LORNE K. ROSENFIELD
A comprehensive examination is crucial to enable the surgeon to properly prepare
the patient and accurately plan surgery.
Physical Examination
The physical exam should include evaluation of all “layers” of the abdominal wall:
the skin, the subcutaneous fat, and underlying fascia/ muscle (with an indirect assess-
ment of the extent of intraabdominal fat).
Skin
The skin examination should involve much more than just the assessment of the clas-
sic pannus of excess lower abdominal skin above the pubis.
Striae
The boundaries of striae are assessed. It should be duly noted and explained to the pa-
tient the extent of the striae that may not be included in the resection (particularly
those above the umbilicus).
Excess Skin
The extent of obvious anterior redundant skin (width of the pannus) is noted first.
This evaluation determines the initial estimation of the length of the incision. How-
ever, a proper assessment must be made beyond the obvious excess lower abdomi-
nal pannus if a more complete correction is to be made at the entire anterior trunk
“aesthetic unit”; that is, the extent of redundancy is evaluated not only above the in-
guinal area but also below the incision, at the hips, thighs, and pubis. If there is par-
ticular excess at the lateral thighs, then the incision will, necessarily be appreciably
Standing, this patient ostensibly has
little excess skin
Same patient in relaxed sitting position

2944
Part XII  Body Contouring
longer, if the high lateral tension abdominoplasty (HLTA) approach is to be prop-
erly applied. On the other hand, if the patient demonstrates minimal excess laterally,
then significant tension should not be planned, for fear of making the incision un-
necessarily longer.
Any excess skin at the upper abdomen should be noted. Here there may be what may
be called a secondary roll or wall of cascading skin, which really represents a mi-
gration of redundancy from the chest rather than the abdomen. Consequently, usu-
ally not all of this upper abdominal skin can be removed from the suprapubic ap-
proach. It is of greater value to conduct this examination with the patient not only
in the supine and standing positions, but also when sitting and bending over. This
is often the only posture in which one can see the areas of redundancy in a patient
who demonstrates what appears to be primarily abdominal wall protrusion. Of equal
importance, the mobility or what may be called the “translation” of the skin should
be assessed, because it can be very telling: the looser the skin, the better the result.

2945
Chapter 83  Abdominoplasty
Adhesions
Waist band
of adherence
The surgeon should note any adhesions of the skin at the thighs and abdomen proper.
Although not previously described, adhesion can also be found at the level of the
waist, particularly laterally: a waistline zone of adherence and contraction. In fact,
there is most often what one may call a second roll of excess skin resting above this
“valley,” most notably in the larger or weight-loss patient. This band essentially di-
vides the abdominal excess skin into superior and inferior segments. The surgeon
must be aware that this adhesion of tight skin will reliably resist the surgeon’s efforts
to efface this upper abdominal excess. And because this zone harbors vital perforators,
only a judicious release of the area by discontinuous undermining should be at-
tempted. Otherwise, this upper abdominal redundancy is best addressed with either
a fleur-de-lis–type abdominoplasty or a second-stage reverse abdominoplasty.
Scars
Any scars at the abdomen are assessed. Of greatest concern are those at the subcostal
and midline areas. These scars require the surgeon to map out the safest and most
effective surgical approach. For a subcostal scar, it is best to restrict the amount of
undermining in this area and if possible even include this scar in the resection with
a fleur-de-lis approach. Similarly, the upper midline scar presents a challenge. Either
a fleur-de-lis–type pattern or a reverse abdominoplasty should be considered. Oth-
erwise, the risk of abdominal flap necrosis is too high. Finally, if there is a full-length
midline scar, the fleur-de-lis template is ideal.

Subcutaneous Fat
Thickness of the Envelope
A topographic sense of the extent of underlying fat must be defined. This mapping
will guide where liposuction could be conducted—and just as important, where it
should not be performed. Usually contouring of the waist, hips, and lateral thigh ac-
centuates the abdominoplasty’s shaping affects and assists the HLTA by facilitating
the translation of pull of the skin with its liposuction-induced discontinuous dis-
section. If the central flap is very thick with fat, it is best to inform the patient that a
second-stage liposuction surgery may be necessary to complete the repair safely.
Abdominal Wall
The Location and Extent of Protrusion
2946
Part XII  Body Contouring
The degree of lower abdominal wall relaxation is assessed with the patient lying
down with knees bent, as well as when standing. The patient, while standing, is asked
to make a conscious effort to relax the abdominal wall. The additional extent of
protrusion that occurs is both surprising and quite informative. Besides the obvious
lower abdominal wall protrusion, one should also assess the magnitude of laxity at
the upper abdomen. Compressing the lower abdominal wall and watching for “her-
niation” of the epigastric area will accomplish this task.
The Presence of a Hernia
The exam should explore for an incisional, epigastric, or periumbilical hernia. This
is particularly relevant, not only for planning to repair the defect, but also to avoid
performing liposuction in these areas before abdominal flap elevation for fear of in-
traabdominal penetration with the cannula.
The Shape of the Waist
If the waist is square and blunted by fat, aggressive liposuction can be very beneficial.
The patient is asked to relax the abdominal wall

Preoperative Photographic Documentation
It is essential to obtain a consistent and complete set of photographs. This should in-
clude one set of eight views (quarter turns) of the patient from neck to knees with
the arms up and a second set with the arms down. Including the anatomic regions
above and below the abdomen mandates that the surgeon assess the entire truncal
“aesthetic unit” to plan the initial surgery or subsequent stages. This allows proper
assessment of the potential far-reaching salutary effects of the HLTA, fleur-de-lis, or
reverse approaches postoperatively.
During the photographic session, the patient is again asked to totally relax the ab-
domen so a true representation of wall laxity can be documented.
Additional views may be photographed, as desired:
 With the patient sitting/bending over to illustrate the true excess skin that is
often hiding (particularly in front of the protuberant abdomen)
 With the patient grasping the excess skin to reproduce the desired lift and po-
tential result of the surgery (for HLTA, reverse, and fleur-de-lis abdomino-
plasties)
Patient Education
Informed Consent
Every patient is told that the general risks of bleeding, infection, delayed healing,
and undesirable scarring are common to any operation. The risks specific to ab-
dominoplasty are also explained, including loss of skin in the lower area of the flap
above the pubis, distortion or malposition of the umbilicus, asymmetry of the scar or
abdominal contour, failure to narrow the waistline, and postoperative seroma. The
surgeon should also clearly define for the patient the extent and limitations of the
planned surgery:
 The excess skin that may not be fully removed: the potential dog-ears at the
lateral margins and the inevitable residual skin or even rolls at the upper ab-
domen, above the zones of adhesion
 The potential scar at the lower midline abdomen, the original site of the um-
bilicus: when all lower midline skin is intentionally not excised to facilitate a
tension-free closure in an aesthetic location
 The possible lateral extension of the abdominal scar: depending on the amount
of excess skin present, the longer the scar, often the better the result
Patient Instructions
The patient is given a set of instructions covering preoperative, intraoperative, and
postoperative considerations (see p. 2948).
2947
Chapter 83  Abdominoplasty

2948
Part XII  Body Contouring
Preoperative Planning
LORNE K. ROSENFIELD
Decision-Making
Before the first stroke of the marking pen is made, the entire anterior trunk must be
analyzed and staged plans made to address all areas of deformity. The key to de-
signing a comprehensive repair is to envision the entire trunk as composed of aes-
thetic units rather than focusing solely on the obvious lower abdominal excess:
1. The hips and thighs: Is there extra fat or skin? If there are discrete noncellulite
fat deposits with nominal excess skin, concomitant liposuction is wise. How-
Preoperative Preparation
To ensure that the patient is optimally prepared for surgery, the following instructions
are given:
 The patient is assisted to accomplish a regular bowel program.
 The patient is instructed to take antiseptic showers and apply antibiotic ointment to
the nares for a few days preoperatively.
 The patient is encouraged to continue regular diet and exercise programs.
 The patient is strongly urged to stop smoking altogether, but if this is not realistic, then
to discontinue all smoking for at least 2 weeks before and 2 weeks after surgery.
 The patient is advised to donate 1 or 2 units of autologous blood, depending on the
extent of the surgery planned.
Intraoperative Information
To promote compliance, the surgeon must inform the patient of any relevant intraopera-
tive activities:
 Antiembolism stockings and pumps will be in place before, during, and after surgery.
 Binder garments, drains, a Foley catheter, and a pain pump may be placed.
Postoperative Instructions
To encourage a predictable recovery, the surgeon must carefully instruct the patient in all
aspects of the postoperative course:
 The minimum time off work will be 2 weeks; the time away from exercise and heavy
lifting will be at least 6 weeks.
 The patient should be assisted to ambulate early, and calf exercises and spirometry ex-
ercises should be conducted regularly.
 A full diet should gradually be introduced over several days.
 Drains and sutures will usually be removed within several to 10 days.
 The timeline of healing includes bruising for at least 2 to 3 weeks and swelling that
will resolve over a minimum of 3 to 6 months.
Patient Information

ever, if skin traction at the hip effects a good contour change at the thigh,
then one needs to consider a high lateral tension procedure.
2. The lower rib cage and upper abdomen: Is there significant redundant skin?
It is unlikely to change after an HLTA; a reverse abdominoplasty at a later
stage or an initial fleur-de-lis–type abdominoplasty would best treat this dif-
ficult zone.
3. The epigastric and supraumbilical abdomen: Is there a prominent subcuta-
neous layer of fat? If so, the surgeon should consider a second-stage aggres-
sive liposuction procedure to treat this deformity definitively and with greater
safety.
4. The pubis: Is it redundant and/or full? If so, liposuction of the area, with or
without excision of excess pubis, will prevent a residual distracting deformity
in this area.
5. The waist: Is it square? Additional fascial sutures and liposuction in the area
could “nip in” this area. If this area harbors large skin excess, a fleur-de-lis
approach should be considered.
6. The breasts: Are they in need of rejuvenation as well? This deformity should
be broached at this time, because the breasts must be considered an aesthetic
unit if a complete repair is to be planned. In addition, any redundant upper
abdominal skin can be efficiently resected at a later stage through the breast
incisions as part of a reverse abdominoplasty.
7. The skin: Are there subcostal or midline scars? In the patient with significant
redundancy, the surgeon should seriously consider a fleur-de-lis approach
that could excise most if not all of these scars and obviate potential ischemia
concerns.
Once all components of the abdomen and its “environs” have been evaluated, the
surgery can be definitively mapped out: A number of surgical approaches are avail-
able to treat abdominal deformities. These range from liposuction only to full ab-
dominoplasty with fascial plication. The decision is based on evaluation of the ab-
dominal skin, subcutaneous fat, and underlying fascia. The patient’s desires must
also be taken into account: Is she seeking recontouring to look better in her cloth-
ing, or is she looking for recontouring and skin tightening so that she can look good
in a two-piece bikini?
Liposuction
The best candidates for liposuction are nulliparous women with a modest amount
of excess fat, tight abdominal musculature, no hernias, and tight skin of normal elas-
ticity. Some women who have had children with minimal to modest loss of skin elas-
ticity and no diastasis may also be candidates for liposuction if they understand that
their skin quality will not be improved but their contour will be greatly enhanced,
especially when they are fully clothed. These women should understand and accept
this tradeoff for a less-invasive procedure.
2949
Chapter 83  Abdominoplasty

Traditional Abdominoplasty
Patients who have excess skin above and below the umbilicus, periumbilical hood-
ing, fat excess, and diastasis or abdominal wall hernias are appropriate candidates
for traditional abdominoplasty. Traditional skin excision and more extensive skin
excision is required to deal with the supraumbilical skin excess. These patients should
anticipate improvement of their appearance in and out of their clothes.
Limited Abdominoplasty
Patients with nominal excess skin above and limited excess skin below the umbili-
cus are reasonable candidates for a more limited abdominoplasty. This approach is
most conducive in a patient with a high-riding umbilicus. The patient may have a
diastasis or even an umbilical hernia, which can be repaired through the limited ap-
proach. The effect on umbilical position is an important determining factor to can-
didacy for this approach. The limited skin incision combined with musculofascial
tightening with liposuction above and below the umbilicus will enhance the patient’s
appearance in and out of her clothing.
High Lateral Tension Abdominoplasty
The “pure” Lockwood type of abdominoplasty is effective for patients with excess
skin at the abdomen, lateral hip and thigh, pubis, and even the anteromedial thigh.
If there is a significant amount of excess skin superolaterally, then either conversion
to a fleur-de-lis approach or a plan for a second-stage reverse abdominoplasty should
be considered. A concomitant reverse abdominoplasty is not recommended, because
the intervening band of blood supply may not be enough to sustain the flaps.
Fleur-de-Lis Abdominoplasty
The fleur-de-lis abdominoplasty is appropriate for patients who require more ag-
gressive treatment for excess skin throughout the abdomen and trunk, particularly
at the upper pole of the abdomen and lower chest and back as well as at the waist,
hips, and thighs. The patient must accept the tradeoff of a full midline scar for a
more complete skin resection. This approach is also efficacious in a patient with ab-
dominal scars that could otherwise compromise the blood supply of a more tradi-
tional abdominoplasty.
Reverse Abdominoplasty
The reverse abdominoplasty is particularly relevant in patients with primarily or
residual excess upper abdominal skin. This approach can be very synergistic when
combined with a Wise pattern type of breast surgery.
2950
Part XII  Body Contouring

2951
Chapter 83  Abdominoplasty
Use of a tumescent technique (usually injection of 500 to 1000 ml Ringer’s lactate
with 50 ml of 1% lidocaine and 1 ml of 1:1000 epinephrine) enables the surgeon
to suction fat with very little blood loss and a nice improvement in abdominal wall
contour.
OPERATIVE APPROACHES
Liposuction
GILBERT P. GRADINGER
Some nonobese women who have a protuberant lower abdomen without excess skin
present with good skin tone, excess lower abdominal fat, and some muscle laxity.
Typically, liposuction alone can improve their contour.

Although liposuction will never improve stretch marks, abdominal wall contour can
be improved in some patients who do not want any form of abdominoplasty, as can
be seen in this patient with poor skin tone and stretch marks.
Traditional Abdominoplasty
GILBERT P. GRADINGER
Anterior abdominal dermolipectomy, with or without liposuction, constitutes tra-
ditional or classic abdominoplasty, which has two significant variations, depending
on the management of the umbilicus. Dermolipectomy of the anterior abdominal
wall removes excess skin and fat, primarily in the vertical direction. The repair re-
sults in tightening and flattening of the abdominal wall. The additional surgical com-
ponent, fascial tightening, further flattens and contours through horizontal tension
narrowing the waistline. Variations on the traditional abdominoplasty include lower
abdominoplasty, HLTA, and fleur-de-lis abdominoplasty.
2952
Part XII  Body Contouring

2953
Chapter 83  Abdominoplasty
Planned
lower incision
within bikini line
New expected contour
following liposuction and diastasis repair
The patient is examined and marked for surgery the day before the procedure. She
has been advised to wear her usual style of underpants or swimsuit bottom (her
choice), so that the garment will conceal the planned incision and resultant scar. The
practice of marking the patient in the office the afternoon before the day of surgery
has served my patients and me well.
An office nurse is present and assists in making the patient feel more comfortable in
this private setting, in contrast to the preoperative holding area. The patient is able to
see the markings in the office, ask questions, and offer an opinion (particularly in
liposuction marking). Thus she will have a better understanding of the location of
incisions and resultant scars.
Planning is vital to successful surgery, and it can be done more accurately in a con-
trolled situation. Photography is achieved with precise consistency of positioning,
lighting, and background. I do not have to arrive in the preoperative holding area to
arouse a medicated patient or request that she not be medicated until I have com-
pleted the markings.
Markings

2954
Part XII  Body Contouring
Planned
skin incision
Midline marking
Planned skin and
subcutaneous fat
excision area
Diastasis
Proposed
neoumbilical site
The periumbilical markings are made with the patient supine on the operating table,
as is the vertical midline mark from the xyphoid process to the umbilicus. The esti-
mated location of the new umbilical skin site is marked.
Surgical marking is performed with the patient standing. The excess skin and fat to
be excised are usually from the umbilicus to the pubis vertically and from one ante-
rior superior iliac spine to the other horizontally. The maximum excision is in the
midline, and it tapers laterally. The surgeon makes a clinical judgment as to whether
supraumbilical skin will reach to the pubis after removal of the intervening skin. This
can be done by grasping the tissue and bringing the proposed midline points together.
The surgeon should be alert for patients with a greater-than-usual distance from um-
bilicus to pubis and a short distance from the xyphoid to the umbilicus.
The patient should urinate before leaving the preoperative holding area for the op-
erating room. By going to surgery with an empty bladder, the patient avoids the need
for a Foley catheter. Operating time is usually less than 2 hours. The patient will have
recovered well enough from anesthesia to void spontaneously. Therefore the risks as-
sociated with an indwelling catheter are eliminated.

Skin incision
marking line
Scarpa’s fascia
Subscarpal fat to be excised
from pubis to ribcage
Operative Technique
2955
Chapter 83  Abdominoplasty
Midline
marking
Two dots for orientation of
superior aspect of umbilicus
After general anesthesia has been induced and the patient has been prepared and
draped, the 3, 6, 9, and 12 o’clock positions of the umbilicus are needle-tattooed
and the circumferential incision is made. Two dots are tattooed at the 12 o’clock po-
sition to prevent accidental rotation of the umbilicus at the time of repair.
Midline marking
Dissection of umbilical
stalk to level of fascia
The umbilical stalk is dissected to the level of the anterior abdominal fascia.
The skin and subcutaneous flap are dissected from the pubic/inguinal region cepha-
lad at the level of the anterior abdominal wall fascia. Dissection continues cephalad
to the lower border of the rib cage laterally and the xyphoid centrally.

2956
Part XII  Body Contouring
The tissue excised is a full-thickness skin and subcutaneous block including sub scar -
pal fat cephalad to the skin excision.
The elevated fat flap from which fat deep to Scarpa’s fascia has been excised is shown.
Dissection and hemostasis are achieved with an electrosurgical unit.

The laxity and underlying diastasis are repaired by a running absorbable monofila-
ment suture (for example, Monocryl) from the xyphoid to the umbilicus (and the
umbilicus to the pubis). Liposuction is performed, then the wound is irrigated with
saline solution and hemostasis is ensured. Jackson-Pratt drains (No. 7) are inserted
in each side through separate incisions in the pubic region.
2957
Chapter 83  Abdominoplasty
The extent of anterior abdominal wall midline fascial laxity is tested with forceps
and the width of laxity marked for repair.
Markings
for planned
diastasis repair
Anterior layer of rectus fascia
Lateral edge of
rectus muscle
Fascia tested
with forceps for
extent of laxity

2958
Part XII  Body Contouring
Skin advanced
inferiorly over umbilicus
Midline suture
1-inch-long
line marking
neoumbilical site
The 1-inch-long horizontal skin incision is marked in the midline directly over the
umbilicus. It is anticipated that the umbilicus will again be vertically oriented after
healing, because the tension placed on the flap by the closure will convert the hori-
zontal opening into a vertical one.
Completed midline
fascia repair
Lateral edge of
rectus muscle
The lowest midline point on the flap is advanced inferiorly to be sutured to the mid-
line pubic skin. Subcutaneous fat is retained at the margin in the midline; this is im-
portant for skin circulation.

2959
Chapter 83  Abdominoplasty
The wound is closed in two layers (Scarpa’s fascia and subcuticular) using 4-0 Vicryl
sutures. It will be obvious that the lower incision is longer than the upper one; it is
more curvilinear, whereas the upper incision is straighter. Closing these incisions of
unequal lengths is not a problem because of the tension and stretching of skin in the
flap, which allows good approximation.
Closure of Scarpa's
fascia with running
absorbable suture
Vertical mattress sutures
of umbilicus to neoumbilical site
Midline
marking
Umbilical
stalk
The umbilicus is delivered through this incision and sutured at the 12, 3, 6, and
9 o’clock positions with one-half dermal (on the skin side) vertical mattress sutures
of 5-0 nylon. The circumumbilical repair is completed with a running subcuticular
4-0 Vicryl suture.

2960
Part XII  Body Contouring
Postoperative Care
Fine mesh, nonadhering gauze and layered 4  4 sponges, ABD pads, and an ab-
dominal binder (three panels, not four, so that respiration is not restricted postop-
eratively) are used for dressing. The patient is placed in bed with the head, knees,
and feet elevated. Intermittent compression stockings, full leg length, are put on the
patient in the operating room before surgery; these are activated throughout surgery,
in the recovery room, and in the patient’s hospital room postoperatively until she is
fully ambulatory, at which time full-length support hose are used and continued for
3 weeks after discharge. Surgery is performed either on an outpatient basis, as was
done in the patient described in this sequence, or with a 1-night hospital stay. An-
tibiotics are administered intravenously at the beginning of the surgical procedure
and are not used again unless there is a problem postoperatively.
Results
Improved
contour
following
liposuction
Improved
contour
following
diastasis
repair
In this photograph of the patient’s appearance on postoperative day 1, the patient
is erect and drains are in place. Drains were removed on postoperative day 3, when
drainage was less than 30 ml per 24 hours.
Patients often ask how the benefits of abdominoplasty would be affected by future
pregnancy and childbirth. To my knowledge, this is the only patient in my practice
who had a child after abdominoplasty. In this instance, because she controlled her
weight and exercised during and after the pregnancy, the benefits of the abdomino-
plasty persisted. (Obviously, one needs to be careful in drawing conclusions based
on a single case.)

The patient is shown preoperatively, 1 day postoperatively, and 1 year postopera-
tively in all three views. Note the shape of the umbilicus in the three anteroposterior
photographs.
2961
Chapter 83  Abdominoplasty
The scar is seen and concealed at 2 years postoperatively.

The patient is shown 3 years postoperatively, 1 year later when she is 6 months
pregnant, and 7 months after that (4 months after vaginal delivery of a 7-pound,
2-ounce boy).
2962
Part XII  Body Contouring
Another patient is shown to demonstrate the dramatic improvement achieved in ab-
dominal flattening and waist contouring.

This patient’s preoperative markings and tissue specimen demonstrate the extensive
removal of fat deep to Scarpa’s fascia. This fat excision, in my opinion, is a safer way
of thinning the upper flap compared with suctioning, because it preserves the blood
supply to the skin through the subcutaneous fat that is superficial to Scarpa’s fascia.
Limited Abdominoplasty
GILBERT P. GRADINGER
In some patients it is not feasible to remove all of the skin between the umbilicus
and the pubic area: a patient who has a relatively high umbilicus, and a patient who
has a low suprapubic scar that dictates where the lower incision should be placed.
Both factors may coexist in some patients.
2963
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Area to be
liposuctioned
Planned
skin incision
Diastasis
Area to be
undermined
16.5 cm
This patient had a low surgical scar; the distance from the scar to her umbilicus was
16.5 cm, approximately the same distance as from her xyphoid to the umbilicus. To
reach the pubis, the skin of the upper abdomen would have to be stretched to dou-
ble its normal length.

The abdominoplasty was modified, with more-conservative excision of skin and fat,
and instead of leaving the umbilicus attached to the abdominal wall, it remained
part of the flap—its stalk having been transected at the level of the anterior abdom-
inal wall fascia (demonstrated with the surgeon’s hand interposed between the flap
and the fascia).
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Umbilical
defect
Umbilicus
Rectus
muscle
Posterior layer
of rectus fascia
Anterior layer
of rectus fascia
Subscarpal
fat
Scarpa’s
fascia
Subcutaneous
fat
Skin
The umbilical fascial defect and diastasis were identified and sutured.
Operative Technique

The flap was advanced inferiorly carrying the umbilicus, and the incision was su-
tured. The umbilicus can be seen to be lower on the abdominal wall than it was pre-
operatively. Drains have been placed and the surgical specimen is seen.
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Chapter 83  Abdominoplasty
Improved
contour
following
liposuction
Improved
contour
following
diastasis
repair
Original
umbilicus
location
The patient is shown 18 months postoperatively. Because of the tension on the flap
created by the closure, the umbilicus is stretched; it is more vertical than it was pre-
operatively. Unfortunately, the result is compromised by the presence of “dog-ears”
(faulty surgical technique). This complication could have been avoided if suturing had
been begun at the lateral ends of the incision instead of medially.

Comprehensive Abdominoplasty:
High Lateral Tension Abdominoplasty With
Complementary Fleur-de-Lis and Reverse Techniques
LORNE K. ROSENFIELD
The abdominoplasty can be deceivingly easy to perform yet maddeningly inconsistent
in its results. The plastic surgeon is challenged to excise all the excess anterior trunk
skin and fat through the shortest possible incision and to ensure optimal healing
with an inconspicuous scar. To begin to rise to this challenge requires one to become
a student of the abdominoplasty. By continuously honing one’s surgical planning
and execution, a more balanced technique can be realized that is both reliably safe
and aesthetically successful. The high lateral tension abdominoplasty, with some
“2.0” modifications, is such a technique.
Traditionally, the primary goal of any abdominoplasty has always been to excise the
central lower abdominal excess skin or pannus and plicate the abdominal fascia
through a suprapubic incision. Unfortunately, this traditional abdominoplasty may
often fall short of this goal: a scar that may ride too high; persistent skin and li po -
dys trophy at the pubis, thighs, flanks, and hips; and a consistent incidence of mid-
line skin necrosis or wound dehiscence.
The HLTA addresses these shortfalls. It may be defined as a more complete treat-
ment of the lower trunk aesthetic unit from the abdomen to the pubis, hips, and
thighs, with a greater overall aesthetic result as well as a greater margin of vascular
safety. What follows outlines the techniques and tools to accomplish these superior
results safely and consistently.
Evolution of the Modern Abdominoplasty
The abdominoplasty technique has evolved significantly over the last four decades.
The modern abdominoplasty was born in South America in the 1960s. The basic
surgical tenets have always been to conduct a rectus plication, with maximal exci-
sion of the central skin excess by extensive undermining of the entire abdominal wall.
The closure is often under some tension and is therefore of necessity conducted with
the patient in significant flexion. When liposuction was introduced in the 1980s, it
soon became apparent that blithely and aggressively adding this modality to the ab-
dominoplasty led to an unacceptable incidence of flap ischemia and skin necrosis.
Liposuction then evolved into a more conservative adjuvant treatment.
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7
83-1 Comprehensive
abdominoplasty

Although there were indeed fewer physiologic problems with this technique, the aes-
thetic results were once again more constrained.
Then in the early 1990s Lockwood published a series of seminal articles that single-
handedly changed the tack of the abdominoplasty technique. Based on his extensive
experience with body-contouring surgery, he decisively demonstrated and definitively
modified the surgical principles of abdominoplasty and reported greater safety and
improved aesthetics. He enumerated several surgical tenets that were in many ways di-
ametrically opposed to those of the classic or traditional abdominoplasty: the
undermining of the central skin flap only to facilitate plication and discontinuous
dissection elsewhere (to enhance vascularity and allow judicious concomitant lipo-
suction) and the initial resection of the lateral excess skin, with more-conservative
resection of the central skin flap to accomplish a more complete and natural repair,
and the use of a planned and controlled high-tension closure, with diligent use of
the underlying superficial fascial system. Thus was born the high lateral tension ab-
dominoplasty.
The High Lateral Tension Abdominoplasty:
A “2.0” Version
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Chapter 83  Abdominoplasty
For a result to be called truly successful, three strict standards must be balanced
equally: the case has to demonstrate the greatest degree of safety (zero tolerance for
complications), with the maximal aesthetic result (correction of all “deformities”),
and a consistent reliability (regardless of patient presentation). As a result, several
important expanded principles of the high lateral tension abdominoplasty validate
this 2.0 advancement.

The surgeon performing an HTLA procedure should not slavishly follow the oth-
erwise arbitrary mandate that all the skin between the pubis and the umbilicus must
be excised. This approach will only truly work in a patient with an enormous pan-
nus. Otherwise, the excisional marking must be placed above the pubic hairline to
accomplish closure of the wound, often with an overly tight closure. This approach
may result in an excessively high scar and superiorly retracted pubis, an unnaturally
flat hypogastrium, and, more seriously, an exaggerated rate of wound dehiscence
and skin necrosis. Instead, any redundant pubis should be corrected with excision,
rather than be used to help close an overly tight suprapubic wound, as is often the
case with a traditional abdominoplasty. The pubis is then closed under no tension
and rests in a lower, more inconspicuous location. As a result, it is most often nec-
essary to close the original umbilical site, since all the skin between the pubis and
the umbilicus may not be excised. The surgeon must resist the temptation to remove
even a few centimeters of intervening abdominal skin for fear of recreating the usual
overly tight closure. This small scar is a reasonable tradeoff when compared with the
traditional closure, which can lead to complications.
Any abdominoplasty should consider not only what is above the future incision (the
traditional pannus) but also what is below; that is, the pubic excess, anterolateral
and medial thigh redundancy, and buttocks laxity. Otherwise, the tissues below the
incision may appear distractingly untreated postoperatively, and the full effect of the
HLTA may not be realized. This tenet underlines one of the greatest benefits to the
HLTA that is not usually considered possible with the traditional abdominoplasty:
one can realize a true “body lift” effect through an anterior incision only. Therefore
this procedure is really simply a “tension abdominoplasty,” with sequential tension
placed from lateral to medial.
This notwithstanding, the goal of the design and placement of the future scar should
primarily be to hide the scar. Lockwood originally described a very high (“French-
cut”) lateral closure, probably because that style of clothing was more fashionable
at the time, and a more oblique vector of pull does more efficiently treat the upper
abdominal excess, as described above. However, considering how fashion changes,
and that a hidden scar will usually trump some residual excess skin, the surgeon
should mark the patient within the margins of her preferred clothing. This becomes
particularly relevant when the patient favors low-cut jeans.
The location and extent of the remaining subcutaneous fat must be evaluated and
respected. This assessment represents an age-old plastic surgical battle between
“beauty and blood.” That is, at what cost to the blood supply does the surgeon at-
tempt to remove all remaining excess subcutaneous fat? Lockwood originally de-
scribed a reasonable detente: liposuction should only be conducted beneath tissues
that have not been undermined. However, most recently, the pendulum has swung
back: published articles are once again advocating more aggressive full truncal lipo-
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