suction at the time of the abdominoplasty. This recommendation is predicated on
the idea that if one follows the original Lockwood admonition to restrain the flap
dissection only as much as needed to conduct a fascial plication, enough perforators
will be preserved to allow for this aggressive liposuction. However, as stated earlier,
Lockwood also warned that despite this conservative undermining, liposuction of
the remaining central skin flap should not be done for fear of skin flap necrosis. And
realistically, some of these same precious perforators are often sacrificed to repair
the more protuberant abdomen. This principle should be respected when one con-
siders Lockwood’s extensive experience.
If the premise is to preserve the central flap’s blood supply by undermining only cen-
trally to allow fascial plication, it may indeed be self-defeating to then disrupt the
very same flap with liposuction. Ironically, the only patients who might be candi-
dates for such an aggressive approach would be those without a significant amount
of fat in the first place; that is, patients with a low BMI. Otherwise, the usual ab-
dominoplasty patients with higher BMIs could undergo liposuction at the waist and
hip rolls, but a second-stage liposuction 6 months to a year later should be planned
for the central skin flap. Only then can a zero tolerance for skin flap necrosis and de-
hiscence be realized.
It is has always been important to evaluate the magnitude of excess skin to be ex-
cised. But to actually design the most “efficient” length and direction of the incision,
it is critical that the extent and orientation of the skin left behind also be assessed. At
once, the surgeon must ensure that the remaining skin is both sufficient to close the
defect and efficiently relieved of its own redundancy. This principle may be applied to
both the central and lateral closure. Specifically, laterally, the excess skin at the hip
and thigh is often neglected by the traditional abdominoplasty. This primarily
obliquely oriented excess tissue is efficiently removed through the oblique inci-
sion/vector of the HLTA. Centrally the superfluous skin at the epigastrium is in fact
a primarily horizontal excess (that has migrated from the chest) that can neither be
efficiently removed nor “used” to close a lower abdominal defect through a hori-
zontal incision. Therein lies the potential flaw in the traditional abdominoplasty as
well as the efficacy of the high lateral tension technique. An incongruent consequence
may occur: the wound closure may be too tight despite the apparent epigastric re-
dundancy, which can in turn be left behind, and the lateral excess cannot be effec-
tively treated because the remaining abdominal flap has been primarily used for the
central closure. To reconcile this paradox, less skin should be excised centrally and
more skin must be removed laterally through an HLTA-oriented incision and repair.
These concepts are illustrated on p. 2970: Using “vector analysis,” the lateral tissue
above and below the incision is redundant in a more oblique vector and so should
be removed through an opposing oblique incision. Serendipitously, this matches the
relative direction of the desired HLTA lateral scar placement. In addition, this oblique
vector also treats the more horizontal excess in the epigastrium. Similarly, this same
2969
Chapter 83 Abdominoplasty
concept can be applied to the fleur-de-lis and reverse abdominoplasties. Thus the
more a procedure follows the vectors of excess of both what is taken and what re-
mains, the more efficient the treatment of all redundant skin.
Equally, the abdominoplasty should not only consider the obvious suprapubic pan-
nus, but also the deformity of excess tissue in the epigastric/midline, subcostal, and
lateral chest—zones that have generally been neglected by the modern abdomino-
plasty. This problem is significantly exaggerated in post–weight loss patients com-
pared with average abdominoplasty candidates. However, the challenge cannot be
ignored, and indeed, experience with post–weight loss patients brings significant
clarity and urgency to addressing the issues. In fact, the good corrective techniques
originally described many years ago have been equally neglected: the fleur-de-lis and
reverse abdominoplasties. The solution is to reharness these procedures as a com-
plement to the high lateral tension approach and in so doing, forge a more compre-
hensive abdominoplasty. Then, the inclusion of a vertical incision to the high lateral
tension procedure makes a better fleur-de-lis abdominoplasty, and the staged appli-
cation of a full submammary incision to the results of the HLTA creates a more pow-
erful use of the “reverse” abdominoplasty. In effect, the abdominoplasty becomes a
true rejuvenation procedure of the entire abdominal aesthetic unit.
2970
Part XII Body Contouring
This potential marriage of procedures is illustrated above. The vectors of skin laxity
at the abdomen are marked and applied in each complementary variation of ab-
dominoplasty. As one can see, the more a procedure follows the vectors of excess,
the more efficient the excision of redundant skin. In turn, the more vectors of ex-
cess that are addressed by surgery, the better the results. Thus by building a suitable
procedure using these harmonizing techniques, a more comprehensive abdomino-
plasty emerges.
To summarize, the primary advantage of these variations on the theme is the more in-
clusive repair of the entire anterior trunk. These procedures are entirely predicated
on careful discontinuous undermining and proper use of the superficial fascial sys-
tem. Then one is assured of viable flaps and a secure and predictable final closure
and scar.
However, the more extensive surgeries can be a disadvantage. These cases require
more surgical time, longer and often a greater number of incisions, and planned but
nonetheless greater closure tension, with the attendant increased risk of dehiscence.
Traditionally, the primary goal of any abdominoplasty has been to excise the supra-
pubic pannus and plicate the abdominal fascia through a relatively hidden incision.
Unfortunately, this established abdominoplasty can fall short of this goal: a scar rid-
ing too high; persistent skin and subcutaneous lipodystrophy in the midline, thighs,
flanks, and hips; and midline skin necrosis.
The comprehensive abdominoplasty addresses these shortfalls. It may be defined as
a more complete treatment of the entire anterior trunk aesthetic unit from the sub-
mammary and lateral chest area to the pubic, thigh, and buttock zones, with a greater
overall aesthetic result and margin of vascular safety.
Pertinent Anatomy
The general abdominal anatomy is well described in the section of this chapter by
Dr. Farzad Nahai. Therefore I will highlight the specific anatomy most relevant to
the understanding and application of this high lateral tension abdominoplasty. There
are three critical anatomic points that should be understood and respected when
planning and performing the HLTA:
1. The superficial fascial system: this layer must be identified and utilized fully
to harness the full lift that this technique can provide and to prevent wound
dehiscence.
2. The perforator blood supply: the abdominal flap’s viability is predicated on
the preservation of as many fascial perforators as possible.
3. The zones of adherence: these various points of skin attachment must be re-
leased, at least bluntly, to realize the maximum “translation” of pull of the
remaining skin envelope, particularly at the anterolateral thigh region. There
is often what may be called a “waist band of adherence” at the patient’s mid-
section that can significantly inhibit this same translation.
Markings
The marking starts and is entirely driven by the delineation of the final position of the
scar. The 2.0 modification ensures that the scar will rest within the patient’s under-
clothes. The next marking outlines the extent of excess skin below the incision (if
any) relative to the final scar, and the final marking is simply an estimate of the ex-
cess skin above the incision.
2971
Chapter 83 Abdominoplasty
Marking is performed with the patient in an upright position against a wall so that
she can be supported as necessary during the “tension” marking.
2972
Part XII Body Contouring
The placement and length of the lateral scar are discussed with the patient; this de-
cision should be made by balancing the merits of the best surgical approach to treat
the problem with the patient’s preferences in clothing styles. The surgeon must con-
sider the planned procedure with the patient wearing his or her most revealing cloth-
ing: underwear, a one- or two-piece swimsuit, and low-cut jeans. The incision will
rise or fall at the hip markings, depending on the style of clothing.
Location of the Eventual Scar
Boundary marking: First, the outline of the patient’s preferred clothing is drawn (un-
derwear, low-cut jeans, or a swimsuit).
Suprapubic marking: Next a point 6.5 to 7.5 cm measured superiorly from the up-
per incisura of the vagina or base of the penis is marked on the skin as it rests.
Lateral limit marking: A vertical line is marked on each side at the lateralmost ex-
tent of the excess skin (pannus).
Closure marking: Finally, the pen is moved superolaterally from this suprapubic mark
on each side to meet somewhere along the lateral mark, always staying within the
borders of the outlined clothing. This line usually rests between the natural inguinal
and abdominal wall gullies. NOTE: One can measure the distance between the fixed
point (anterior superior iliac spine) and this marking to aid in an intraoperative cross-
check and adjustment of the final resting place of the closure.
To ensure a harmonious scar, particularly in a very “ptotic” patient, it is useful to
extend the marking to include the design of a posterior body lift that may be planned
or desired in the future.
Defining the Lower Margin of Excision
2973
Chapter 83 Abdominoplasty
The marking pen is placed over the line of future closure, and this position is main-
tained this while pulling the excess skin is vigorously pulled upward until taut (this
is the “tension” in the HLTA); then the surgeon marks the skin that is now below
the tip of the pen.
This maneuver is performed across the width of the abdomen as needed to define
the lower incision. NOTE: Because the maneuver can and should be quite forceful, it
is helpful to have the patient lean against a wall during the marking.
Estimating the Upper Margin of Excision
2974
Part XII Body Contouring
The excess skin is pinched with the thumb on the lower incision line and the fingers
at the superior extent of the excess, while maintaining the premarked final closure
line visible at the middle of the skin roll. Marking begins laterally and extends me-
dially. The resultant line will usually rest several centimeters above the level of the
umbilicus laterally and a few centimeters below the umbilicus centrally.
Deciding How to Treat the Umbilicus
Depending on the patient’s body habitus, the umbilicus should be about 9 to 12 cm
above the superior margin of the pubis. The umbilicus should rest slightly above the
latitude of the superior margin of the iliac crests. However, in the final analysis, as
with many challenges in plastic surgery, a critical eye should ultimately drive the sur-
geon’s decision.
The treatment of the umbilicus is determined by two factors: The amount of excess
skin above and below the umbilicus and the location of the umbilicus in conjunc-
tion with the length of the abdomen and waist.
If there is no excess above and mild excess below, the excision may be con-
ducted with the umbilicus left intact, as a mini-abdominoplasty.
If there is moderate excess below the umbilicus and little to no excess above,
and the umbilicus appears high-riding on the abdomen, it can be maintained
in situ and stretched on its stalk for a couple of centimeters.
If there is moderate excess of skin below and above and the umbilicus is rela-
tively high-riding, the umbilicus may be “floated” inferiorly with release of its
stalk, again for a few centimeters.
If there is a large excess, above and/or below the umbilicus, then it must be cir-
cumscribed and translocated.
2975
Chapter 83 Abdominoplasty
The areas for liposuction are marked as needed, including the hips, waist, pubis, and
thighs. Finally, the surgeon checks the surgical plan markings and reconciles expec-
tations by simply instructing the patient to reproduce the desired result by perform-
ing an “examination room lift” (right). This maneuver is particularly valuable with
a weight-loss or postpartum patient.
The final markings are shown above.
Green line: estimated upper incision
Red line: planned location of final closure
Blue line: defined lower incision
Operative Technique
The patient is positioned supine on a warmer, an antiembolic compression device is
applied, and a Foley catheter is usually inserted. With a needle and dye, the quad-
rants of the umbilicus are marked; the center point of the pubis and the estimated
location of the future umbilical site are also marked.
2976
Part XII Body Contouring
The lower markings are incised and the skin flap is elevated off the deep fascia, just
wide enough to allow plication of the rectus fascia. One should also attempt to leave be-
hind as much of the fascial and particularly inguinal “lymphatic” tissue as possible.
Plication of the midline abdominal wall fascia is then accomplished using a heavy
stitch (0 or 1-0 PDS) in a running pattern. The surgeon should try to avoid capturing
any of the underlying muscle. A second running suture is performed to reinforce and
allow for further plication of the fascia as necessary. Additional plication may be
carried out in an oblique or horizontal vector at the anterolateral abdominal wall to
narrow the waist and further flatten the abdominal wall.
Further mobilization of the flap and release of the skin flap adhesions may be con-
ducted cautiously beyond the midline. The guiding principle is to preserve as many
perforators as possible. The surgeon could use either a measured, vertically oriented
spreading of a large Mayo-like scissors or a gentle penetration with one or more fin-
gers, oversized suction cannula, or, as I prefer, a Lockwood underminer cannula (By-
ron Medical, Tucson, AZ).
With a Lockwood abdominal demarcator (Byron Medical), a modified D’Assumpçao-
type clamp, the excess skin is marked for resection. This must be performed from
the lateral aspect of the abdomen toward the center to truly carry out a high lateral
tension resection. As an insurance maneuver, the preoperatively determined desired
distance between the anterior superior iliac spine (ASIS) and the future closure can
be checked intraoperatively and appropriate adjustments made (and more or less
skin removed).
2977
Chapter 83 Abdominoplasty
First, Kocher clamps are placed on the upper flap and the skin clamp tongs are se-
cured into the skin edge of the lower margin of the incision. Then with simultane-
ous pulling of the Kocher clamps on the flap and the pushing of the Lockwood in-
strument at the lower incision, the excess skin is marked. The vector of pull of the
flap is decidedly inferior and lateral.
The tip of the demarcator is pulled back a centimeter or so and the incision is skived
to maintain a little more skin than subcutaneous tissue. In this way, when the deep
closure is performed, the tension will be more on the fascia, and the skin will “heap
up,” with virtually no wound tension.
An effort should be made to avoid closure over the ASIS itself to prevent additional
tension to the wound. And contrary to the traditional approach, it is not necessary or
desirable to place the operating table in a “lawn chair” position, because the Lock-
wood technique does not mandate the excision of all the infraumbilical skin and thus
excess tension on the suprapubic closure and the resulting side effects are prevented.
As planned, not all the skin between the umbilicus and the pubis is usually excised,
so depending on the amount of skin resection, the umbilicus can be stretched in
place, allowed to float, or circumscribed and translocated with the original umbili-
cal site closed vertically when necessary. As needed, a triangular segment of mons
pubis can be excised if there is significant horizontal excess.
Once skin is excised and tacking sutures are placed, tumescent fluid is suffused and
liposuction conducted at the waist, hips rolls, pubis, and thighs as planned. The ar-
eas that deliver the greatest reward, yet are most often neglected, are the waist and
the pubis.
The new umbilical site, when needed, is then incised in a vertical direction, since this
wound will be pulled open to an appropriate shape with the significant lateral pull of
the high-tension approach. A small elliptical excision of skin on either side of the
vertical incision may be conducted as needed to increase the width of the umbilicus.
Three or four 10 mm flat drains are placed before closure, along with a bupivacaine
catheter for postoperative pain control.
2978
Part XII Body Contouring
Bupivacaine may also be injected directly into the fascia for immediate postopera-
tive relief. Using 1-0 or 0 PDS suture, the superficial fascial system is reapproximated
every few centimeters. This is probably one of the most important steps in the whole
operation. The more confident one is of the fascial closure, the more definitive and
aggressive one can be of the skin traction/resection. The final closure is then made
with 2-0 Vicryl for deep dermis and 3-0 Monocryl for superficial dermis.
2979
Chapter 83 Abdominoplasty
The closure should have a decidedly rolled border, indicating no skin tension. Short-
ened Steri-Strips (to prevent edema-induced blisters) are placed. Fluffs are applied
along with an abdominal binder to complete the dressing.
Postoperative Care
Immediately after surgery, the patient is placed on a hospital bed in a “lawn chair”
position, with the Foley catheter in place. The patient is transferred to an outpatient
facility for 1 to 3 nights to ensure proper pain control and hydration, assistance with
ambulation, showering, and so on. A spirometer, antiembolic pumps, and TED-like
hose are all ordered for continuous use until the patient is ambulating regularly. The
Foley catheter is usually removed at that time. Patients are given stool softeners once
they are taking food by mouth. The pain-control catheter is removed in 4 or 5 days.
Drains are left in place for 5 to 14 days, depending on the amount of drainage.
The patient wears a Velcro binder as much as possible for up to 2 weeks; then the
patient is encouraged to wear some form of commercial girdle-type compression un-
dergarment for an additional 6 weeks.
2980
Part XII Body Contouring
Complications
The entire purpose of the HLTA is to deliver the optimal correction with the lowest
complication rate. Just as with Lockwood’s original opus on the subject, the 2.0 up-
graded version described here is predicated on a zero tolerance for complications. As
well, many of these outcomes are not really complications but rather planned trade-
offs for better or safer results. When a patient is informed of an expected residual de-
formity, he or she will then consider it as part of the surgical plan rather than as a
complication; that is, the patient will then appreciate a secondary surgery as a stage
rather than a revision. Otherwise, complications may include aesthetic mistakes,
which may be irreversible, as well as physiologic misadventures, which can be dev-
astating. These are discussed next, with a brief description of methods of prevention
and treatment.
Aesthetic Complications
Abdominal Scar Too Long
The scar can only be “too long” if the patient was not clearly informed of its often
requisite length. The lateral scar is the primary literal footprint of the HLTA; that is,
if any tension lifting is attempted at the lateral thigh and hip area, the incision will
inevitably be longer. Therefore the surgeon should critically evaluate this anatomy
preoperatively and decide, with the patient’s input, whether there is enough laxity
to warrant extending the incision. Otherwise, experience would indicate that as long
as a scar is of good quality, corrects the deformities, and, what is most important to
the patient, is hidden, the patient will always accept a lengthier repair.
Lateral Scar Too High or Too Low
In general, the greater the excess skin present, the more unpredictable the scar place-
ment can be. This outcome is usually caused by a poor marking design; that is, an
overestimation or underestimation of the magnitude of skin redundancy below the in-
cision. There are several ways to avoid this problem, depending on the magnitude of
redundant skin:
If there is significant excess below the incision, there is a real danger of un-
predictable scar placement (usually riding too high), and during the marking
the surgeon must be certain to place the skin on maximum tension and, like
any good tailor, measure twice and cut once—that is, recheck the markings
and “test” them by having the patient recreate the lift by pulling up the excess
tissues to the desired location.
If there is not a notable excess below the incision (usually in the thicker, less
mobile skin envelope), the scar could be predictably too low if too much infe-
rior skin is removed. Therefore the surgeon should place the skin on less ten-
sion when marking.
Intraoperatively, the preoperative measurement of the distance between the fixed
ASIS and the desired level of the final wound may be used as a guide. It is best
to be conservative with any additional resection (especially in a more adipose-
filled flap), since the thigh skin below may drift inferiorly postoperatively.
Finally, after surgery the surgeon should always critically assess the preoperative
markings against the final result to properly hone his or her tailoring techniques.
Pubis Too Tall or Too Short
A pubis with an incongruent height is usually the result of inaccurate estimation of
the true redundancy of the pubic area. The surgeon must put the pubis on maximum
stretch during marking and leave at least 6.5 cm of pubic height. The pubis can also
be too wide, with the tension surgery potentially worsening the aesthetic effect. If
necessary to prevent this appearance, a wedge resection of the pubis can be done
concurrently or at a later stage. Again, the surgeon should always revisit and the pre-
operative markings and compare them with the postoperative scar placement.
Poor Umbilical Closure Scar
Poor umbilical closure is often the most feared (more by the surgeon than the patient)
but least realized complication. These scars uniformly resolve into short, thin, white
lines. Rarely, a steroid injection or revision will be necessary. Even so, as the patient
is made aware, this 1-inch scar is a small price to pay for the alternative: a 11⁄2-foot-
long abdominoplasty scar that rests too high, pulling the pubis along with it.
Residual Fat at the Suprascar and Central and Superior Abdomen: The Inverted-T
This “complication” is more accurately a deliberate “neglect” of this subcutaneous
fat in an effort to preserve the maximum blood supply to the central flap. The sur-
geon must decide what his or her individual tolerance is for the very real complica-
tions that may ensue from an attempt to remove this fat. Otherwise, patients are sim-
ply informed that they may be best served with a second-stage, unfettered abdominal
liposuction procedure.
Residual Skin at the Upper Abdomen
Residual skin is a complication not really unique to the HLTA. In fact, there is a good
argument that because this technique has a more oblique vector of pull, it can efface
more of this redundancy. However, the patient with significant excess (a second pan-
nus) should be informed preoperatively of its probable persistence. Only a fleur-de-
lis or reverse abdominoplasty can treat this zone definitively and should otherwise
be considered in the first place.
Lateral Dog-Ears
The best way to avoid lateral dog-ears is to fully liposuction this area and to intrep-
idly extend the incision as necessary, particularly the more tension-filled the lift.
2981
Chapter 83 Abdominoplasty
Epigastric Recurrent/Residual Protrusion
Because of the more conservative dissection in the upper abdomen with an HLTA,
in a patient with a very protuberant abdomen it is possible that a less than complete
repair will be performed. Consequently, there can be some degree of epigastric re-
currence/residual deformity postoperatively.
Physiologic Complications
Superficial Fascial System Stitch Abscesses
The stitches used for the tension closure of the fascia are per force of large caliber
with abundant knots. Therefore, stitch abscesses may arise postoperatively (surpris-
ingly very late) particularly if permanent suture is used. This problem is far less likely
with well-buried, absorbable sutures.
Seroma
Because there is far less dissection and no central liposuction with an HLTA, the an-
noying problem of seromas should be rare. For the same reason, the idea of flap ad-
hesion stitches is not really applicable to the HLTA. When a seroma does occur, a
consistent set of aspirations usually solves the problem within a few weeks. The pri-
mary modes of prevention include maintaining the web of lymphatic-containing tis-
sue overlying the fascia and groin when elevating the flap, and placing multiple drains
(three or more).
Deep Venous Thrombosis and Pulmonary Embolism
Volumes of analysis and advice have been written on this subject, particularly in the
last few years. Clearly, with good patient selection, consistent use of antiembolism
pumps, and early mobilization, the incidence of this problem should remain rare. As
for chemical prophylaxis, considering the still unsettled status of this approach, the
surgeon should always refer to the latest recommendations in the literature.
Skin Necrosis
Skin necrosis is a dreaded complication that can occur if the surgeon pushes the en-
velope during surgery: the usual culprits are maneuvers of overaggressive flap mo-
bilization in an effort to remove the maximum amount of redundant skin (particu-
larly from the upper half of the abdomen) and excessively zealous flap fat removal
(by liposuction or direct excision) to thin the flap as much as possible. Unfortunately,
the patients who would need these additional efforts to be taken are often the can-
didates that present the greatest risk, with high BMIs and massive excess of fat and/or
skin. And for the patients who fall in between, there is no accurate selection mech-
anism to determine who will do well with these more-invasive techniques; therefore
surgeons must decide for themselves between “blood and beauty.”
2982
Part XII Body Contouring
Outcomes
The essential advantage of this technique is the ability to deliver consistently supe-
rior and safer results:
The incision is maintained low and hidden within the patient’s clothing.
More skin is removed below the incision both laterally (which, in effect, results
in a significant “lift” of the anterolateral thighs) and centrally (which promotes
a lift of the pubis and anteromedial thighs).
There is little opportunity for flap ischemia because a maximal blood supply
is maintained: local perforators are preserved with judicious and discontinu-
ous undermining, and the flap’s integrity is respected with restraint of any li-
posuction or direct fat removal from the flap itself.
There is less tension at the lower central abdomen, resulting in a lower inci-
dence of flap ischemia and a more aesthetically pleasing mild convexity at the
hypogastrium.
The excess skin in the horizontal plane of the abdomen, particularly in the up-
per poles, is more effectively treated with the oblique vector of excision.
Any residual fat, particularly within the abdominal flap itself, can be treated ag-
gressively, with relative impunity, as a second-stage procedure within 6 months to a
year of the abdominoplasty.
If there is residual skin resting laterally and posteriorly, this can be addressed at a
second-stage procedure with a posterior extension of the abdominal incision for a
completion posterior body lift. If there is remaining skin superiorly at the epigastric
and subcostal areas, this can also be treated later with either excision through sub-
mammary incisions or with a proper reverse abdominoplasty.
If the lateral scar rests slightly outside the patient’s preferred clothing, the scar can
be easily moved up or down by excising the appropriate amount of skin with the pa-
tient under local anesthesia.
Fleur-de-Lis Abdominoplasty
Dellon first popularized the fleur-de-lis technique in 1985. He pointed out that his
technique was an extension of Regnault’s classic “W” technique. For a longer his-
torical perspective, the fleur-de-lis, as Dellon describes, is really a direct, albeit melded,
descendant of the transverse resection technique described by Kelly in 1910 and the
vertical resection approach considered by Babcock in 1916.
2983
Chapter 83 Abdominoplasty
The basic principle and power behind the fleur-de-lis approach is the ability to de-
finitively excise not only the traditional lower abdominal pannus but also much of
the aforementioned redundant upper abdominal tissue. Put another way, this ap-
proach realizes a more complete resection of not only the vertical but also the hori-
zontal vector of excess. But it is important to realize that this technique, in contrast
to its original description, can now be “supercharged” with the addition of the high
lateral tension procedure. The corollary would be that the fleur-de-lis is really an
HLTA with the addition of a vertical incision. Thus the fleur-de-lis approach becomes
even more potent at correcting the entire abdominal unit. In fact, if a reverse ab-
dominoplasty is also included, either conservatively at the time or in a staged repair,
this trio of techniques can make the most complete and impressive correction.
In combination with the high lateral tension technique, the fleur-de-lis can deliver
far-reaching effects: in addition to recontouring the upper abdominal zone with direct
excision, there is an indirect corset effect of the entire anterolateral chest, the flank,
and the back. In fact, this technique can truly address the residual excess skin rolls
beyond the pannus, tissues often left untreated by any “regular” abdominoplasty.
This advantage is particularly relevant in weight-loss patients. In fact, in these pa-
tients, when the surgeon has completed a proper fleur-de-lis resection, the extent of
skin resection can expose most of the anterior abdominal wall. Then, dramatically,
the peripheral “waistcoat” of skin, lying in the wings, advances to close the defect.
Markings
The basic principle behind the marking of the fleur-de-lis is to evaluate, measure,
and mark the horizontal excess independent of the vertical redundancy.
Horizontal marking: With the patient standing, HLTA marking is performed as
though it were to be the only procedure planned.
Vertical marking: Next, with the patient supine, the horizontal excess is outlined,
again as though it too were the sole surgery to be conducted. The surgeon simply
gathers the excess skin with an aggressively wide pinch, marks the margins, and “con-
nects the dots” to realize the vertical marking.
Fleur-de-lis design: With these two apposing markings, the outline of the fleur-de-
lis is actually realized. The outline of the intersecting markings is drawn to define the
borders of the fleur-de-lis abdominoplasty.
Key point: The pivotal point in the marking is the intersection of the horizontal and
vertical markings laterally. This is the best estimation of the location of the wound
edge that will ultimately contribute to the inverted-T closure.
2984
Part XII Body Contouring
The final markings are demonstrated. The yellow stars indicate key points marking
the tips of the upper flaps and the midline of the suprapubic area. The blue lines are
the estimated margins of the fleur-de-lis. The red line is the estimated future site of
the scar.
NOTE: The only marking that is actually used in surgery is the lower horizontal line
of the HLTA portion of the design, with the rest of the outline acting as guideposts.
The important point is to reserve final judgment regarding the margins of excision
until surgery.
It is very important to resist marking the superior pole of the incision much above
the xiphisternum, which could cause the final closure to rest between the breasts
(and even worse, cause synmastia). That is, one should expect the upper wound to
ride up several centimeters with the removal of the heavy abdominal skin and clo-
sure of a very wide wound.
2985
Chapter 83 Abdominoplasty
★
★
★
★
★
Marking test: The excess skin is inverted and the T closure is reproduced. Clearly,
the thinner the patient, the easier and more accurate this maneuver will be. The pri-
mary objective of this step is to estimate the adequacy of skin for comfortable clo-
sure of the T wound. Otherwise, one runs the risk of an excessively tight closure that
in turn can lead to problems ranging from an unaesthetic, constricting, high-riding
scar and pubis to a devastating skin necrosis.
2986
Part XII Body Contouring
Operative Technique
The horizontal and vertical premarked incisions are performed down to the under-
lying fascia.
The skin flaps are raised cautiously, roughly within the boundaries of the premarked
fleur-de-lis template, to preserve the maximum blood supply. Routine abdominal pli-
cation is then performed using a 1 or 0 Ethibond type of suture in running, locking
fashion.
Then, using a large staple gun or suture and an assistant’s help, the surgeon vigor-
ously tailor-tacks the wound by rolling the excess skin below the flaps. As described
previously, it is critical that one begin this tailoring at the suprapubic inverted-T
wound to confirm that there is adequate skin for closure. In effect, this medial com-
mencement of tacking is opposite the traditional Lockwood abdominoplasty in which
the excision is estimated and conducted starting laterally.
Once the lower midline closure is estimated, the tacking should continue alternately
between the midline toward the xiphisternum and laterally toward the hip, in an at-
tempt to evenly distribute the estimated excision of the excess. As noted earlier, the
surgeon should not tailor-tack the vertical closure superiorly any higher than the
xiphisternum to ensure that the eventual scar lies on the abdomen rather than be-
tween the breasts.
2987
Chapter 83 Abdominoplasty
★
The excess skin is then marked at the margins of the tailor-tacking, and the skin is
excised through both the vertical and horizontal incisions.
Then the T closure is tacked again to guarantee the adequacy of the skin for closure.
At the vertical wound, one can often tailor-tack and excise skin a second time, es-
pecially in a patient with very thick or excessive skin. Any remaining skin at the hor-
izontal wound should be removed, as one would with an HLTA using the Lockwood
skin clamp.
The closure is then performed in the same manner as in a routine abdominoplasty. An
ellipse of the wound margin from each flap is excised at the site of the umbilicus,
which is then inset.
With experience, particularly in thinner patients, the surgeon can consider just tailor-
tacking the skin at the inverted-T closure only, directly excising the vertical marking
and then applying the Lockwood abdominoplasty to the lower excess.
Problems and Complications
The midline scar can extend too far superiorly with the creation of some synmastia
unless care is taken to prevent its migration. The primary tactic to avoid this prob-
lem is marking the repair deliberately no higher than the xiphisternum and resisting
the impulse to chase the excess skin superiorly onto the chest. Also, if the tacking or
excision itself is not symmetrical, the vertical scar can be crooked. If this is noted at
surgery, an attempt at correction should be made with the necessary skin resection
from one side or the other.
Outcomes
The effects of the fleur-de-lis procedure can be the most dramatic of all abdomino-
plasties: because of the significant recruitment of skin from the lateral trunk, an im-
pressive correction is made at the waist, back, and flank folds. With excision of most
of the horizontally redundant skin, particularly at the upper abdomen, the result is
clearly more complete. Additionally, because of the wide exposure of the fascia, the
abdominal wall deformity can be fully corrected with this technique. This is espe-
cially true in the epigastric area, where the repair can be otherwise constrained by
the HLTA’s narrow tunnel of dissection.
The inverted-T scar heals surprisingly well and becomes a thin white line. Despite
the impressive dissection, since primarily all the undermined skin is excised (espe-
cially the suprapubic swath of skin), flap ischemia is not a major concern.
Reverse Abdominoplasty
The reverse abdominoplasty was initially described in 1972 by Rebello and Franco in
the South American literature. In 1979 Baroudi et al published the first paper in the
United States describing the technique in combination with reduction mammaplasty.
The reverse abdominoplasty is most efficacious when combined with the other ab-
dominal contouring surgeries already described; that is, the principal indication for
reverse abdominoplasty is for cleanup of the residual redundant tissue at the supe-
rior abdominal pole after any lower abdominoplasty. This approach is particularly rel-
evant when treating weight-loss patients. Even after proper application of the high
lateral tension technique, a reverse abdominoplasty should be anticipated as a sec-
ond stage. Otherwise, this technique is indicated in the relatively rare patient who
presents with skin excess and abdominal protuberance primarily in the upper pole
of the abdomen. The utility of this approach is even more compelling if the major-
ity of striae and surgical scars are also principally confined superiorly. A reverse ab-
dominoplasty may be easily married to a Wise pattern breast procedure, since join-
ing the two submammary incisions entails only a few centimeters of additional scar.
2988
Part XII Body Contouring
Otherwise, with more limited skin excess, direct excision of skin through separate
submammary incisions could be considered, particularly in a Wise pattern type of
breast surgery.
Markings
2989
Chapter 83 Abdominoplasty
The patient is marked in the supine position. The upper margin of the skin resection
is outlined initially. The mark should start as far lateral as the excess skin demands,
always maintaining the final closure within the bra strap line. The markings then
continue along the submammary line, with the two sides meeting at the epigastrium
as a V. If there is to be concomitant breast surgery, the mammary markings should
be conducted first.
The excess skin at the upper pole of the abdomen is then pinched and pulled supe-
riorly, and an approximate line of redundancy is marked. The extent of excision is
guided by observing the maximum tautness of the upper abdominal skin.
The mobility of the inframammary crease is gauged. The more ptotic the breast, the
greater the potential inferior displacement of the crease. Thus the crease must be se-
cured at the time of surgery.
The laxity of the umbilicus (the length of its stalk) must also be assessed. The sur-
geon should attempt to prevent excessive superior displacement of the umbilicus with
advancement of the upper flap.
Operative Technique
2990
Part XII Body Contouring
The upper incision is made and the abdominal flap elevated several inches beyond
the skin redundancy. This dissection should be no farther than several centimeters
from the umbilicus to block the potential excessive advancement superiorly.
The most critical step in this technique is to define the inframammary fold at the ap-
propriate level so that the skin excision can be more accurately estimated. This is ac-
complished by first marking the position of the future breast fold on the chest. This
should be done with the patient in the upright position to more accurately determine
the natural coordinates of the inframammary fold. Otherwise, in the supine posi-
tion, the fold can rise unnaturally by several centimeters, and the eventual crease
could then be sutured too high.
Using Kocher clamps and upward and slightly lateral traction, the surgeon marks
the excess and sequentially excises it. As with the abdominoplasty, skin excision is
made 1 or 2 cm more proximal to the marked excess point to prevent too much
wound tension. The resultant wound can be as much as 6 to 8 inches in height.
2991
Chapter 83 Abdominoplasty
Superficial fascial
system sutures
The upper abdominal flap is then inset along the now “tamed” inframammary crease.
The deep fascia is employed to ensure a secure closure, along the length of the chest
using 0 or 1-0 PDS-type suture. As with the abdominoplasty, the suture should be
placed in the superficial fascial system approximately 2 cm behind the upper margin
of the abdominal flap to ensure a rolled, tension-free skin closure. If a breast lift or re-
duction is to be performed at the same time, it is preferable to perform the reverse ab-
dominoplasty first. This surgical order creates a solid shelf on which the breast can
then be built. Otherwise, a completed breast repair may be compromised by the pos-
sible recruitment of some of the lower breast skin when the abdominal flap is inset.
Final closure is similar to that for routine abdominoplasty, using 2-0 Vicryl for the
dermis and 3-0 Monocryl for the skin. Two 10 mm drains are placed before closure.
Problems and Complications
With or without a concomitant breast surgery, the sheer heft of the inset abdominal
flap can result in some deformation of the breast shape as the tissues relax. The best
measure of prevention is to “overengineer” the repair of the abdominal flap to the
defined inframammary crease, with an abundance of sutures.
By virtue of the advancement of the upper abdominal flap, the umbilicus can be teth-
ered superiorly. This is particularly true with an umbilicus with a longer stalk. Ma-
neuvers to resist this displacement include reining in such a stalk with direct sutures
to the rectus fascia and halting the upper skin flap mobilization several centimeters
above the umbilicus.
Outcomes
With an aggressive application of the reverse abdominoplasty technique, there can
indeed be a rewarding correction of the disturbingly persistent excess skin at the up-
per abdomen after a routine abdominoplasty. The central 3 inches of additional scar
resting between the breasts heals remarkably well. It can be even more inconspicu-
ous if it is designed to rest inferiorly in a V shape. Postoperatively the breast should
remain in a stable, aesthetic position as long as a secure reinsertion of the abdominal
flap is performed at the appropriate inframammary level. Some superior advance-
ment of the umbilicus can occur despite all efforts to the contrary.
2992
Part XII Body Contouring
2993
Chapter 83 Abdominoplasty
Results
High Lateral Tension Abdominoplasty
This 46-year-old woman who had had four children requested abdominal repair af-
ter her last child was born. A high lateral tension abdominoplasty was performed,
along with a mastopexy/augmentation. She is seen 4 years postoperatively, revealing
evidence of the significant lateral excision accomplished with this technique, by virtue
of the removal of her entire tattoo. The benefits of the HLTA with a more aesthetic
waistline and smoother epigastric zone are apparent.
This 46-year-old nulliparous woman was seen after losing 66 kg (145 pounds) fol-
lowing a gastric bypass. She did not want a midline scar, but otherwise desired as
much improvement as possible. She underwent a high lateral tension abdominoplasty
with liposuction of the hips and lateral thighs. A mastopexy was performed at the
same surgery. Note the presence of the supraumbilical line of demarcation carrying
the more redundant skin above. Therefore dissection was deliberately discontinuous
in this area and the patient was informed of the likelihood of residual epigastric ex-
cess postoperatively. She healed without complication. She is seen 8 months post-
operatively. Note the correction of the abdominal deformity, even in the epigastric
area, because of the oblique vector of its excision. The HLTA’s body-lift effect was
realized in the anterolateral thigh and buttock areas.
2994
Part XII Body Contouring
2995
Chapter 83 Abdominoplasty
This 57-year-old woman had had two children and had lost close to 45 kg (100
pounds). She underwent an HLTA with liposuction of the hips and thighs and a
breast reduction. Note the reconstitution of an aesthetic abdomen and the lifting of
the buttocks.
2996
Part XII Body Contouring
This 43-year-old nulliparous woman lost more than 45 kg (100 pounds) through a
gastric bypass procedure. She elected to have an HLTA with liposuction of the hips
and thighs. In evidence are the lift and correction of the lateral thigh/buttock region
through well-placed scars.
2997
Chapter 83 Abdominoplasty
This 39-year-old nulliparous woman had lost 91 kg (200 pounds) through diet and
exercise alone. She demonstrated the most desirable skin envelope: thin and mobile.
The patient underwent an HLTA using an extended posterior incision so that a more
complete excision and lift of the lateral trunk could be achieved, while still properly
treating the central tissues. Liposuction of the hips and lateral thighs as well as
mastopexy with implantation were also performed.
2998
Part XII Body Contouring
This 43-year-old nulliparous woman had undergone a bypass procedure and achieved
a 66 kg (145-pound) weight loss. She subsequently underwent an HLTA and is seen
9 months postoperatively. The hallmarks of the HLTA effects are evident: the scar
rests in a hidden position, the suprapubic skin is not overly tight, and the thigh and
hip regions have been lifted. The closeup photo of the thigh reveals the qualitative
improvement in the skin extending practically to the knee.
2999
Chapter 83 Abdominoplasty
This 50-year-old woman requested rejuvenation of her abdomen; she had had one
child. She underwent an HLTA with liposuction of the hips and lateral thighs and
augmentation mammoplasty. The pleasing aesthetic of the abdominal repair is real-
ized with a well-placed scar, a not overly tight suprapubic region, and an improved
hip-thigh contour. Note the “stealth” skin redundancy, visible when the patient is
sitting and bending, and its repair postoperatively. And still there is some residual
skin excess in the epigastric area postoperatively.
3000
Part XII Body Contouring
High Lateral Tension Abdominoplasty With Staged Liposuction
3001
Chapter 83 Abdominoplasty
This 35-year-old woman had one child; she desired correction of her abdominal pro-
trusion. She demonstrated a similar excess of skin when bending or sitting. An HLTA
was performed with liposuction of the hips and thighs. The benefits of this technique
are demonstrated with the return of her prepregnancy contour. As planned, the scar
is properly hidden within the patient’s underclothes. For safety, a planned second-
stage liposuction was performed of the abdominal flap to complete the repair.
This 36-year-old woman, 5 feet 3 inches tall and 70 kg (155 pounds), complained
of residual abdominal deformity despite aggressive diet and exercise. She had had
three children.
3002
Part XII Body Contouring
Markings for HLTA
Markings for post-HLTA liposuction
The patient underwent an HLTA with aggressive liposuction of her hips and thighs.
Note the relative lift of both the buttocks and thighs. Rather than potentially com-
promising the blood supply at the first surgery, a secondary liposuction of the ab-
dominal flap was performed instead.
3003
Chapter 83 Abdominoplasty
As planned, the very productive, although lengthy, scar
is hidden within her underwear.
First Stage: High Lateral Tension Abdominoplasty
Second Stage: Reverse Abdominoplasty With Mastopexy
3004
Part XII Body Contouring
A high lateral tension abdominoplasty was performed with a concomitant mastopexy;
no implants were placed. In these photographs, taken approximately 15 months post-
operatively, improved contours are evident, particularly full correction of the inguinal
and hip areas as well as the waist.
This 32-year-old nulliparous woman had undergone a gastric bypass procedure. She
had lost approximately 60 kg (132 pounds) and wished to improve the appearance
of her anterior trunk, abdomen, and breasts.
A reverse abdominoplasty and synchronous mastopexy were performed. This resulted
in a rewarding correction of her upper abdominal deformity. Seen 9 months post-
operatively, the appropriate location of the inframammary crease is evident after
proper fixation at the time of the abdominoplasty. The photos also demonstrate a
slightly overly raised umbilicus, a potential minor stigma of a productive reverse ab-
dominoplasty. As outlined, the surgeon should maintain tissue above the umbilicus
undissected and secure the umbilicus to the underlying fascia.
3005
Chapter 83 Abdominoplasty
The patient then requested correction of the residual redundant tissue at the upper ab-
domen. Approximately 7 to 8 inches of excess tissue was marked for excision.
This 43-year-old woman who had had three children underwent a gastric bypass
with a resultant loss of 66 kg (145 pounds). She complained of redundant skin
throughout her abdomen. Although she would have been an ideal candidate for a
fleur-de-lis abdominoplasty, she did not want a midline scar. A high lateral tension
abdominoplasty was performed with the ultimate plan of including a reverse ab-
dominoplasty at the time of breast rejuvenation to address the inevitable residual
upper abdominal tissue. She is seen approximately 18 months postoperatively. On
the oblique views, note the significant reshaping of the hip and lateral thigh contours.
3006
Part XII Body Contouring
3007
Chapter 83 Abdominoplasty
The patient later underwent a reverse abdominoplasty and mastopexy/augmentation
to complete her repair. The excess upper abdominal skin remaining after the HLTA is
now corrected.
First Stage: High Lateral Tension Abdominoplasty
Second Stage: Reverse Abdominoplasty With
Augmentation/Mastopexy
3008
Part XII Body Contouring
This 46-year-old woman had undergone a gastric bypass procedure. She had an HLTA
first and then a staged reverse abdominoplasty for correction of the excess tissue at
the upper abdomen and chest. The progressive results are seen.
Fleur-de-Lis Abdominoplasty With High Lateral Tension
3009
Chapter 83 Abdominoplasty
This 41-year-old female achieved a 64 kg (140-pound) weight loss from gastric by-
pass surgery. Her goal was simply to have the abdominal redundancy improved as
much as possible. The patient was otherwise very healthy. The massive upper ab-
dominal “second pannus” could only be properly and safely repaired with a fleur-
de-lis technique. Significant body contouring was accomplished despite the patient’s
thicker habitus. She also underwent a concomitant mastopexy.
This very fit 65-year-old woman desired a better contour with correction of her ab-
dominal redundant skin and protrusion. She had had two children. She elected to
have a fleur-de-lis procedure to more fully improve her shape. Note the excess stealth
skin that becomes more obvious with change in position or when put on tension.
Her aesthetic habitus allowed the full effect of the fleur-de-lis to be expressed with
a particularly dramatic improvement in her pubis, waist, upper abdomen, and back
folds. In addition, the patient’s posture appears to have improved.
3010
Part XII Body Contouring
3011
Chapter 83 Abdominoplasty
This 59-year-old woman underwent a gastric bypass and a subsequent weight loss
of more than 45 kg (100 pounds). She requested abdominal correction, and because
of the excess skin in the upper poles of the abdomen, we elected to perform a fleur-
de-lis abdominoplasty with a proper high lateral tension approach to the lower ab-
domen.
3012
Part XII Body Contouring
The results demonstrate the rewarding improvement not only of the abdomen, but
also a more far-reaching correction of the waist and back (fleur-de-lis) as well as the
thighs and buttocks (HLTA).
3013
Chapter 83 Abdominoplasty
This 33-year-old nulliparous woman had undergone a gastric bypass and lost 50 kg
(110 pounds). She desired as complete an abdominal recontouring as possible in one
stage. Therefore she was very accepting of a fleur-de-lis approach and equally pleased
with the relatively full repair of her redundant tissue, as seen here 7 months post-
operatively.
3014
Part XII Body Contouring
3015
Chapter 83 Abdominoplasty
3016
Part XII Body Contouring
Fleur-de-Lis Abdominoplasty With Posterior Body Lift
This 40-year-old nulliparous woman had lost 73 kg (160 pounds) as a result of gas-
tric bypass surgery. A concomitant fleur-de-lis abdominoplasty and posterior body
lift were performed. Note the correction of both the abdomen and the surrounding
aesthetic units.
3017
Chapter 83 Abdominoplasty
First Stage: High Lateral Tension Abdominoplasty
With Posterior Body Lift
Second Stage: Reverse Abdominoplasty With Augmentation/
Mastopexy
This 53-year-old nulliparous woman had originally lost 50 kg (110 pounds) after a
gastric bypass. She was seen 6 months after an HLTA with a posterior body lift and
now desired repair of a significant redundancy of the upper abdomen. At the time
of the reverse abdominoplasty, a mastopexy with augmentation was also performed.
By insetting the abdominal flap before the breast surgery, a definitive breast platform
was created. At 4 months postoperatively, note the tight appearance of the upper ab-
domen. The sequential results are illustrated (see p. 3018).
3018
Part XII Body Contouring
It is instructive to ask the patient to perform an examination room “nonsurgical lift”
(see p. 2975) of the excess skin to demonstrate her goals. As can be seen, the results
came very close to meeting those goals.