The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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• I. Minimal incision brachioplasty
• II. Standard brachioplasty
• III. Extensive brachioplasty with possible proximal or distal
extension
• IV. Thoracobrachioplasty
Each of these procedures can be done with or without lipo-
suction, depending on the extent of existing lipodystrophy. As
previously noted, a select group of patients are candidates for
liposuction only.
A determination is also made about additional procedures
that might be included with the arm recontouring. These might
be breast procedures or upper body lifts. In general, an attempt
is made to create a logical strategy in multistage operations for
the massive-weight-loss patients. Upper body recontouring—such
as of arms, chest wall, upper back, and breast—is considered one
stage and is generally done concomitantly and not combined with
lower truncal or lower extremity operations.
88.4.1 Minimal Incision Brachioplasty
Patients who present with skin laxity of the proximal upper arm
and mild to moderate lipodystrophy are candidates for minimal
incision brachioplasty (Fig. 88.6a1,a2). It is imperative not to
overpromise regarding correction of distal laxity and excess or
the general effectiveness of this operation. Minimal-incision bra-
chioplasty can be done with or without liposuction, depending
on the extent of lipodystrophy of the proximal upper arm.
Fig. 88.2 Regions of the arm (I, II, III) as they relate to regions of
defects of excess skin and fat.
Fig. 88.4 A midarm cross-sectional presentation of the deep anatomy
of the arm.
Fig. 88.3 Normal arm anatomy in a 36-year-old woman.
Fig. 88.5 Anatomical distribution of the medial brachial cutaneous
nerve and the medial antebrachial cutaneous nerve.

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Fig. 88.6 Preoperative presentation and illustration of types of arm recontouring to be selected. (a) A 39-year-old woman is evaluated for a mini-
mum-incision brachioplasty. (b) A 39-year-old woman is evaluated for a standard brachioplasty. (c) A 47-year-old woman is evaluated for an extensive
brachioplasty. (d) A 42-year-old woman is evaluated for a thorachobrachioplasty.

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88.4.2 Standard Brachioplasty
This common operation is appropriate for a large group of
patients with significant excess of skin of the upper arm with
“bat wing deformity” (Fig. 88.6b1,b2). This effective operation
addresses the skin laxity and can also be done with or without
liposuction, depending on the presenting lipodystrophy. The
extent of the excision is generally limited to the upper arm.
88.4.3 Extensive Brachioplasty
Patients whose excess is not simply limited to the upper arm and
who have laxity of skin and lipodystrophy of the proximal fore-
arm or proximal chest wall will require an extensive brachio-
plasty (Fig. 88.6c1,c2). The extension of the excision will depend
on the presenting magnitude of excess in both the proximal
forearm and the chest wall. This group will also be evaluated for
the possibility of suction-assisted lipectomy as an adjunct to the
recontouring.
88.4.4 Thoracobrachioplasty
This extensive operation (Fig. 88.6d1,d2) is reserved for patients
who have not only a dramatic excess of arm skin but also signifi-
cant excess on the lateral chest wall. This group often complains
of excessive “bra rolls” and will need an overall recontouring
of the arm and chest wall. These patients tend to need breast
recontouring and occasionally will undergo an upper body lift.
Once a treatment plan is devised, based on the presentation,
every effort is made to clearly describe the technical aspects of the
operation along with the expected outcome. All patients undergo
a very detailed evaluation of their history, and appropriate pre-
operative evaluations are obtained, including possible operative
clearance. The course of recovery is also clearly described to the
patient, including limitations on professional activity, travel, and
intimate contact. The hazards of tobacco are described, and all
patients who smoke are advised to stop immediately. All patients
will undergo a nicotine test on the day of the procedure, and any
trace will lead to cancellation of the operation and the potential
logistical and financial implications. Patients meet with financial
and patient coordinators who clearly explain all obligations of
the proposed plan. This includes a very detailed discussion of the
policy regarding possible revisionary operations.
Once the patient is scheduled for an operation, a system of com-
munications is initiated that conveys the importance of prepa-
ration prior to the operation. This includes avoidance of herbal
medications, nonsteroidal anti-inflammatory drugs, and any other
agent that might interfere with blood clotting. Two weeks prior to
the operation, the patients undergo a preoperative examination.
At this point they receive final preparatory instructions, including
their prescriptions and an antibacterial body wash that they
will use prior to the operation. At this visit we undertake a very
detailed review of the informed consent paperwork. Each patient
receives an information booklet that summarizes and describes
in detail the preoperative, operative, and postoperative elements
of their procedure. As with all surgical procedures, a clear and
concise transmittal of information is paramount in establishing
a healthy medical and psychoemotional relationship between the
patient and the physician.
88.5 Preoperative Planning,
Including Markings
A well-executed brachioplasty is highly dependent on identifi-
cation of the defects of excess skin in the described regions I–III
(Fig. 88.2) and a subsequent decision about the four different
types of treatment (Fig. 88.6). The planning also considers
methodical, safe, and predictable areas of excision so that the
operation can be performed efficiently without risk of overresec-
tion or excessive edema.
All patients are marked in a standing position shortly before
the operation. The arms are evaluated, first while relaxed at the
sides and then with shoulders abducted and extended at 90° at
the shoulder joint and flexed 90ƒ at the elbow joint. The patient is
asked to assume this posture and release to a relaxed posture with
arms at the sides multiple times in order to see the extent and
position of the markings. The arms are so dynamic in their motion
that such positional evaluations during markings are imperative
for determining accurate boundaries of excision. Asymmetries are
again recognized and pointed out to the patient.
The philosophical approach of the markings and preparation is
based on a customized individual solution. Considering the exten-
sive and variable presentations of different arms with different levels
of lipodystrophy, excess skin, and regional involvement, it behooves
the surgeon not only to understand the basics of these operations
but also to have a totally open mind in positioning these markings.
Another important objective of the markings is the final
position of the scar. The minimal incision brachioplasty (group
I) will leave a scar between the anterior and posterior extent of
the axilla in order to prevent visibility when the arm is in repose.
The linear incision of the different full brachioplasty procedures
(groups II–IV) is best placed in a posterior–medial position. There
has been extensive discussion about optimal placement of the
scar, and it is widely believed that the posterior–medial position is
the most aesthetically pleasing, as the scar is not visible when the
patient’s arm is in repose (Fig. 88.7). Positioning the scar there is
also believed to reduce the risk of injury to some of the sensory
nerves of the upper arm.
88.5.1 Group I: Minimal Incision
Brachioplasty
The anterior and posterior of the apex of the axilla are marked
with the patient in the standing position (Fig. 88.8) and
rechecked in repose. It is important not to extend the incision
beyond these points (points A,B) so that the scar will not be
visible when the patient is in a standing position with arms in
repose. It is also important to recognize that the eventual closure
of this elliptical defect will elongate this axillary scar and can
theoretically extend the length of the final closure beyond the
proposed points. Therefore, while the shoulders are abducted
and the elbows flexed at 90ƒ, a slightly shorter line is chosen
(points Aɼ, Bɼ). The extent of skin excision on both the arm side
and the axillary region is based on the patient’s skin laxity. This
is an arbitrary measurement, usually 3 to 5 cm from the most
central axis of the scar. The area of liposuction is also marked;
it is generally performed in the proximal posterior elements of
the arm. As with other types of brachioplasty, it is important to

88 Brachioplasty
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always determine ease of closure and aesthetic outcome in the
operating room by using forceps to approximate the result before
committing to excision lines.
88.5.2 Groups II–IV: Brachioplasty—
Standard, Extensive, and
Thoracobrachioplasty
The core principle of the design of excision of these groups is sim-
ilar; each is differentiated by the distal and proximal extension
(Fig. 88.9). The patient is marked in a standing position. After a
detailed analysis of the anatomy, while the patient’s shoulders
are abducted and elbows flexed at 90ƒ, two central points³the
medial epicondyle and the apex of the axillary fossa—are
marked. First, the expected and predicted eventual position of
the scar is marked in red on the posterior–medial axis. Distally,
a slight upward line follows the natural curvature of the distal
upper arm. If there is extension distally into the proximal fore-
arm, a slight change in angle is designed to prevent a straight
line through the elbow joint. Proximally, this line either ends at
the axilla or continues toward the chest wall. When an extension
is made in the chest wall, a fairly acute angle is created at the
apex of the axillary fossa; the extension then ends in an appro-
priate position in the upper chest wall, or continues in a lazy
S pattern toward the lower chest wall to end at the level of the
lateral inframammary fold. This acute turn alleviates the need
for a complicated, cumbersome, and distorting Z-plasty in the
axilla. The techniques described here are based on adaptive and
improvised intraoperative maneuvers and allow for tailor-tack-
ing. This is done so that there is no chance of overexcision, which
can have a devastating outcome. Therefore, a committed line
is chosen approximately 1 cm above the expected line of the
scar and marked with a solid line. The extent of this committed
line depends on the choice of brachioplasty as necessitated by
the presentation. A noncommitted inferior excision line is also
marked, in a discontinuous hashtag marking, recognizing that,
depending on the technique used, the extent of excision might
vary. The placement of this inferior marking is determined by
manually pinching and visually approximating its path. The
patient is then asked to raise the arm high so that the linear and
geometric proportion of the upper and lower scar can be deter-
mined. At this point adjustments are made to prevent dog-ears
and unequal scar approximation.
88.6 2SerDWiYe 7eFKniTue
88.6.1 Positioning
All operations are done with the patient under general anes-
thesia and placed in a well-padded supine position. Sequential
compression garments are placed over the calves. The arms
are abducted at 90° and circumferentially prepped. Each arm
is addressed, and during the resection each side is rotated up
to approximately 130° (Fig. 88.10). This maneuver is useful in
establishing some tension for the eventual excision.
88.6.2 Operative Strategy and Resection
There are two essential brachioplasty techniques. They are both
based on the need for control and efficiency, and they allow
Fig. 88.7 Various descriptions of the brachioplasty scar and the
preferred posterior–medial position.
Fig. 88.8 Minimal-incision brachioplasty markings.
Fig. 88.9 Brachioplasty markings.

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significant intraoperative improvisation. For thinner arms with
copious skin excess, the intraoperative staple approximation
technique is used. The sequential resection and approximation
technique is often used in conjunction with suction-assisted
lipectomy for arms with excess fat. The choice of these two
techniques is determined preoperatively by physical and visual
assessment. Manual grasping and pinching of the excess fat and
skin can guide that assessment.
,nWrDRSerDWiYe SWDSOe ASSrR[imDWiRn 7eFKniTue
As the patient is positioned, the arm is rotated up (Fig. 88.11a)
and the excess skin is examined circumferentially. Starting
distally from the elbow and moving toward the axilla, the excess
skin is grasped between forceps with fairly significant tension,
recognizing that the eventual resection of the included skin will
ease the closure. This staple line is carried to the axilla; at that
point, a sharp turn is made toward the apex of the fossa and then
carried toward the lateral chest, depending on the amount of
excess (Fig. 88.11b). This technique can end at the axilla or can
be taken farther down the chest wall, depending on the amount
of excess skin. A marking pen is used to demarcate lines comfort-
ably outside the row of staples (Fig. 88.11c). Cross-hatchings are
then done for ease of approximation (Fig. 88.11d). The staples are
removed, and the markings are solidified (Fig. 88.11e). Xylocaine
with dilute epinephrine is injected into the new markings. The
area of the axillary fossa is marked and distinguished. In this
Fig. 88.10 Operative positioning of 130° abduction of the arm of a
61-year-old woman.
Fig. 88.11 A 61-year-old woman with a history of massive weight loss undergoing a brachioplasty using the intraoperative staple approximation
technique. (a) Arm abducted for a clear visual continuity of the entire scar line. (b) Tight closure using staples. (c) Demarcation of the outside of the
staple line. (d) Segmental marking and cross-hatching. (e) Removal of staples and final excisional marking. (f) Removal of skin and maintenance of a
healthy brachial fascia. (g) Closure of superficial fascial system. (h) Final closure.

88 Brachioplasty
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area, a more superficial dissection should be made to avoid
damage to lymphatics and vital structures. The incisions are
made and deepened past the SFS. The flap is elevated off the bra-
chial fascia and some subcutaneous tissue from the elbow to the
lateral chest (Fig. 88.11f). A slight undermining is done to ease
closure and grasp of the SFS (Fig. 88.11g). Care is taken to leave
a healthy brachial fascia, which will serve as the bottom point of
a three-pointed progressive closure and will also theoretically
cover and hence protect the various lymphatic channels and
sensory nerves.
SeTuenWiDO 5eVeFWiRn Dnd
ASSrR[imDWiRn 7eFKniTue
In this technique, the arm is also rotated. Most patients who
undergo this technique will most likely have concomitant
liposuction. An approximation of the excision is once again deter-
mined. A dilute standard wetting solution is injected through a
small incision at the distal aspect of the scar. After the necessary
time has elapsed, a liposuction device of choice is used to suction
out the subcutaneous fat under the proposed area of resection
(Fig. 88.12a). The cannula is advanced past the lower proposed
line into the posterior compartment of lipodystrophy according
to the preoperative markings. The area under the proposed resec-
tion is aggressively emptied to a point that the cannula is visible
(Fig. 88.12b). This will serve as a plane for a quick and bloodless
dissection toward the proposed and improvised lower resection
line. Once the amount and extent of liposuction are determined
to be appropriate, attention is turned to the sequential resection
and closure technique. The entire upper committed incision is
made and deepened past the SFS. The pocket of liposuction under
the proposed resection paddle is then approached. With inferior
traction, a bloodless and loose fibrous remnant of the area of
liposuction is opened inferiorly slightly past the lower line of
resection (Fig. 88.12c). This is performed from the elbow to what-
ever extent of the lateral wall has been previously determined,
marked, and aspirated. As with the other technique, care is taken
to leave a healthy layer of brachial fascia and subcutaneous fat on
the floor of the resection. At this point, the inferior flap is advanced
systematically and segmentally up to the committed line (Fig.
88.12d), and excess skin is determined, marked, and incised (Fig.
88.12e). Each excised segment is temporarily closed with staples
(Fig. 88.12f). It is wise to establish hemostasis so that this will be
the final reapproximation prior to closure of the defect. Once the
entire defect is closed, cross-hatchings are marked (Fig. 88.12g)
for an accurate approximation of the final closure.
Fig. 88.12 A 33-year-old woman with a history of massive weight loss undergoing a brachioplasty using the sequential resection and approximation
technique. (a) Liposuction of the arm. (b) Complete liposuction of the area of excision with visualization of the cannula. (c) Dissection of the flap
through the loose tissue of the zones of liposuction. (d) Sequential advancement and marking of the excess skin. (e) Excision of the excess skin.
(f) Temporary closure and approximation with staples. (g) Marking and cross-hatching for eventual closure. (h) Final closure.

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88.6.3 Closure
Once the basics of contour and hemostasis are confirmed to be
appropriate, the closure of the arm is performed in a manner
to reduce tension on the scar and also to alleviate the need for
drains by closing the dead space. Approximation of the SFS of the
arm has long been considered vital; as with the rest of the body,
this layer reestablishes anatomical continuity and reduces ten-
sion. This fascial layer can be thin, especially in bigger arms that
have significant lipodystrophy. It is imperative to use caution in
identifying, preserving, and using this layer in this closure. The
three-pointed progressive closure (Fig. 88.13) is a technique that
reapproximates the SFS of the upper and lower resection lines
and includes the floor of the brachial fascia to eliminate any dead
space. Long-term absorbing polydioxanone sutures are used
either in an interrupted manner or in a running barbed suture
of equivalent composition and size for a continuous closure. This
method of closure and the progressive elimination of any dead
space makes drains unnecessary. The strength of this fascial
closure reduces the tension and assists in the eventual approxi-
mation of the scar. The superficial dermal layers are also closed
with long-term absorbing polydioxanone sutures and eventually
a superficial layer of a running barbed Monocryl suture (Fig.
88.11h, Fig. 88.12h). Because scar widening and thickening is a
significant sequela of brachioplasty, a meticulous low-tension
closure is essential, as is the use of long-term absorbing sutures.
Such closure of the brachioplasty defect is the first step in estab-
lishing a good scar line.
Prior to closure, the areas of excision and closure can be injected
with either a long-acting local anesthetic or an extended-release
formulation. This can provide a tremendous level of comfort for
the difficult initial few hours and days, respectively.
88.7 Ancillary Procedures
Brachioplasty can be done concomitantly with other operations,
the most common and important being liposuction. As described,
appropriate use of liposuction in the execution of the operation
can be important both as an adjunct for recontouring and in
ensuring the technical success of the procedure. Liposuction has
been determined to be a safe adjunctive operation.
Other logical concomitant procedures include an upper body
lift. This operation is effective in excision and lift of the upper back
and lateral chest wall. Breast recontouring, mostly in the form of a
reduction or a lift, is another element of upper body recontouring
that is done in conjunction with brachioplasty.
The upper body—consisting of arms, chest wall, breasts, and
upper back—is an important anatomical subunit in body contour-
ing. It is therefore wise to limit the ancillary operations to the
regional area. The combined resection of arms and chest wall in
the form of a thoracobrachioplasty, along with breast recontour-
ing, with or without upper body lifting (Fig. 88.14), is a logical
addition to the constellation of types of body contouring used for
patients with excess skin and lipodystrophy of the upper body.
88.8 Postoperative Care
After the procedure, all incisions are covered with occlusive tape,
such as Steri-Strips. A bolero garment (Fig. 88.15) is placed on
the patient, who is instructed to elevate the arms on soft pillows
for the first 48 hours after the procedure. Patients are warned
against rapid and strong flexion of the elbow or abduction of
the shoulder for the first 24 hours. They are also instructed not
Fig. 88.15 A typical bolero garment worn by a 48-year-old woman
after a brachioplasty.
Fig. 88.13 The three-pointed progressive closure technique. Points 1
to 3 depict the three points of reapproximation—the superficial fascial
system of the upper and lower flap and the brachial fascia.
Fig. 88.14 A 40-year-old woman at 4.5 months postoperative after a
composite augmentation mastopexy, thoracobrachioplasty, and upper
body lift.

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to engage in vigorous activity for the first 2 weeks. Patients are
advised that edema is common after a brachioplasty and are
warned to refrain from wearing rings for the first 2 weeks after
the operation.
Postoperative care is mostly based on confirming proper wound
healing and also starting a regimented protocol of postoperative
scar control. For the first 2 weeks the incisions are covered with
Steri-Strips. For the third week, micropore brown tape is used.
Subsequently, a rest period is recommended to allow the scar
to dry and to verify that there are no separations of the incision.
At this point, silicone gel sheeting is begun and continued for
approximately 4 months. It is imperative to compress the sheeting
with a garment. Given the difficulty of placing strips on a moving
arm, occasionally silicone gel spray is provided to patients to
improve compliance.
Patients receive specific instructions to stretch their arms at
about 1 month. This tends to stretch the scar and can eliminate
any axillary fibrosis of the scar. Patients are given the go-ahead to
start their exercise regimen at 1 month and are totally cleared for
any activity at 6 weeks.
Standardized photography to capture the postoperative results
is done at 3 months, but given the prolonged maturity of brachio-
plasty scars, patients are asked to follow up at 6 to 9 months after
the operation for a final photo.
88.9 Outcomes
With our expanding knowledge base of brachioplasty and the
significant increase of this operation in plastic surgery, various
contributions to the literature have addressed the complications
of this procedure. Infection, bleeding, minor and major wound
separations, seroma, edema, and sensory disruptions have all
been described. However, the maturity and the quality of the
scar continue to be the primary issues with this operation. There
is no doubt that, regardless of any of the reported positions of
the scar, a brachioplasty scar is not in an optimal position for
tension-free and natural healing. The scars invariably thicken
and form hypertrophic areas (Fig. 88.16). Various intraoperative
and postoperative maneuvers are imperative to counteract this
inherent tendency. As with other body contouring operations,
proper closure of the SFS is imperative to reduce the eventual
tension of the scar. Use of long-term absorbing polydioxanone
sutures, in either an interrupted fashion or a continuous barbed
suture of equivalent composition and size, is one of the first steps
to achieving a secure and low-tension closure. The superficial
layers of the skin—the dermal layers—are also closed with long-
term absorbing polydioxanone sutures. This too contributes to a
long-term tension-free closure. Postoperative strategies include
the described regimen of taping and silicone products. Perhaps
one of the most important elements of scar maturity and out-
come is time. Maturing of a scar of the arm lags the maturing of
scars elsewhere in areas of body contouring. This unavoidable
reality should be explained to the patient in order to establish
realistic expectations (Fig. 88.17) Steroid injections should
be viewed with caution. As the skin of the arm is thin, steroid
injections can further widen the scars, cause telangiectasias,
and also contribute to subcutaneous atrophy, which can cause
contour deformity. Occasionally secondary revision of the scars
is recommended, but with the cautious advice that there are no
guarantees of improvement (Table 88.1).
As with many other body contouring procedures, especially in
the massive-weight-loss population, the longevity of the results
can be limited. The arm is ever moving, has a thin circular sleeve
of skin, and has variable levels of lipodystrophy. This makes the
results prone to a recurrence of laxity and redundancy despite
execution with the best of techniques. Secondary operations
and revision must be a part of any preoperative discussion and
informed consent process (Fig. 88.18).
Fig. 88.16 (a) A hypertrophic scar in a 34-year-old woman 5 months
postoperative from a brachioplasty and (b) a 55-year-old woman 6
months postoperative from a brachioplasty.
Table 88.1 Overall scar control strategy
Deep intraoperative tension reduction by superficial fascial system closure
Meticulous dermal closure using long-term absorbing sutures
2 weeks occlusive coverage with Steri-Strips
1 week occlusive coverage with brown micropore tape
1 week rest period to ensure a dry, well-healed scar
4 months coverage with silicone gel sheeting or topical silicone
Compression during silicone coverage
Stretch exercises to soften deeper fibrosis
Patience
1-year postoperative evaluation for possible revision
Cautious use of intracicatricial injection of steroids

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Fig. 88.18 (a) A 40-year-old woman with a history of weight loss presenting for a brachioplasty. (b) Three months after a brachioplasty and mas-
topexy. (c) Six months after the procedures. (d) Five years after her original operation, with clear recurrence of laxity of the arms.
Fig. 88.17 (a) A 47-year-old woman with a history of massive weight loss presenting for upper body contouring. She underwent a staged body
contouring, including a lower body lift and a two-stage augmentation mastopexy. (b) At 4 months after her brachioplasty. (c) Long-term follow-up at
4 years shows the maturity and fading of her brachioplasty scar.

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Two distinct anatomical features are difficult to treat (Fig.
88.19). One is significant distal elbow lipodystrophy (Fig. 88.19a),
which can be resilient after brachioplasty despite proper exci-
sion and liposuction. Another is occasional restrictive bands of
the upper arms (Fig. 88.19b). These tend to be inherent in the
structural definition of the arms and also tend to be resilient
after brachioplasty. These restrictive bands can also be iatrogenic
and can occur as a result of overzealous and tight closure in one
segment of the arm. It is important to discuss these limitations
with the patient.
88.10 Results
Minimal incision brachioplasty (Fig. 88.20)
Standard brachioplasty (Fig. 88.21)
Extensive brachioplasty (Fig. 88.22)
Thoracobrachioplasty (Fig. 88.23)
Combined thoracobrachioplasty, mastopexy, upper body lift
(Fig. 88.24)
Brachioplasty in nonoptimal candidates (Fig. 88.25)
88.11 Concluding Thoughts
In the past half-century, brachioplasty has entered the main-
stream of predictable and effective body contouring operations.
As the powerful implications of toned arms have shaped demand,
mostly in the massive weight loss population, brachioplasty has
become increasingly popular. The variability of presentation
allows the surgeon to address the existing anatomical defects.
The choices of liposuction, minimal or extensive brachioplasty,
and thoracobrachioplasty depend on the quality and excess of
skin and the involvement of the regional upper body areas, such
as the chest wall. Accurate and predictable preoperative marking,
correct understanding of the anatomy of the layers and nerves,
and an insightful prediction of the scar position can provide the
baseline for a good outcome. Intraoperative techniques such as the
intraoperative staple approximation technique and the sequential
resection and approximation technique are guides for safe, effec-
tive, and reproducible results. Understanding of the mechanism of
low-tension closure, progressive reduction of dead space by use of
the three-pointed closure technique, use of long-term absorbing
sutures, and postoperative scar control have made it possible to
achieve predictable results with the best possible scar quality.
The informed consent process, including demonstration of both
the expected outcomes and some of the inherent limitations and
risks, is essential to preparation for this operation.
Fig. 88.19 (a) Elbow lipodystrophy in a 41-year-old woman presenting
for an extensive brachioplasty, as well as (b) restrictive midarm band in
a 48-year-old woman who presented with bilateral restrictive midarm
bands after a brachioplasty done elsewhere.
Fig. 88.20 (a) A 39-year-old woman with a history of weight loss
underwent a minimal incision brachioplasty with concomitant
suction-assisted lipectomy and augmentation mastopexy. (b) At 4
months after the procedures.

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Fig. 88.21 (a) A 57-year-old woman with a history of weight loss
underwent a standard brachioplasty. Her previous body contouring
operations included lower body lift and augmentation mastopexy. (b)
At 1 year after her brachioplasty.
Fig. 88.23 (a) A 37-year-old woman with a history of weight loss underwent a thoracobrachioplasty, augmentation mastopexy, and a lower body lift.
(b) At 4 months after her thorachobrachioplasty.
Fig. 88.22 (a) A 45-year-old woman with a history of weight loss
underwent an extensive brachioplasty. She has a history of a mas-
topexy and a lower body lift. (b) At 4 months after her brachioplasty.

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Clinical Caveats
• A thorough physical examination leads to analysis of the
myriad types of presentation of arm deformity.
• The choice of liposuction, minimal or standard brachioplasty,
extensive brachioplasty, or thoracobrachioplasty depends on
the anatomical presentation of the patient.
• A detailed informed consent should be a prerequisite of any
brachioplasty. The limitations of the scar and the occasional
need for secondary operations should be explained to the
patient.
• Careful preoperative markings can assist in eventual place-
ment of the scar in the posterior–medial axis of the arm.
• The techniques of staple approximation or sequential exci-
sion and reapproximation allow intraoperative flexibility and
decision making, and prevent the serious complication of
inability to close the defect.
• Progressive three-pointed closures alleviate the need for
drains.
• Meticulous closure of the defect, using methods to reduce
tension—namely, closure of the superficial fascial system and
use of long-term absorbing sutures—improves the ultimate
quality of the scar.
• Postoperative scar control (taping, silicone products, and
compression) is one of the important determinants of a well-
healed scar.
Fig. 88.24 (a) A 36-year-old woman with a history of weight loss underwent a combined thoracobrachioplasty, mastopexy, and upper body lift.
(b) At 4 months after the operation.

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Suggested Reading
[1] Appelt EA, Janis JE, Rohrich RJ. An algorithmic approach to upper arm contour-
ing. Plast Reconstr Surg 2006;118(1):237–246
[2] Bossert RP, Dreifuss S, Coon D, et al. Liposuction of the arm concurrent with
brachioplasty in the massive weight loss patient: is it safe? Plast Reconstr Surg
2013;131(2):357–365
[3] Chowdhry S, Elston JB, Lefkowitz T, Wilhelmi BJ. Avoiding the medial brachial
cutaneous nerve in brachioplasty: an anatomical study. Eplasty 2010;10:e16
[4] Correa-Inturraspe M, Frenandez JC. Braquial demolipectomia. Prensa Med Argent
1954;34:24
[5] Egrari S. Brachioplasty: A personal approach. Aesthet Surg J 2016;36(2):193–203
[6] El .hatib HA. Classification of brachial ptosis: strategy for treatment. Plast Recon-
str Surg 2007;119(4):1337–1342
[7] Lockwood T. Brachioplasty with superficial fascial system suspension. Plast
Reconstr Surg 1995;96(4):912–920
[8] Miotto G, Ortiz-Pomales Y. Arm contouring: review and current concepts. Aesthet
Surg J 2018;38(8):850–860
[9] Nguyen L, Gupta V, Afshari A, Shack RB, Grotting JC, Higdon KK. Incidence and
risk factors of major complications in brachioplasty: analysis of 2,294 patients.
Aesthet Surg J 2016;36(7):792–803
[10] Shermak MA. Aesthetic refinements in body contouring in the massive weight
loss patient: Part 2. Arms. Plast Reconstr Surg 2014;134(5):726e–735e
[11] Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: tech-
nical refinements in upper arm contouring. Plast Reconstr Surg
2008;121(1):305–307
[12] Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr Surg
1998;102(2):545–551, discussion 552–553
Fig. 88.25 (a) A 60-year-old woman with a body mass index of 38 desired a brachioplasty. She underwent a concomitant suction-assisted lipectomy
of the arms (450 mL aspirated from the left and 425 mL aspirated from the right) and brachioplasty. (b) At 4 months after the operation.

89 Decision Making in Upper Back Contouring
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89 Decision Making in Upper Back Contouring
Joseph P. Hunstad and Alexandra C. Schmidt
Abstract
The upper back is an often-overlooked area in body contouring.
Patients present with rolls and folds that are due to some com-
bination of skin laxity, excess adiposity, and retaining ligaments.
Various liposuction techniques and excisional procedures can be
combined to address each of these components. Identification of
the etiology is critical for choosing the ideal treatment plan and
achieving the best outcomes. This chapter reviews the liposuc-
tion techniques that are most useful for addressing the upper
back as well as the senior author’s (JPH) preferred excisional
technique, the bra-line back lift.
Keywords
back contouring, bra-line back lift, liposuction, trunkplasty,
torsoplasty, bra fat, back rolls and folds
89.1 Indications and
Contraindications
Patients seeking upper back contouring are often concerned
with excess adiposity, skin laxity, and rolls and folds of redun-
dant skin and fat. There are three common patient presentations.
The majority of patients seeking upper back body contouring
are of normal weight and have experienced moderate swings in
weight over time and are mostly concerned with excess skin and
moderate excess adiposity. A smaller, but very important, group
are the massive-weight-loss patients who may have significant
excess skin but also residual excess adiposity. A third group of
patients are those who are significantly overweight and present
with significant excess adiposity with associated rolls and folds
due to skin tethering by ligamentous bands connecting the skin
to the underlying body wall.
A careful examination to determine the true etiology of the
deformity is important, because what many people view as
excess adiposity is in reality significant skin excess with only a
modest amount of excess fat. Although the patients believe they
have a significant amount of fat to be removed, the reality is that
their deformity is primarily one of excess skin. These patients are
best treated with excisional methods. Several variations of the
trunkplasty and torsoplasty have been described; however, these
procedures often leave highly visible scars that are unacceptable
to many patients. The senior author (JPH) has developed the bra-
line back lift, which is aesthetically pleasing, and the incision is
concealed under bathing suits or undergarments.
In patients that have significant rolls and folds consisting pri-
marily of excess adiposity, various liposuction techniques can be
employed to contour the area while promoting skin retraction. A
careful examination of the existing bands and folds is necessary
to properly design the liposuction methodology such that these
ligamentous structures can be treated to achieve a smooth, even
contour. If left untreated, they will persist and remain frustrating
to the patient and the surgeon.
For those patients with true skin laxity in addition to significant
surrounding excess adiposity, a combined approach of excision
with surrounding liposuction may be of greatest benefit to the
patient. After excision of the rolls in the midback, the remaining
tissues superior and inferior to the excisional pattern can be
treated by thorough liposuction techniques. This may also be
undertaken in a staged approach. Aesthetic surgery neophytes
in particular may be more amenable to first trying liposuction
before committing to a long incision.
89.2 Pertinent Anatomy
The subcutaneous tissues of the upper back area consist of two
layers of subcutaneous tissue, superficial and deep, separated by
an intervening superficial fascial system (SFS) (Fig. 89.1). Fat in
the superficial layer is more compact and fibrous, with smaller
globules, whereas the fat in the deep layer has larger, loose
globules overlying an areolar layer. In patients with a higher
body mass index (BMI), the superficial subcutaneous fat layer is
significantly thicker than the deep subcutaneous fat layer and is
typically treated preferentially in cases of liposuction. However,
in areas of significant excess adiposity, both layers contribute
considerably to the bulk of rolls and should be addressed.
Retaining ligaments, as described by Guerrerosantos, create
adherence between the skin and the underlying body wall,
leading to formation of rolls and creases that can be seen in many
individuals (Fig. 89.2). These ligaments originate from the spinous
processes of the cervical, thoracic, and lumbar vertebrae and
extend horizontally to the posterior axillary line where they join
together with the SFS. These ligaments form boundaries between
defined compartments of adipose tissue. Clinically, patients
present with one to four rolls, which are consistently found at
the extension of the breast fold, the base of the scapula, the lower
thoracic area, and the hip (Fig. 89.3). Intermediate back rolls in
the so-called no man’s land are notoriously difficult to treat with
traditional excisional body contouring methods (i.e., upper body
lift and belt lipectomy), and to achieve adequate correction, the
ligaments must be disrupted.
There are strong zones of adherence overlying the spine and
between the hip and lateral thigh (Fig. 89.4). This is important to
consider in preoperative planning, because it will affect how the
tissues redrape after excision. After a lower body lift, tightening
will not be transmitted to the upper back due to the midline zone
of adherence as well as the distance to the target area.
89.3 Preoperative Assessment
Patients presenting for upper back contouring should be carefully
analyzed to determine the relative contributions of excess adi-
posity versus skin laxity. Accurate identification of the deformity

1388
XII Body Contouring
is critical for achieving good results (Table 89.1). In cases where
the skin tone is reasonable and skin laxity is minimal, thorough
all-layer liposuction is indicated. :here significant skin laxity
exists, an excisional procedure should be considered. There are
certain candidates, however, with moderate to significant skin
laxity who can have a successful outcome with thorough all-
layer liposuction, including the use of concurrent energy into the
subcutaneous tissues. Various sorts of energy include laser-as-
sisted liposuction, ultrasonically assisted liposuction, and more
recently radiofrequency-assisted lipolysis, which can be used in
conjunction with liposuction. These energy sources can create
heating of the muscular cutaneous fibers that will subsequently
contract, maintaining or improving skin tone. There can also be
a modest tightening of the skin surface, particularly when used
with superficial liposuction techniques.
In certain cases, concurrent excision and liposuction may be
indicated. These indications include significant excess adiposity
and skin laxity. For those patients, liposuction should be per-
formed outside of the excision pattern superiorly and inferiorly to
obtain a more optimal outcome. Alternatively, these procedures
may be performed in a staged manner depending on the patient’s
goals and concurrent procedures.
Patient selection should also include a thorough history and
physical examination. In our practice, laboratory testing is tai-
lored to each patient. Relative contraindications include smoking,
poorly controlled diabetes mellitus, BMI > 35, continuing weight
Fig. 89.2 Retaining ligaments between skin and underlying body wall,
creating boundaries between defined compartments of fat.
Fig. 89.3 Image of typical back folds, which are consistently found
at the extension of the breast fold, the base of the scapula, the lower
thoracic area, and the hip.
Fig. 89.1 Layers of subcutaneous tissue: superficial fat, superficial fascial system, deep fat.

89 Decision Making in Upper Back Contouring
1389
loss that has not plateaued, poor nutritional status, use of antico-
agulants, history of pulmonary embolus or unprovoked deep vein
thrombosis, and significant medical problems (Table 89.1).
89.4 Preoperative Planning,
Including Markings
Markings should be made with the patient standing, because the
contour changes significantly with lying. Topographical liposuc-
tion markings are useful and will define the areas of excess full-
ness as well as areas where there is less excess fat. When strong
adhesions are present between the skin and the underlying
trunk, they should be marked as well for intraoperative release
(Fig. 89.5). When excisional procedures, such as the bra-line back
lift, are being planned, the final desired incision line should be
marked first and ideally concealed beneath a bra or swimwear.
This location should be agreed upon by the patient. While the
bra-line back lift is ideal for female patients, the excision pattern
may require more discussion in male patients and should be
customized to the individual’s desires. Strong bimanual palpation
will identify the excess skin to be removed. It is important to
keep the final desired incision line centered in the tissue gathered
when estimating removal (Fig. 89.6). When the entire pattern is
marked, it should be emphasized that the tissue excision in the
Table 89.1 Treatment algorithm based on deformity
Fat
Skin
Treatment
Excess adiposity
No excess skin
Liposuction
Excess adiposity
Mild skin excess
Liposuction with
energy (UAL, LAL)
No excess adiposity
Moderate to severe
skin excess
Skin excision
Excess adiposity
Moderate to severe
skin excess
Skin excision
with surrounding
liposuction, combined
or staged
Abbreviations: LAL, laser-assisted liposuction; UAL, ultrasound-assisted
liposuction.
Fig. 89.4 Drawing of the zones of adherence of the back, overlying the
spine and between the hip and lateral thigh.
Fig. 89.5 Creases marked for intraoperative release.
Fig. 89.6 Markings for the bra-line back lift. (a) Strong bimanual palpation at multiple points along the back, with the planned incision line centered
in the tissue gathered, is used to identify the resection pattern. Medially, very little tissue is removed due to the spinal zone of adherence. (b,c) The
marks are connected in order to outline the final excision pattern.

1390
XII Body Contouring
midline is always of the least amount due to the strong midline
zone of adhesion. Realignment marks are very useful in properly
reapproximating the tissues. They are marked across the back at
various points. The final excision pattern typically begins in the
anterior axillary line at the inframammary fold.
89.4.1 2SerDWiYe 7eFKniTue
For patients with significant excess adiposity, thorough lipo-
suction commonly requires the use of general anesthesia. We
perform these procedures typically in the prone position with
an endotracheal tube securely in place. While liposuction
may be performed in the lateral decubitus position, excisional
procedures for the back, such as the bra-line back lift, are best
performed prone to ensure symmetry. When performing this
procedure in the lateral decubitus position care must be taken to
minimize the risk of stretching in the axilla, which could harm
the brachial plexus.
When performing liposuction, a thorough dilute lidocaine and
adrenaline infiltration should be performed throughout all areas
to be suctioned. This ´tumescentµ infiltration can be effective at
magnifying the deformity, hydrating the tissues allowing easier
cannula passage, as well as exsanguinating the tissues allowing
the adrenaline to be maximally effective on the compressed ves-
sels. :hen possible, fluids should be warmed prior to injection.
Back liposuction is consistently more difficult than that of other
areas due to the fibrous nature of the subcutaneous tissue. For this
reason, we use energy, currently in the form of pulsed ultrasound,
to expedite the process. Skin protectors are placed to avoid skin
burns. Cannulas are run through the tissue until resistance is lost,
which indicates the end point.
We have also found the “SAFE” method of liposuction, described
by Wall, to be very helpful in this area and use it in conjunction
with ultrasonic energy. It is specifically a three-part procedure
consisting of separation, aspiration, and fat equalization. A basket
cannula is used in a vibratory fashion with a power-assisted
handpiece. This is done thoroughly throughout the tissues, again
achieving a loss of resistance as the end point. Following complete
loss of resistance, both superficial and deep layers are now ready
for liposuction.
In the area of adhesions where the dermis has strong connec-
tions to the underlying body wall, disruption of these ligaments
is an important step. In these areas either the basket cannula or
modified cannulas developed by De Souza Pinto and Becker can
be useful as the sharp tips can sever these fibers (Fig. 89.7). A
thorough release of these adhesions can eliminate or significantly
lessen the visibility of these distinct ligamentous boundaries,
resulting in a much smoother contour. When thorough liposuction
is performed, particularly of the lower back, a drain is commonly
used, because there can be significant serous fluid formation after
these procedures, and risk of seroma is high. A technical nuance
of drain placement involves use of the existing liposuction access
sites. A liposuction cannula is passed through paired lower back
stab incisions, the drain is affixed to the end, and the cannula is
withdrawn through the tissue with power on, bringing the drain
out through the skin. The cannula, with the drain still affixed to
the end, can then be pushed back through the incision anteriorly
to bring the drain through an abdominal incision for improved
patient comfort and control (Fig. 89.8).
If an excisional procedure is planned, liposuction using these
techniques is performed superior and inferior to the area of tissue
resection. When excisional procedures are performed without
concurrent liposuction, a dilute lidocaine and adrenaline solution
is infiltrated into the dermis along the proposed incision pattern.
This will minimize bleeding, which is always a benefit to the
patient. A small volume of dilute lidocaine and adrenaline can be
infiltrated deep into the loose areolar plane, as well, in order to
facilitate dissection.
Dissection is performed through the skin to the loose areolar
plane superficial to the muscle. Large perforating vessels are com-
monly encountered laterally and should be carefully controlled.
Leaving the muscle fascia intact is important for space-obliterat-
ing sutures, which eliminate the need for drains in this procedure
(Fig. 89.9).
The excision is strongly tapered into the inframammary fold
at the anterior axillary line. A modest dog-ear is commonly
Fig. 89.7 Pinto cannulas and basket tip cannulas are sharp cannulas
that can be used for release of the retaining ligaments.
Fig. 89.8 A liposuction cannula is passed through paired lower
back stab incisions, the drain is affixed to the end, and the cannula is
withdrawn through the tissue with power on.

89 Decision Making in Upper Back Contouring
1391
encountered at this point, which usually resolves postoperatively.
If it persists, dog-ear revision should be considered.
As experience is gained, the entire pattern can be excised
and then closed. :hen first performing excisional procedures,
to ensure that undue tension does not exist across the incision
line, pilot incisions are recommended, and the excision can be
performed segmentally. Careful inspection of the incision line
and excision patterns during the procedure will help achieve a
smooth, consistent, and desired final incision line.
Closure is performed in three layers. Reapproximation of the
SFS is critical in achieving a high-quality fine-line scar without
indentation. First, the skin edges are reapproximated with pene-
trating towel clamps. Closure of the SFS should be performed with
three-point sutures also grasping the muscle fascia or loose are-
olar tissue superficial to the muscle. This completely obliterates
dead space and eliminates the need for drains. Buried interrupted
sutures are then used to approximate the dermis, whose closure is
under minimal tension because all of the tension across the inci-
sion line is held by the SFS sutures. A final intracuticular closure is
then performed, completing the three-layer closure.
89.5 Ancillary Procedures
Postoperative care for back liposuction can include various
modalities (e.g., deep massage) and vacuum roller technology
(e.g., endermology). This is usually best tolerated 2 or more
weeks following the procedure and can be very beneficial for
reducing edema and improving range of motion.
In our experience, the bra-line back lift often results in a
high-tension incision and scar revisions are common. About half
of patients have some persistent scar hyperpigmentation (Fig.
89.10). This can be effectively treated with laser therapy, such as
V beam. About one-third of patients have scar widening that is
best corrected with excisional scar revision (Fig. 89.11).
89.6 Postoperative Care
Following excisional procedures, patients should be instructed
to limit arm extension. Usually by 2 weeks, full arm extension
can be realized but should not be pushed. Patients should also
avoid sun exposure on all incisions as long as they remain red or
hyperemic. Scar therapy, such as taping for a prolonged period of
time, can improve scar quality. Silicone formulations applied to
the incision can also be beneficial.
After liposuction, patients should be placed in an abdominal
binder or vest immediately postoperatively and instructed to
continue gentle compression for 3 weeks. Drain duration in our
liposuction patients is dependent on daily output, and removal
generally occurs when output is less than 30 mL per day. Our prefer-
ence is to continue oral antibiotics while the drain remains in place.
89.7 Outcomes
Because of the fibrous nature of the subcutaneous fat of the
back, effective liposuction procedures are often quite strenuous
and time consuming. Liposuction of the back also tends to be
associated with a higher percentage of blood in the aspiration
compared with other areas of the body, such as the abdomen
and thighs. Surveillance or monitoring of the aspiration should
be performed throughout the procedure to reduce the need for
transfusion or hospitalization.
Fig. 89.9 (a) The markings are confirmed by approximating the
proposed incisions with a towel clamp. (b) Dissection is performed to
the loose areolar plane leaving the muscle fascia intact. (c) Three-point
sutures are placed, including the superficial fascial system and muscle
fascia, to obliterate dead space.

1392
XII Body Contouring
Excisional procedures of the back should not be performed
under excess tension, which could result in dehiscence and pro-
longed healing. Making pilot incisions in determining sequentially
the appropriate amount of tissue to be removed is suggested
when first performing these procedures. This will minimize the
risk of overresection. Should the final scar become thick, raised,
or widened, a scar revision can be performed that should follow
an appropriate time for maturation, usually 6 months or longer.
The body contouring patient population is prone to postoperative
weight fluctuations, and in our practice, we frequently perform
revisions for recurrent laxity or fat excess.
Contour irregularity can be seen postoperatively, especially in
those inexperienced with thorough all-layer liposuction. Care
should be taken to use long, broad strokes fanning over the entire
area without oversuctioning any particular areas. Symmetry and
contour should be confirmed by inspection, palpation, and pinch
Fig. 89.10 Patient with persistent scar hyperpigmentation after back
liposuction.
Fig. 89.11 Patient with scar widening after back liposuction.
Fig. 89.12 This 51-year-old woman underwent SMART liposuction to the upper back and hip rolls (11,944 J hip rolls, 10,366 J upper back, 10,000 mL
total lipoaspirate, 5,800 mL fat). (a-c) Preoperative photos, including markings. (d,e) Postoperative photos at 4 months.

89 Decision Making in Upper Back Contouring
1393
thickness. The SAFE liposuction technique is helpful in achieving
a smooth contour.
89.8 Results
By performing a very thorough liposuction using energy and
SAFE modalities as well as release of adhesions successful results
can be achieved. Excisional procedures of the back, such as the
bra-line back lift, enjoy an extremely high level of patient satis-
faction and an extremely low level of complications (Fig. 89.12,
Fig. 89.13, Fig. 89.14, Fig. 89.15, Fig. 89.16).
89.9 Concluding Thoughts
Contouring of the upper back is a challenging and often multi-
modal procedure. Identifying the deformity as either skin laxity
Fig. 89.13 A 36-year-old woman who underwent a bra-line back lift (1,518 g resected) as well as concurrent hip roll liposuction (3,225 mL total
lipoaspirate, 1,800 mL fat) and fleur-de-lis abdominoplasty. (a–d) Preoperative photos, including markings. (e,f) Postoperative photos at 3 months.
Fig. 89.14 A 67-year-old woman who underwent a bra-line back lift (1,542 g resected) and back liposuction (6,350 mL total lipoaspirate, 3,350 mL
fat). (a–d) Preoperative photos, including markings. (e,f) Postoperative photos at 3 months.

1394
XII Body Contouring
or excess adiposity or a combination of the two will allow
successful design of a treatment plan with which to achieve
the best outcomes. Because of the arduous task of performing
liposuction properly on the back, one must be prepared to
spend the time necessary when performing these procedures. It
should be emphasized to the patient that this is not a minimally
invasive procedure but actually is a very significant one that
has a substantial recovery. Excisional procedures are actually
easily tolerated and have a dramatically minimal morbidity in
comparison with liposuction.
Clinical Caveats
• A thorough physical examination is necessary to identify the
elements that need to be addressed in upper back contouring
procedures.
• The patient’s complaint may not be reflective of the true
etiology. Many patients feel that they have significant excess
adiposity (upper back fat) when in fact they have significant
skin excess and very modest excess adiposity.
• Demonstrating the effect of skin excision in a mirror for
these patients will show them the dramatic improvement
and elimination of rolls and folds existing in the back and
flanks.
• Often, multimodality treatment is necessary to achieve
the optimal result. Skin excision, various liposuction
techniques, and energy (ultrasound, laser, radiofrequency)
can be combined in different ways to best address the
deformity.
• Very thorough liposuction, including the use of energy as
well as a thorough release of the fibers that create the rolls
and folds of the back, is a challenging yet highly rewarding
procedure. For the patient, recovery is substantial.
Fig. 89.15 A 36-year-old woman who underwent a bra-line back lift (751 g resected) and subsequently VASER liposuction to the full back (VASER 15
min, 6,600 mL total lipoaspirate, 2,500 mL fat). (a,b) Preoperative photos, including markings for the bra-line back lift. (c,d) Postoperative photos at
2 months, including markings for back liposuction. (e) Postoperative photos at 6 months.

89 Decision Making in Upper Back Contouring
1395
Suggested Reading
[1] Baroudi R, Fereira CAA. Changing concepts in aesthetic contouring of the trunk.
Oper Tech Plast Reconstr Surg 1996;3(1):82–85
[2] Clavijo-Alvarez JA, Hurwitz DJ. J torsoplasty: a novel approach to avoid circum-
ferential scars of the upper body lift. Plast Reconstr Surg 2012;130(2):382e–383e
[3] De Souza Pinto EB, Erazo P-, Muniz AC, Salazar GH, Abdalla PCSP. Superficial lipo-
suction of the back and waist. Oper Tech Plast Reconstr Surg 1996;3(2):106–116
[4] Guerrerosantos J. Liposculpture of the back. Oper Tech Plast Reconstr Surg 1996;3(1):31–34
[5] Hunstad JP, Jones SR. Abdominoplasty with thorough concurrent circumferential
abdominal tumescent liposuction. Aesthet Surg J 2011;31(5):572–590
[6] Hunstad JP, Khan PD. The bra-line back lift: a simple approach to correcting
severe back rolls. Clin Plast Surg 2014;41(4):715–726
[7] Hunstad JP, Repta R. Bra-line back lift. Plast Reconstr Surg 2008;122(4):1225–1228
[8] Hurwitz D-. Aesthetic refinements in body contouring in the massive weight loss
patient: trunk. Plast Reconstr Surg 2014;134(6):1185–1195
[9] Hurwitz DJ, Ayeni O. Body contouring surgery in the massive weight loss patient.
Surg Clin North Am 2016;96(4):875–885
[10] Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000
cases. Plast Reconstr Surg 1983;72(5):591–597
[11] Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a
new concept. Plast Reconstr Surg 1991;87(6):1009–1018
[12] Neira R, Ortiz-Neira C. Low-level laser-assisted liposculpture: clinical report of
700 cases. Aesthet Surg J 2002;22(5):451–455
[13] Neligan PC, Warren RJ, Van Beek A. Aesthetic. Plastic Surgery, Vol. 2. Philadelphia,
PA: Elsevier Saunders; 2012:507–529, 568–598
[14] Strauch B, Rohde C, Patel MK, Patel S. Back contouring in weight loss patients.
Plast Reconstr Surg 2007;120(6):1692–1696
[15] Wall S Jr. SAFE circumferential liposuction with abdominoplasty. Clin Plast Surg
2010;37(3):485–501
[16] Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16(4):287–298
Fig. 89.16 A 69-year-old woman who was the first patient to undergo a bra-line back lift, with a simultaneous lower body lift. (a) Preoperative photo.
(b) Preoperative photo without flash, which highlights the back folds. (c) Preoperative markings. (d) The result 17 years postoperative.

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90 Body Lift
Karen B. Lu and Jeffrey M. Kenkel
Abstract
The lower body lift is a popular procedure for patients desiring
a more well-defined body contour who are not candidates for
liposuction alone. Many patients seeking this surgery have
lost significant weight and have excess redundant tissue in
the lower truncal region, excess skin laxity in the posterior
region and buttocks, as well as laxity of the lateral thigh. This
procedure effectively addresses these areas by combining a
circumferential resection of the lower truncal unit, a lateral
thigh lift, and a buttock lift, and it often includes liposuction.
When considering patients for a body lift, one must perform
a thorough evaluation. Nutritional status should be assessed,
particularly for weight loss patients. Additionally, many factors
should be considered in regard to timing and the combination
of procedures. A lower body lift may be performed as one
stage or broken up into two stages depending on the goals and
desires of the patient, physician preference, and associated
comorbidities. Postoperatively, these patients should be mon-
itored closely. Many plastic surgeons choose to admit these
patients in a manner similar to that for patients undergoing an
abdominoplasty.
Keywords
lower body lift, circumferential body lift, belt lipectomy, abdom-
inoplasty, lateral thigh lift, buttocks lift, liposuction
90.1 Introduction
Due to the nutritional and exercise habits of the American pop-
ulation, obesity has been on the rise for the last several decades,
with approximately 40 of adults over the age of 20 classified
as obese. There has been a concomitant rise in the demand for
bariatric surgery; over 228,000 patients sought bariatric surgery
in 2017, a 5.5 increase from 2016. Following significant weight
loss, either through diet and exercise or from bariatric surgery,
patients often experience a significant amount of skin laxity,
which can affect all aspects of the body from head to toe. In some
cases, this may result in rashes, skin infections, and physical
impairment, which can directly affect further weight loss and/
or cause weight gain, as well as psychological stress. Body con-
touring surgery in this patient population allows them to close
the loop on their weight loss journey, allowing many of them to
“look as good as they feel.”
Techniques for body contouring continue to evolve in an
attempt to allow for predictable and safe results in these chal-
lenging patients. Likewise, we have seen a better appreciation
of the aesthetic norm of the trunk, particularly the abdomen
and buttock. Procedures simply removing skin are no longer
acceptable to physicians and patients alike. The focus has shifted
from solely an anterior improvement to a circumferential change
highlighting the underlying framework visible after significant
weight loss.
The circumferential resection of the lower trunk has been
referred to as circumferential dermatolipectomy/lipectomy,
torsoplasty, circumferential or extended panniculectomy, central
body lift, lower body lift, and belt lipectomy. Although all these
terms have been used interchangeably, they do not necessarily
imply the same technique or outcome. Throughout this chapter,
the procedure will be referred to as a body lift.
90.2 Indications and
Contraindications
90.2.1 Indications
There are several indications for performing a lower body lift,
massive weight loss being the most common. However, obese
patients and those of normal body mass may still benefit from a
body lift, given the proper indications.
Massive-Weight-Loss Patients
Patients who undergo significant weight loss are often unhappy
with their appearance. Poor skin quality and laxity maintain
some of the stigmata often associated with morbid obesity. Body
contouring surgery is often the final step in their transformation.
As is true for all patients, massive-weight-loss (MWL) patients
come in a variety of sizes and contours. Each patient presents
with unique challenges that require the surgeon to tailor the
procedure to the specific patient.
Many components of the physical exam are assessed, skin
laxity, skin quality, and degree of lipodystrophy are critical to
creating a safe and effective plan and are intimately involved in
the outcome. How the body changes during the process varies
from patient to patient and from male to female. Body mass index
(BMI) at presentation and total weight loss are important consid-
erations as one begins to assess what contour can be achieved
and the safety of the procedures planned. Further assessments
regarding this patient population are detailed under the medical
history section.
The surgical goals for MWL patients usually vary from patient
to patient. However, patients should begin seeking body contour-
ing surgery when they are close to their ideal body weight or goal
weight and have maintained a stable body weight for a minimum
of 3 months. The lower body lift will help patients achieve a more
desirable body contour, eliminate excess redundant tissue, and
help define the lower back and buttocks region (Fig. 90.1).
Non-Massive-Weight-Loss Patients
Although lower body lifts are more commonly performed in
patients following MWL, it may be an option for some patients

90 Body Lift
1397
seeking purely contour changes. These patients may have
significant striae or poor-quality skin, making decompression
with liposuction more unpredictable. In this patient type, a more
predictable improvement in the waist may be realized with a
circumferential excision (Fig. 90.2).
90.2.2 Contraindications
As with any elective procedure, patients with significant med-
ical or psychiatric issues should not be considered for surgery.
Significant comorbidities where a thorough medical evaluation
is warranted include a history of cardiovascular disease, pulmo-
nary insufficiency, smoking, prior history of venous thromboem-
bolism, and other major medical problems. Additionally, patients
who have a significant presence of intra-abdominal fat are not
good candidates; there is a limit to how much improvement one
may gain with excision and plication.
90.3 Pertinent Anatomy
90.3.1 Blood Supply
As with any surgical procedure, a thorough understanding of
the anatomy allows for safer execution of the procedure. After
transection of the lower abdominal tissue and elevation from the
underlying muscular fascia, the blood supply of the abdominal
flap is reduced to the lateral intercostal, subcostal, and lumbar
vessels. Techniques such as lipoabdominoplasty limit undermin-
ing, preserving the rectus abdominis musculocutaneous perfo-
rators. This decreases the risk for wound healing problems that
may be seen with more widespread, subcutaneous undermining
of the abdominal skin.
90.3.2 Nerves
Nerve injury during the anterior resection may occur. Pain may
also result with direct injury or entrapment of the nerves with
sutures. Certain techniques involving suturing and dissection on
the deep fascia place these nerves at higher risk. These nerves
include the anterior and lateral femoral cutaneous nerves, the
iliohypogastric and the ilioinguinal nerves, and, less commonly,
the genital and femoral branch of the genitofemoral nerve,
obturator nerve, and pudendal nerve. Injury to these nerves
may result in a number of different symptoms, including pain,
burning sensation, and paresthesias.
90.3.3 SuSerÀFiDO )DVFiDO SyVWem
The superficial fascial system (SFS), first described by Lockwood
in 1991, has been pivotal to the plastic surgeon’s understanding
Fig. 90.1 (a) A 62-year-old woman lost 170 lbs. following Roux-en-Y gastric bypass. (b) She has both vertical and horizontal laxity of her anterior
abdomen and is shown 6 months following vertical abdominoplasty.
a
b

1398
XII Body Contouring
of truncal surgeries. The SFS is composed of connective tissue
that separates the epidermis and dermis from the underlying
muscles. This connective tissue provides strength and support
through its dense interconnection of fibrils. Closure of this
layer offers increased tensile strength of wounds. The fibrils of
the SFS run vertical and horizontally, encasing adipose cells. In
certain areas of the body, the SFS contains a distinct horizontal
component, the Scarpa’s fascia in the trunk and Colles’s fascia in
the perineum, which provide the majority of the strength when
resuspending these layers.
Although strong, the SFS displays the same characteristics
as skin and can stretch and expand with gravity and/or added
weight. This is important to consider when addressing MWL
patients. Patients who have undergone extensive weight loss
will have laxity of the SFS and skin resulting in excess skin
folds. In body contouring surgery, excision and resuspension
of the SFS along with the skin help provide a desirable body
shape. The SFS also contributes to outcomes in liposuction.
The loss of adipose cells causes excessive pulling of the SFS
fibrils against the dermis, resulting in dimpling seen on the
skin. The SFS helps increase wound strength and resuspension
in body contouring procedures. Understanding the properties
and function of the SFS can provide better aesthetic outcomes
(Fig. 90.3).
90.4 Preoperative Assessment
90.4.1 Medical History
A thorough medical history should be taken from all patients
being evaluated for body lift surgery. Assessment should include
current weight, initial and current BMI, weight stability, amount
of exercise, previous bariatric procedures, nutritional disorders,
medications, history of abdominal procedures (including cesar-
ean sections), and current smoking status and history, as well as
gastrointestinal, cardiac, and pulmonary history. It is important
to thoroughly evaluate the patient’s personal and familial his-
tory of venous thromboembolism. These may require further
evaluation by a hematologist prior to surgical consideration.
Weight stability of at least 3 months is essential to allow patients
the best possible contour.
Associated comorbidities should be assessed and when pres-
ent may dictate the number of procedures performed and the
associated risk. Emphasis should be placed on the amount of
weight loss and method. Based on a previous study by our group,
there is a strong correlation with increased postoperative com-
plication rate and weight loss greater than 100 lb. Additionally,
bariatric surgery is also correlated with higher postoperative
risks than diet and exercise alone as the method of weight
loss. Another factor to consider, as mentioned previously, is
the patient’s current BMI. A study by Varun Gupta et al showed
that with increasing BMI, the complication rate in aesthetic
surgery gradually increases, with overall complication rates at
2.3% with a BMI of 25 to 29.9, 3.1% at 30 to 39.9, and to 4.2%
for a BMI greater than 40. The study also noted that infection,
venous thromboembolism, and pulmonary dysfunction were
twice as likely in overweight patients. Therefore, it is prudent
to consider all these factors when operating on an MWL patient
and encourage maximal weight loss prior to surgery in order to
obtain the lowest BMI.
90.4.2 Physical Exam
The patient’s overall body habitus should be examined thor-
oughly. Anterior evaluation will include degree of skin laxity
in both the horizontal and the vertical dimensions. The degree
of lipodystrophy is assessed, as is the presence of a diastasis. It
Fig. 90.2 (a,c,e) This 51-year-old woman is 7 years s/p abdominoplasty
and 5 years following flank excision. (b,d,f) She wanted an enhanced
waist and elected to have a delayed excision to accomplish this.

90 Body Lift
1399
is important to note that diastasis recti can occur in both men
and women and is not always secondary to pregnancy. Large
BMI changes may also mimic pregnancy and result in similar
findings. Finally, the presence or absence of intra-abdominal
fat is determined. Any significant amount must be addressed
through ongoing weight loss for ideal contour change. Laterally,
one must determine the extent of skin laxity and lipodystrophy
contributing to the lateral thigh silhouette. Posteriorly, the skin
laxity and degree of deflation is determined in the flank and
buttock region. Patients and physicians alike should under-
stand that the degree of buttock deflation is often exaggerated
with lifting and tightening of the flank region. Lifting and
mobilizing the skin on the patient in front of a mirror nicely
simulates some of the effects the patients may see with a lower
body lift.
90.4.3 Nutrition
Nutrition plays a key role in the recovery process and outcomes
in a patient seeking body contouring surgery following massive
weight loss. Wound healing complication rates in this patient
population are reported to be as high as 80%. The causes of these
high complication rates are multifactorial. Due to the anatomical
changes occurring in the gastrointestinal tract of MWL patients,
particularly in the postbariatric patient, patients often suffer
from nutritional deficiencies resulting from a decreased ability to
absorb vitamins, such as folate and B12, leading to iron deficien-
cies and microcytic anemia. Iron deficiency has been described
to affect cutaneous wound healing. Patients with iron deficiency
should have iron supplementation to avoid any potential wound
healing complications.
Protein deficiency and chronic malnourishment are common
following postbariatric surgery. Food intake dramatically
decreases after surgery, which can cause rapid body weight
loss in both fat and lean body mass. Additionally, many stud-
ies have shown postbariatric surgery patients to have a very
low intake of high-protein foods. Endocrinology, obesity, and
bariatric surgery societies have established clinical guidelines
recommending 1.5 g/kg of protein intake of the desired body
weight per day. Nevertheless, several studies have reported an
average protein intake of less than 60 g/day at 6 and 12 months
postsurgery.
It is critical to correct these protein deficiencies prior to body
contouring surgery, because protein deficiencies can result in
poor wound healing and catabolic processes, causing loss of lean
muscle mass. :ound healing factors, such as fibroblast formation,
collagen production, and angiogenesis, can slow without adequate
protein. Several algorithms have been described to replenish
proteins in the postbariatric patient. One study described 80 g of
protein supplement daily for 4 weeks prior to surgery and 4 weeks
after body contouring surgery for a total of 8 weeks and noted a
significant decrease in wound healing complication rates in the
protein-supplemented group.
Due to these nutritional concerns, liver function tests, albu-
min, and prealbumin, and vitamin levels may be checked early
in the surgical planning process to allow sufficient time to
correct these deficiencies. For the standard population, 1 to 2 g/
kg of protein supplementation is recommended, however, in the
author’s practice, protein supplementation is increased 1.5 to 2
times beyond the standard of 2 to 4 weeks prior to surgery to
1 month postoperatively. This protocol for protein supplemen-
tation will hopefully address any deficiencies preoperatively and
postoperatively.
90.5 Preoperative Planning
90.5.1 Planning and Staging
Large procedures, such as a lower body lift, should be approached
with safety in mind and tailored to the patient’s risk assessment.
Many patients in this population will require multiple proce-
dures in order to achieve their desired body contour. While body
lifts can be performed as a single operation, there are advantages
to staging the circumferential procedure. The preference for a
two-stage procedure eliminates the opposing forces of anterior
and posterior closure. Additionally, the two-stage approach
allows for two opportunities to address the anterolateral thigh
area, which has a higher recurrence rate. Staged procedures are
separated by a minimum of 3 months to allow for mobility and
resolution of the majority of swelling.
Fig. 90.3 Different characteristics of the superficial fascial system (SFS) depending on body area. (a) Dense and (b) loose connective tissue layers.

1400
XII Body Contouring
The arms, breast, lateral chest, and abdomen are often
addressed at the first stage. Staging the lateral chest can be con-
sidered, as this resection can cause displacement of the breast
and an unsatisfactory shape. When performed simultaneously,
the breast mound must be established first prior to excision of the
lateral chest redundancy. The second stage addresses the flank/
hips and thighs (Fig. 90.4). This does require a position change,
which is not necessary in stage one. Buttock augmentation with
perforator-based rotational flaps should be reserved for two-stage
procedures to help decrease the morbidity encountered with
lower body lift and simultaneous buttock augmentation. The
combination of a body lift with gluteal augmentation may cause
undue tension on the posterior closure and compromise the vas-
culature, resulting in poor healing as well as skin and fat necrosis.
Other options that may be considered for these patients include
fat grafting and/or implant-based augmentation. Fat grafting in
this patient population may be challenging; the patients that may
benefit from the procedure the most are patients of lower BMI,
who simply lack the donor sites necessary. Additionally, the safety
of transferring fat to the buttock must be addressed and discussed
by the physician and the patient.
Each stage described requires an operative time of 4 to 6 hours.
Procedures requiring more than 3.1 hours of operative time
have been associated with an increase in complications, such
as wound infection, dehiscence, and necrosis. It is imperative
that the surgeon and the patient understand both the risks and
benefits of longer operative times. It is essential to the informed
consent process. Longer operative times allow fewer stages and
less cumulative recovery than expanding these stages to 2 to 3
times more surgical procedures. Understanding the impact of
longer operative times allows the surgeon to better plan both the
intraoperative and the postoperative care of the patient.
It is important to listen to our patients’ priorities and desires
regarding timing and staging. For example, despite the preference
for a two-stage approach to the lower trunk, some patients may be
best served by a single-stage lower body lift given their concerns
and expectations. Additionally, there are a few combinations of
procedures that are best avoided due to opposing vector forces
created by the individual procedures. Combining an abdomino-
plasty or body lift with a thighplasty creates tension between the
two areas, resulting in an unsatisfactory contour or complications.
As a general rule, it is helpful in the patient’s recovery process
to preserve one pair of extremities, which helps with mobility
during the patient’s recovery. Exceptions can always be made
regarding the foregoing recommendations based on the patient’s
wishes and existing comorbidities.
90.5.2 Markings and Scar Positioning
Marking the weight loss patient can be challenging and time
consuming, particularly when outlining the planned excision.
Redundant, inelastic skin is difficult to manage and mark. That being
said, the position and quality of the scars created through excisional
surgery are still important to the patient and surgeon. However,
predictability remains challenging in this patient population.
Preoperative markings are done in the office setting 1 to 2 days
prior to surgery. This environment allows for careful translation
of the surgical plan onto the patient in the form of marks. It min-
imizes interruptions and offers a more comfortable environment
for both the patient and the surgeon than the morning of surgery.
Photographs are taken at the time of the markings for further
affirmation, evaluation, and planning. Finally, these marks allow
the surgeon to better understand surgical outcomes when com-
paring them to the planned marks. The “lift and drop technique”
seems most appropriate for these patients given the degree of
laxity and inelasticity.
With the patient standing, the midline of the back is noted,
and any curvature of the spine and its subsequent impact should
be appreciated. The superior line of posterior excision is marked
where the ultimate scar placement is desired, accounting for some
mobility of the incision caudally with closure. Using the “lift and
place” technique, the lower incision is drawn. Moving laterally, a
larger portion of tissue is marked, as the greatest degree of laxity
occurs furthest from the midline. This extends around the most
lateral point, commonly just above the adherent area of the lateral
thigh. The goal of our excision is to lift and suspend the lower tissue
at the level of the upper incision to have the greatest impact on the
lateral thigh, buttock, and waist. Excision at the midline is limited
due to less laxity and the postoperative anterior flexion, and to
account for an increased risk of dehiscence. Once the upper and
lower incisions are determined, vertical hash marks are created
at set intervals to facilitate alignment of tissues intraoperatively.
Moving anteriorly, the anterior midline is marked. It is easiest
to mark the mons area with the patient in the supine position. The
mons is often ptotic and is displaced cephalad. The central mark
is made by transposition of the pubis on the skin under moderate
tension. This is 5 to 7 cm above the introitus in most woman. The
anterior superior iliac spine (ASIS) is marked under similar tension,
and the lateral extent of the incision follows a point approximately
2 cm below the ASIS. There is a transition point laterally from the
lower posterior marks to the more adherent anterior marks lateral
to the iliac crest. The lower incision marking is then connected in
a downward angle to the posterior marking (Fig. 90.5).
90.6 2SerDWiYe 7eFKniTue
As previously discussed, the author’s practice prefers a two-stage
approach to a body lift procedure. When a single stage is desired,
our preference is to perform the procedure prone then supine.
Abduction of the legs allows for greater excision of the lateral
tissue in both the prone and supine positions. A lateral–lateral–
supine or supine–lateral–lateral may also be chosen (video).
90.6.1 Posterior Excision
The patient is positioned in the prone position, with the bony
prominences carefully padded. The legs are positioned on
bariatric spreader bars, padded, and abducted. Liposuction is
performed when necessary in the lateral thigh and flank region.
The resection begins with the superior incision. This is taken
down through the subcutaneous layer and Scarpa’s fascia toward
the deep fascia. It is easiest to identify this closer to the midline.
Once found, an artificial plane is created, leaving a small amount
of fat on the deep fascia, which helps prevent seroma formation
in this area. It is important to understand that the fat lateral
to the paraspinous muscles is lobulated, making this artificial
tissue plane more difficult to maintain. Once undermined to the

90 Body Lift
1401
Fig. 90.4 (a–h) This 25-year-old woman is 7 months s/p upper body lift and (i-p) 4 months following flank excision and thighplasty.

1402
XII Body Contouring
level of the lower incision, towel clips are used to mobilize the
lower flap to the upper incision, confirming the inferior mark.
The tissue is then resected.
Liposuction can be used to debulk and help mobilize the lateral
thigh. A roughly 10 × 10 cm area of the lateral thigh is additionally
undermined to further enable mobilization of this area. The lateral
thigh flap is suspended using a long-lasting absorbable monofil-
ament suture. The suture secures the mobilized superficial fascia
to the deep fascia in two rows, elevating and stabilizing it. Tension
is placed to maximize the effect.
Next, the posterior incision is closed in layers. Three-point
sutures are run from the superficial fascia to the deep fascia at
the level of the upper incision, bringing the lower incision up to
the upper. A long-lasting absorbable monofilament suture is used.
Three-point sutures provide good control of the scar position and
help eliminate dead space. Once the deep layer is closed, a drain
is buried to be brought out anteriorly. The dermis is closed with
interrupted monofilament sutures, followed by a running subcu-
ticular suture. It is the author’s preference to use an expandable
dermal tape and adhesive as the final dressing.
90.6.2 Anterior Excision
The anterior part of the procedure begins with infiltration of
the abdominal area, if liposuction is planned. If the patient has a
history of abdominal surgery, other than laparoscopic surgeries,
then infiltration is performed after the flap is elevated to allow for
direct visualization of the abdominal wall to rule out any undi-
agnosed hernias. The anterior incision is begun at the marked
lower incision. In one-stage procedures, the anterior incision is
connected to the posterior incision. The dissection is extended
through the superficial fascia in the direction of the deep fascia. In
the body lift patient, the drain should be identified and secured.
The anterior abdominal flap is then elevated below the Scarpa’s
fascia while preserving areolar/fatty tissue along the deep fascial
plane. This technique differs from that described by Saldanha,
which leaves Scarpa’s fascia down after debulking liposuction.
A central tunnel is created to the xiphoid, exposing the medial
borders of the rectus muscles. We feel strongly that approxima-
tion of the medial borders corrects the diastasis. There is no need
to “tighten” patients beyond that, and doing so may subject the
patient to greater pain and theoretically play a role in venous
thromboembolism. Furthermore, by limiting dissection in this
area, the lateral row of rectus perforators is preserved.
The abdominal wall midline is then marked and the area of pli-
cation delineated. The tension of the rectus plication is set using
monofilament absorbable sutures. 1ext, a continuous absorbable
barbed suture is run through the fascia to complete the plication.
After plication, the appropriate quantity of liposomal bupivacaine
is injected as a transverse abdominis plane block.
Fig. 90.5 Photos of markings.

90 Body Lift
1403
The epigastric area is next addressed. Advancing, braided,
absorbable sutures are run from the superficial fascia to the deep
fascia in the midline. These sutures displace tension from the
lower, midline closure to this region. Advancing the epigastric area
allows for a better contour, delineates the midline, and eliminates
the dead space.
The redundant skin is next assessed and the upper mark
is confirmed. The goal is to set the location of the lower flap,
bringing the upper flap down and transposing the position on
the upper flap. This is aided by suspending the Scarpa’s fascia of
the mons to the deep fascia at the level of the mons. As the mons
is addressed laterally, it is important to advance superiorly and
laterally and not directly vertical to prevent framing of the mons.
Laterally, the lower flap is stabilized 2 cm beneath the ASIS with
a towel clip.
:ith conservative flexion at the hips, the upper mark can be
transposed from the underlying inferior incision. The marked area
is then resected. The patient will remain in the flexed position
for the remainder of the procedure. The bed is placed in the
Trendelenburg position; the calves and feet are lowered, flexing
the knees; and the bony prominences are once again checked.
If resection of the prior umbilicus is not possible or would
require excessive flexion of the hip, a small vertical extension off
the transverse incision should be strongly considered.
The umbilicus can be re-created from the original stalk. The
caudal position of the umbilicus is transposed on the abdominal
flap after the flap is set under the expected tension. An inverted-V
incision is made. The umbilicus is attached at the 3, 6, and 9 o’clock
positions using an absorbable monofilament three-point suture.
This technique creates an aesthetically appealing umbilicus and
accentuates the upper fullness of the umbilicus while also flatten-
ing the lower portion of the umbilicus and placing the incisions
internally at all sites except the 6 o’clock position. Skin sutures
around the umbilicus should be avoided, as this area is prone to
hypertrophic scarring. If the stalk is redundant, some shortening
can be accomplished as long as there is depth to the umbilicus. If
shallow, the aesthetic result will be flat and not depressed and a
neoumbilicoplasty should be considered.
Braided, absorbable sutures are then placed in the midline and
laterally, advancing the flap toward the lower incision, anchoring
the superficial fascia to the deep fascia. Slight depression in the
midline and highlighting the lateral rectus position helps improve
the abdominal contour. Similar to the posterior closure, the
anterior closure first uses three-point sutures from the superficial
fascia to the deep fascia to help control the scar position (bringing
the upper flap to the predetermined lower flap location) and to
obliterate the dead space. It is imperative to locate the pertinent
sensory nerves and to avoid deep fascial sutures in these anatom-
ical areas. The dermis is closed with interrupted monofilament
sutures, followed by a running subcuticular suture. The anterior
incision is similarly dressed with dermal expandable tape and
sealed with dermal adhesive. A supportive garment is placed (Fig.
90.5, Fig. 90.6, Fig. 90.7).
90.6.3 Male Considerations
In general, male patients undergoing lower body lifts are very
similar to females. However, there are a few differences when
considering male MWL patients. Male patients tend to have more
truncal laxity, including both vertical and horizontal laxity of
the mons pubis area.
Curvilinear incisions both posteriorly and anteriorly are femi-
nine. During planning, every attempt is made to try to make these
incisions straighter in males. Usually, the mons pubis area in male
patients requires more debulking of the fatty tissue. Resection
of this area is performed under direct visualization at the level
below Scarpa’s fascia. Alternatively, debulking of this area can be
performed with liposuction as well. Using the same methods of
stabilization and suspension, the mons pubis area is elevated and
placed in the appropriate position. However, due to the excessive
Fig. 90.6 A 33-year-old woman s/p 125-lb. weight loss, (a–f) shown
here before and (g–l) 8 months following lower body lift and liposuc-
tion of her thighs.

1404
XII Body Contouring
horizontal laxity, this area may need to be addressed primarily or
in a secondary procedure (Fig. 90.8).
90.7 Ancillary Procedures
90.7.1 Vertical Abdominoplasty
Excess epigastric horizontal laxity, often seen in patients
following weight loss, can be dealt with primarily or second-
arily through midline or lateral excisions. When recognized, a
vertically oriented abdominoplasty helps address excess in both
dimensions, excising dog-ears horizontally along the normal
transverse abdominoplasty incision pattern. This pattern is in
contrast to the traditional fleur-de-lis excision. This resection
constricts the waist due to the discrepancy between the length of
the upper and lower limbs. The vertical abdominoplasty results
in a visible vertical scar but is acceptable for most MWL patients.
Vertical abdominoplasty patients are more susceptible to an
increased risk for wound healing problems at the T junction. This
T junction may also distort the mons pubis region.
Lateral resection to address the horizontal excess is another
option. This type of intervention can address epigastric laxity but
Fig. 90.7 A 34-year-old woman s/p 70-lb. loss, shown here
(a–f) before and (g–l) 1 year following lower body lift.
Fig. 90.8 A 37-year-old man who lost 155 lbs. through diet and
exercise. He is shown here (a–f) before and (g–l) 1 year following
lower body lift, chest excision, and thighplasty.

90 Body Lift
1405
is not as aggressive, because it is remote from the main point of
action. Lateral resection may also result in breast displacement
and widening of scars (Fig. 90.9, Fig. 90.10).
90.7.2
Buttock Lift
A popular adjunct to a lower body lift surgery is autologous
gluteal augmentation. Vascularized flank tissue is used in this
dermal–fat flap and is an excellent method of addressing gluteal
deficits. Gluteal flaps have been regularly incorporated into body
lifts for a number of decades and in a variety of methods, as
described by Hunstad et al.
:hen planning a rotational flap, the design of the posterior
flank excision must be lowered to accommodate the point of rota-
tion, allowing maximal projection of the buttock at the correct
point. This caudal shift on the resultant scar may compromise the
aesthetic outcomes of the flank excision and leave the scar in a less
anatomical position. Using a reverse Gilles technique helps with
the design and determine the amount of tissue to be maintained.
In a typical gluteal augmentation, the lower incision is made first.
After created a subcutaneous pocket overlying the buttock, the
Fig. 90.9 (a,b,d,e,g,h,j,k) A 41-year-old woman who lost 125 lbs.
following Roux-en-Y gastric bypass (c,f,i,l) who underwent a lower
body lift with an anterior vertical extension.
Fig. 90.10 A 57-year-old man who is s/p 70-lb. weight loss following
a gastric sleeve. He is shown here (a,b,d,e,g,h,j,k) before and
(c,f,i,l) 1 year following vertical abdominoplasty and chest excision .

1406
XII Body Contouring
upper incision is confirmed, and the flap is de-epithelialized and
elevated laterally. The surrounding fascia is then incised to help
facilitate rotation. Once the flap is released, the flap should be
cautiously rotated to ensure adequate blood supply.
Gluteal flap augmentations are associated with a higher risk of
morbidity. This can be due to a variety of reasons: the counter-
acting forces of an anterior and posterior trunk closure, increased
volume in the posterior closure resulting in additional tension,
decreased vascularity due to undermining of the posterior skin
flap and inset of the dermal–fat flap, compromise of sacral perfo-
rators supplying the flap due to a 90ƒ rotation, and/or compromise
of the ideal scar position and gluteal aesthetics due to planning
of the flap. Given these hypothesized reasons, patients for gluteal
augmentation should be selected with caution. The author prefers
to limit the procedure to patients with a BMI < 32 kg/m2 and
staging of the body lift. By staging the procedure, these patients
are able to remain upright during the posterior procedure, which
decreases tension on the posterior area because patients are able
to lie on their side and/or stomach.
Alternatively, fat may be transferred as an injectable graft.
Multiple donor sites may be required for adequate harvest. The
impact of further deflation on poor skin must be considered.
Finally, there are important safety considerations one must plan
for and discuss with the patient if this procedure is chosen for
the patient. Furthermore, multiple stages are often needed to
reach the optimal volume. It is important to understand that the
addition of fatty tissue in the buttocks does not address the issue
of laxity, which most commonly requires a skin lifting procedure.
One may consider a prosthetic device to augment the buttock.
These devices do often require a staged approach addressing
volume and skin laxity at different stages (Fig. 90.11).
90.8 Postoperative Care
Following surgery of this magnitude, patients stay at an over-
night facility for 1 to 2 days. Careful and detailed instructions are
given to both the patient and nursing staff. The patient is given
chemoprophylaxis and ambulated the day of surgery.
For pain management, liposomal bupivacaine and intravenous
acetaminophen are given intraoperatively. Gabapentin for 24 to
72 hours can be considered, and ketorolac is begun. However,
the earlier the patient ambulates, the less pain is reported. Drains
commonly remain for approximately 1 to 2 weeks. Compression
garments are maintained for several weeks to help support and
compress the surgical sites.
Between 2 and 3 weeks postoperatively, the surgical tape is
removed. The patients begin using a topical silicone gel or scar
cream at this point to help lessen the appearance of scars. At 3
weeks, patients may begin to perform exercises that increase
their heart rate and their range of motion. Patients are advised to
slowly increase their activity level. Swelling will be noticeable for
approximately 3 to 6 months, and patients should be instructed
that their overall body contour will stabilize in about 1 year.
90.9 Complications
According to a few recent reviews, the rate of complications
following circumferential body lift procedures ranges from
approximately 35 to 55%. The most common complication is
wound dehiscence or seroma formation, at 17% and 13%, respec-
tively. Major complications such as infection, thromboembolism,
and hematoma are rare. MWL has been shown to be associated
with poor wound healing and other wound complications. One
study noted that 30.6 of M:L patients suffered complications
after undergoing body contouring procedures. The same study
showed a twofold increased risk based on the amount of weight
lost. Regardless of the method of weight loss, MWL patients are
at a higher risk of complications than traditional body contouring
Fig. 90.11 (a,d,g,j) A 46-year-old old woman with 110-lb. weight loss
(b,e,h,k) following Roux-en-Y gastric bypass, shown (c,f,i,l) 1 year fol-
lowing a lower body lift with gluteal augmentation and (g–l) 6 months
following thighplasty.

90 Body Lift
1407
patients. Additionally, patients with higher BMIs at surgery
are more likely to experience postoperative complications in
general. Flap necrosis may also occur along the lower midline of
the abdominal flap. This necrosis is usually due to loss of lateral
perforators reaching this area or undue tension in the flap.
90.10 Outcomes
In general, most patients experience significant improvements
in body contour following the surgery. The lower body lift proce-
dure adequately addresses redundant abdominal tissue, lateral
thigh, buttock ptosis, and fullness in the flank. As with any
procedure, proper patient selection is key to achieving successful
results.
90.11 Concluding Thoughts
The lower body lift can be a life-changing procedure for both
MWL patients and traditional patients. By resecting the entire
midsection of the lower trunk, this procedure is able to dramati-
cally reduce the amount of excess tissue in the lower trunk while
also providing a lifting effect on the lateral thighs, mons pubis,
and buttocks. Given the rate of complications, with proper patient
selection, the body lift can be as safe as an abdominoplasty and
more effective in treating circumferential tissue excess. This
procedure has continually evolved over the last decade to better
address desired body contour and predictability of outcomes.
The body habitus and variability of patients’ tissue quality make
this a challenging procedure, especially in the MWL patient
population. This technique and its variations will likely continue
to evolve to better address the variety of desires of patients and
providers.
Clinical Caveats
• The goal of the body lift is to reduce redundant tissue and
provide a more aesthetically pleasing body contour.
• The most common indication for a body lift is massive weight
loss; however, many other types of patients may also benefit
from this procedure.
• Nutrition plays an important role in wound healing and com-
plication rates, particularly in the MWL patient population.
Nutritional deficiencies should be adequately replenished
and addressed prior to surgery.
• Patients should be at their ideal weight or have maintained a
stable weight for at least 3 months prior to surgery.
• Markings should be done 1 to 2 days prior to surgery, in the
office, to allow for adequate time and patient comfort.
• Surgery can be performed in one stage or two stages, but the
preference of the patient and provider should be considered.
• Ideal scar position can be better achieved by using a three-
point suture running from the superficial fascia to the deep
fascia.
• In males, incisions should be straight and less curvilinear to
produce a more masculine contour.
• Seroma and wound dehiscence are common complications.
Closure of dead space intraoperatively and compressive
garments postoperatively prevent the formation of seromas.
Wound dehiscence can be prevented by reduction of flexion
and extension of the trunk and slowly regaining range of
motion after 3 weeks.
• It can take up to 1 year for patients to obtain their ideal body
contour, and this may continue to improve with further more
weight loss.
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[14] 14. Estimate of Bariatric Surgery Numbers, 2011–2016. American Society
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91 Abdominoplasty
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91 Abdominoplasty
Dennis C. Hammond and Jonathan Nathan
Abstract
Surgical rejuvenation of the abdomen and torso is one of the most
commonly performed procedures in plastic surgery. To accom-
plish safe, consistent, and aesthetic results in the wide variety
of patient subtypes who present for surgical correction requires
an organized approach with strategic application of the various
surgical techniques used to successfully treat these patients. This
chapter presents these various techniques and outlines how they
can be applied in different clinical situations to obtain outstand-
ing results in abdominoplasty in all its various forms.
Keywords
abdominoplasty, mini-abdominoplasty, circumferential abdomi-
noplasty, liposuction, muscle plication, complications
91.1 Introduction
Few procedures in aesthetic surgery can have as dramatic an effect
on the patient’s appearance as rejuvenation of the abdomen. The
combination of removing excess or damaged skin, recontouring
areas of fatty accumulation, and repairing the abdominal wall
dramatically improves the aesthetics and proportion of the torso
in relation to the rest of the body in a way that can be life-chang-
ing for many patients (Fig. 91.1). At the same time, however, few
aesthetic procedures require the same degree of tissue manipula-
tion, undermining, and repair as abdominoplasty. The magnitude
of the operative exposure is significant, and great care is required
in the planning and performance of the procedure to ensure
safety and provide aesthetically consistent results. This chapter
outlines in detail the preoperative, technical, and postoperative
considerations necessary to successfully perform this procedure
in a wide variety of clinical settings.
91.2 Pertinent Anatomy
When considering aesthetic procedures of the abdomen, the
surgeon must be thoroughly 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
Fig. 91.1 (a–d) Preoperative and 1-year postoperative appearance of a 38-year-old woman after undergoing a full abdominoplasty with muscle
plication. This result highlights the dramatic improvement in the appearance of the abdomen that can be achieved after abdominoplasty.

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XII Body Contouring
concomitant liposuction 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 abdominal procedures. The specific anatomy most relevant
to the understanding and application of these complementary
techniques includes the zones of adherence, the superficial fas-
cial system, and the blood supply remaining after each approach.
91.2.1 Soft Tissue Layers of the
Abdominal Wall
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 symphysis pubis—a
sort of elongated hexagon. The layers of the abdominal wall are
consistent in their relationship to each other; the variability occurs
with regard to the quality of the tissues and amount of fat present.
91.2.2 Skin
The skin of the abdomen receives its blood supply from multiple
muscle and fascial perforating vessels that feed a subdermal vascu-
lar plexus. Depending on multiple patient characteristics (such as
age, body mass index [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 elasticity and multiple striae.
These striae are surface evidence of attenuated or absent underly-
ing dermis. The location and extent of striae should be considered
when planning skin incisions, because at the time of closure these
areas of poor or absent dermis are more difficult to close and are
at risk for separation. The surgeon should attempt 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.
91.2.3 Fat
The adipose layer of the abdominal wall can be divided into
two layers³superficial and deep³based on Scarpa’s fascia. The
superficial fat layer has a more robust blood supply, is usually
thicker, and has a denser and more durable type of fat. Its vas-
cular supply is from both the subdermal plexus and the under-
lying musculocutaneous perforators. 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
abdominoplasty. This difference in blood supply to the super-
ficial and deep layers of fat is an important factor to consider
during lipectomy of the abdominal flap. Because the anterior
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 overly-
ing skin (Fig. 91.2).
91.2.4 Muscle and Fascia
There are four principal paired muscle groups of the abdominal
wall: the rectus abdominis, 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, spanning 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 fascia
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 transversalis aponeurosis, along with
the deep division of the internal oblique muscles, progressively
transfers to the anterior fascial layer, leaving only the preperito-
neal fat between the rectus muscle and the underlying perito-
neum (Fig. 91.3).
Fig. 91.2 Different characteristics of the superficial fascial system depending on body area. (a) Dense and (b) loose connective tissue layers.
a
b

91 Abdominoplasty
1411
91.2.5 Blood Supply
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 intercon-
nections that are important for abdominoplasty. Understanding
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 internal
thoracic artery, enters the posterior rectus sheath on its way into
the rectus abdominis muscle as it emerges from the costal margin
immediately lateral to the sternum. 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 anastomoses with the deep inferior epigastric artery.
Perforators through the anterior rectus 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 artery, which passes inferolaterally deep to the
ribs at the costal margin where it anastomoses 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 cutaneous branches. Caudal to these are
the subcostal and lumbar arteries, both dorsal branches of the tho-
racic aorta, which contribute to this anastomotic network of vessels
that course between the transversalis and internal oblique muscles.
One of the anastomoses between the superolaterally based
vasculature and the inferiorly based vasculature exists within this
intermuscular space. 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 arteries (DIEAs), a branch of the external iliac
artery, and the superficial epigastric arteries, a branch of the femo-
ral artery. The DIEA travels superomedially from its origin, pierces
the transversalis fascia, and runs along the posterior border of the
rectus abdominis muscle before entering it. Once in the muscle,
Fig. 91.3 Muscular and fascial anatomy of the abdominal wall. (a) Superficial and (b) deep layers.
a
b

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XII Body Contouring
it branches on its way cephalad 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 umbilicus. It often arises as a common trunk with the super-
ficial circumflex iliac artery, superficial external pudendal artery,
and deep circumflex iliac artery (Fig. 91.4).
91.2.6 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 distinct sources: the principal supply
is from branches of the right and left DIEAs; additional flow is
from the ligamentum teres and the median umbilical ligament.
Multiple 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 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.
Fig. 91.4 Blood supply of anterior trunk. (a) With relation to skeletal system. (b) With relation to chest wall musculature.
a
b

91 Abdominoplasty
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91.2.7 Nerves
Cutaneous sensation of the abdomen is derived from the lateral
cutaneous and anterior cutaneous branches of intercostal nerves
T7 through T12. The lateral cutaneous 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 pene-
trate the posterior rectus sheath lateral to the rectus muscle
before entering the rectus muscle on their way to the overlying
fascia and skin.
The anatomy of the lymphatic system of the abdominal wall
is important because it is clinically related to the occurrence of
serous fluid accumulation and edema after abdominoplasty. A
plexus of lymphatic vessels resides within the subscarpal fat layer
just superficial to the anterior rectus sheath. Below the umbilicus,
the lymphatic 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.
Le Louarn and Mustoe published favorable results demonstrat-
ing 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 are diminished.
91.3 Evaluation
When evaluating the abdomen for potential surgical rejuve-
nation, it is helpful to remember that in almost every circum-
stance, the abdomen of the patient at some point demonstrated
attractive aesthetics. Also, the structures of the abdominal wall
generally age well, and it is the rare patient who presents for
rejuvenation with an uncomplicated history. Any alteration in
the appearance of the abdomen is usually secondary to a “life
eventµ that changes both the structure of the affected tissues
and how these tissues interact with each other. Whether these
changes are secondary to pregnancy, weight gain or loss, trauma,
surgery, or some other etiology, essentially the normal anatomy
of the abdominal wall has been altered in a way that adversely
affects what was at one time an aesthetically pleasing abdomen.
With this in mind, the three major tissues that require surgical
alteration are the skin, fat, and muscle/fascia.
91.3.1 Skin
The skin of the abdomen, lateral abdominal wall, and especially
the back has a substantial dermal layer and, without any type
of stress as can occur with pregnancy or weight gain, tends to
maintain its structural integrity well over time. However, the
stresses that do occur with weight gain and certainly pregnancy
can severely challenge the dermal architecture, leading to dermal
rupture with the formation of stretch marks, loss of strength,
and reduced elastic rebound (Fig. 91.5). Expansion of the skin
envelope leads to a proportional mismatch with the underlying
fatty layer as well as the abdominal wall, leading to redundancy,
folding, and loss of an aesthetic contour.
91.3.2 Fat
Typically for many patients, changes in the skin and dermis of
the abdomen are often accompanied by excess fatty accumula-
tion. These fatty deposits can occur in fairly consistent isolated
areas, including the upper and lower abdomen as well as the
posterior hips (Fig. 91.6), or can be part of a general increased
level of obesity affecting the entire torso (Fig. 91.7). Fatty excess
in these areas can alter the desired smooth hourglass contours of
an aesthetic abdomen, creating excess bulging anteriorly as well
as laterally, most notably in the posterior hip area.
91.3.3 Abdominal Wall
Stretching of the musculofascial elements of the abdominal wall
can occur most notably with pregnancy, although a history of
obesity can also result in a loss of overall tone to the abdomen.
While general stretching of the rectus and internal and external
oblique musculature and the associated fascial coverings can
occur, one dramatic effect of pressure from inside the abdomen
is the creation of a separation in the midline between the paired
rectus abdominis muscles. This damage to the midline support
structures of the abdomen is termed a diastasis recti; in selected
patients the resulting distance between the medial muscle edges
can be quite large (Fig. 91.8). Such loss of musculofascial support
to the abdomen results in an unavoidable bulging of the abdomen
generally; however, a very prominent protrusion of abdominal
viscera directly in the area of the diastasis can occasionally be
seen with abdominal exertion in some patients. Additionally,
outright fascial failure can result in herniation of preperitoneal
fat or, in severe cases, abdominal viscera, through the areas of
weakness. Repair of these deformities is a critical part of the
overall treatment plan for abdominoplasty in selected patients.
Fig. 91.5 After pregnancy, expansion-induced damage to the dermis
of the skin of the abdominal wall can manifest as stretch marks that
extend across the abdomen from hip to hip and from well above the
umbilicus down to the pubis.

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XII Body Contouring
91.4 Preoperative Considerations
91.4.1 General Health
In evaluating the potential abdominoplasty patient, it must be
remembered that for most patients the procedure requires an
extensive amount of operative dissection, tissue undermining,
suture plication of the abdominal wall, and long cutaneous
scars. Therefore, the patient must demonstrate the ability to
heal these extensive surgical wounds. Any medical condition
that can adversely affect wound healing must be optimized
preoperatively to ensure an uncomplicated course. In par-
ticular, the general nutritional status of the patient must be
normalized to support wound healing. Common conditions
that can affect wound healing include diabetes, obesity, and
malnutrition, as can occur after gastric bypass surgery. It
is reasonable to evaluate nutritional health in these types
of patients using basic hematologic parameters, including
hemoglobin/hematocrit levels, liver function tests, and total
serum albumin levels, as an indirect indicator of wound heal-
ing potential. Altered values in these parameters can identify
patients who are at risk for postoperative complications. In
such cases, surgical intervention can be delayed until these
parameters are normalized.
91.4.2 Smoking History
In patients who are active smokers, the risk for any type of
complication is generally double that of nonsmokers. It is not an
unreasonable approach to delay surgery in smokers until they
have been smoke-free for a variable period of time, ranging
from 6 weeks to 6 months or longer. Blood testing for nicotine
levels is often done the morning of surgery by some surgeons
to ensure compliance with the smoke-free requirement, with a
positive test resulting in cancellation of the procedure. Another
more practical approach is to agree to perform the procedure,
albeit with a modified, less aggressive technique. Using a
technique of limited undermining with little to no concomitant
suction-assisted lipectomy, an acceptable result can be safely
achieved with reasonable surgical risk. Such a result would likely
be less dramatic than that obtained using standard techniques;
however, the operative risk mandates that a more conservative
approach be used. This may be an acceptable circumstance given
that the alternative may be not to operate at all.
91.4.3 Body Habitus
It is preferred that the patient be at a nonfluctuating and stable
weight when undergoing abdominoplasty. Many patients will
“diet down” in preparation for the procedure only to regain
weight afterward, a circumstance that can adversely affect
the result. The opposite situation is also not ideal, meaning
the patient who wishes to have surgery with the goal of then
losing weight postoperatively. Such a strategy could result in
recurrence of redundant skin and loss of abdominal contour if
the weight loss were to become significant. Therefore, no matter
what the weight or BMI level of the patient is, the most important
factor is that the weight be stable for a period of at least several
months prior to the planned surgery. Special note should be
made of the patients who present with BMI greater than 25.
While the overall level of fatty deposition is elevated, there is
quite commonly a prominent anterior abdominal skin folding
that is present that will not resolve even with extensive weight
loss. It is not unreasonable to perform a basic abdominoplasty
in such patients simply as a means of removing the redundant
tissue and thus facilitating simple tasks, such as moving more
freely or wearing clothes more easily. Also, such an approach
could potentially jumpstart a weight loss program designed to
improve overall health. Using this approach, significant improve-
ment in quality of life can be achieved in such patients with an
acceptable surgical risk profile.
Fig. 91.6 Fatty accumulation in the area of the posterior hips with
interruption of the desired hourglass contour of the abdomen as it
extends down to the hips and thighs is commonly seen in patients
presenting for abdominoplasty.
Fig. 91.7 Generalized fatty excess can often be seen in association
with excess and damaged skin in abdominoplasty patients.

91 Abdominoplasty
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91.4.4 Future Pregnancies
If future pregnancy is planned, it is generally a preferable option
to delay abdominoplasty until after completion of childbearing.
While an uncomplicated pregnancy can be expected after
abdominoplasty, intentional stress of the abdominal wall is
best avoided if possible to prevent recurrence of abdominal wall
laxity and redundancy of the skin and fat.
91.4.5 Deep Venous Thrombosis
One of the more severe potential complications associated with
abdominoplasty relates to the development of venous thrombo-
embolic events (VTEs), including deep venous thrombosis (DVT)
and pulmonary embolism (PE). Many factors have been shown
to increase the risk for VTE, including advancing age, prolonged
operative times, elevated BMI, previous history of a cancer diag-
nosis, previous history of DVT, and history of a clotting disorder.
As a result, various models designed to predict the risk associ-
ated with VTE have been developed. Based on this risk profile,
decisions are then made regarding the indication for mechanical
VTE prophylaxis using lower-extremity pneumatic compres-
sion devices, as well as the need for chemoprophylaxis using a
variety of anticoagulating agents given either preoperatively,
postoperatively, or both. While mechanical VTE prophylaxis is
almost uniformly used due to the fact there is no risk associated
with its use, chemoprophylaxis with systemic anticoagulants is
more controversial. Due to the extensive amount of soft tissue
dissection with undermining that is associated with abdomino-
plasty, systemic anticoagulation has a variable risk of postoper-
ative bleeding and hematoma formation. For this reason, many
surgeons are reluctant to use chemoprophylaxis. This decision
is also complicated by the fact that plastic surgery–directed
research designed to assess the risk of plastic surgery procedures
for VTE has not resulted in a uniform consensus regarding the use
of chemoprophylaxis. It is up to each individual surgeon to assess
the risk for each patient who presents for abdominoplasty and to
use both mechanical and chemoprophylaxis when appropriate.
When chemoprophylaxis is chosen as a deterrent to VTE,
several strategies have been developed to guide appropriate
dosing. Currently, there is no consensus as to the most beneficial
approach. One strategy involves administering an anticoagulant
preoperatively and then continuing for 1 week postoperatively.
Another common approach is to begin the anticoagulant a short
time after the procedure. It remains for each individual surgeon
to identify the strategy that makes sense to provide a safe and
effective prophylaxis against VTE while at the same time reducing
as much a possible the risk for a postoperative bleeding event.
91.5 Combination Procedures
It is not uncommon for patients who are having other types
of abdominal procedures, and in particular gynecological
procedures, to request that these procedures be performed in
conjunction with abdominoplasty. These combined operations
are best approached with caution. As noted previously, one of
the most clinically significant potential complications associated
with abdominoplasty relates to VTEs, including DVT, in the
lower extremity, and the even more serious and potentially
life-threatening complication of PE. Combining an at-risk
procedure such as abdominoplasty with other intra-abdominal
procedures that have their own risk profile for DVT and PE
unnecessarily exposes the patient to further increased risk for
such thromboembolic events. What’s more, chemoprophylaxis
Fig. 91.8 (a–c) Excessive stretching of the abdominal wall after
pregnancy can result in a pronounced separation of the medial
margins of the paired rectus abdominis muscles, leading to weakness
and loss of support in the midline of the abdomen, the classic diastasis
recti deformity.

1416
XII Body Contouring
becomes almost mandatory if combined procedures are per-
formed, and with the use of such anticoagulation, the risk for
postoperative hemorrhage and hematoma formation increases.
For these reasons, it is generally recommended that abdomino-
plasty be performed as an isolated procedure apart from other
intra-abdominal operations.
One caveat to this recommendation relates to combining
abdominoplasty with other body contouring types of procedures,
such as breast reduction, mastopexy, or augmentation. Due to the
superficial nature of these operations, it is generally considered
appropriate to combine these types of procedures, keeping in
mind the total operative time. As operative times become longer,
the indication for combining mechanical and chemoprophylaxis
becomes stronger. All these factors can affect the decision of
whether to use anticoagulation prophylactically in the abdomi-
noplasty patient.
91.6 7eFKniTue 2YerYieZ
91.6.1 Management of the Excess Skin
Excision of the redundant and generally damaged abdominal wall
skin is the major goal of abdominoplasty. This is accomplished by
removing a tapered ellipse of skin and fat that extends from just
above the umbilicus down to the pubis and extending laterally
enough to prevent a dog-ear from forming at the lateral ends
of the excision (Fig. 91.9). There are numerous mild variations
in this general approach, designed to either place the resultant
scar lower on the abdominal wall or limit the lateral extent of
the scar. No matter what pattern is used, the overall goal of the
procedure is to remove as much of the redundant skin and fat
as possible while keeping the scar as low as possible along the
lower anterior abdominal wall and at the same time creating a
smooth lateral contour with no irregularity or dog-ear formation
at the lateral ends of the scar.
91.6.2 Management of the Excess Fat
To further contour the abdomen, liposuction can be performed
in conjunction with skin excision to reduce specific areas of
fullness. Typically, these areas include the posterior hips as well
as general fatty deposition in the upper abdominal panniculus
(Fig. 91.10). Any technique of liposuction can generally be used,
depending on the surgeon preference, and although individual
surgeon preferences may differ, conservatively approached lipo-
suction of the upper abdominal flap can be safely performed in
conjunction with the surgical undermining required to accom-
plish the skin excision without risk for the creation of significant
ischemia in the abdominal flap.
91.6.3 Management of the
Abdominal Wall
Repair of the abdominal wall can have the most dramatic effect
on the overall result after abdominoplasty. To accomplish this,
various patterns of muscle and fascial repair are used as needed
Fig. 91.9 (a) Preoperative appearance of a 35-year-old woman in preparation for extended abdominoplasty after massive weight loss. (b)
Preoperative marks include a wedge resection of skin and fat that runs from the pubis to just above the umbilicus in the midline and extends laterally
far enough to prevent the development of a dog-ear after closure. (c) Angling the incision along the relaxed skin tension lines greatly facilitates the
creation of a smooth, lateral closure. (d,e) Postoperative result 6 months after the performance of an extended abdominoplasty.

91 Abdominoplasty
1417
to restore competence to a traumatized or lax musculofascial
abdominal wall. By repairing any tendency for a patient to
demonstrate a diastasis recti or reinforcing the lateral muscu-
lofascial envelope, the waist can be narrowed and a pleasing
and flat abdominal contour can be created that enhances the
rejuvenation of the torso (Fig. 91.11).
91.6.4 Management of the Umbilicus
By definition, abdominoplasty includes the creation of a neoum-
bilical opening through which the umbilicus is translocated, as
opposed to the more limited panniculectomy procedure, where a
wedge of skin and fat is simply removed from the lower abdomen
with no umbilical translocation. To this end, numerous tech-
niques for the design of this translocation have been described.
The basic tenets of any technique are to create a mild umbilical
depression with a hidden scar properly positioned in the midline
of the abdomen. A carefully constructed and positioned umbili-
cus can greatly enhance the quality of the aesthetic result after
abdominoplasty.
91.7 Procedures
91.7.1 Full Abdominoplasty
Indications
A standard full abdominoplasty is the basic procedure most
commonly performed for patients who present for abdominal
rejuvenation. Such patients present with enough redundancy to
the skin and fat of the anterior abdominal wall that the resection
pattern can easily be carried above the umbilicus. This will allow
the resulting postoperative scar to be positioned low along the
anterior abdominal wall while at the same time facilitating
an umbilical transposition through the inferiorly transposed
abdominal flap that creates a single contoured and aesthetic scar
around the umbilical stalk. The classic patient also presents with
a moderate to severe amount of musculofascial relaxation, so
that abdominal wall plication will dramatically affect the result.
Finally, any areas of isolated fatty deposition can be treated in a
way that only enhances the quality of the overall result.
Fig. 91.10 (a) Preoperative appearance of a 49-year-old woman in preparation for abdominoplasty along with planned liposuction to the posterior
hips. (b) After liposuction recontouring of the right posterior hip area, the dramatic effect of removal of fat from this area on recontouring of the
posterior and lateral torso can be seen. (c) After both sides have been treated, the result is very aesthetic contours, particularly when this procedure
is combined with abdominoplasty. (d) Postoperative result at 1 year showing improved contour of the entire posterior and lateral torso.

1418
XII Body Contouring
Patient Marking
The patient is marked in the standing position with the arms
comfortably at the sides (Fig. 91.12a–c). One of the goals of the
marking procedure is to create a low-riding and symmetric scar
across the lower abdomen that removes as much of the excess
skin and fat as possible but does not create inordinate tension on
the closure. :hen predicting the final result, it must be realized
that while the upper panniculus will in fact “window shade”
downward as it is pulled inferiorly after undermining, the lower
incision will also ride up to meet it simply as a result of the inher-
ent elasticity of these tissues. Therefore, the final scar will be
variably positioned at a point several centimeters above where
the lower mark is drawn. This observation becomes important
in those cases where the patient wishes the scar to be able to be
concealed underneath clothing or a bathing suit. In point of fact,
depending on the specific conditions for each individual patient,
some garments may not cover the scar after abdominoplasty, no
matter how low the lower incision is drawn, and this fact must be
discussed with the patient preoperatively to avoid postoperative
dissatisfaction with the result.
The other major goal of the marking procedure is to avoid one
of the most common and yet avoidable complications associated
with the procedure, namely the creation of persistent dog-ears
at the ends of the scar. When these occur, it is distressing to
the patient and can adversely affect what may otherwise be an
expertly performed procedure. Subsequent revision is easily
performed secondarily; however, in the vast majority of cases,
this complication can be prevented by being sure to carry the
marking pattern laterally enough to close the wound smoothly. As
well, if the resection pattern follows the relaxed skin tension lines
of the lateral abdominal wall, further protection against dog-ear
formation is provided.
When marking the patient, it is important to note that the lower
mark as well as the location and angle of the lateral extent of the
marking pattern define where these incisions will be made at sur-
gery, and the location of these marks is not subject to change. The
upper mark, as it variably curves around the umbilicus and upper
abdomen, can be modified during surgery depending on the elas-
ticity of the tissues. At times a more conservative location for the
upper mark is indicated to avoid inordinate tension on the wound,
while in other circumstances, a more aggressive tissue removal
pattern can be employed. This decision is made intraoperatively
depending on how easily the wound edges can be approximated.
Therefore, a common landmark to begin the marking is the apex
of the labial cleft. Measuring approximately 5 to 7 cm above this
point with the skin under stretch will position the scar low enough
to be aesthetically acceptable (Fig. 91.12d,e). If a C-section scar is
present, every attempt is made to place this initial lower mark
below the level of this scar to ensure that it is removed with the
tissue resection. The lower border of the pattern is then marked
by symmetrically extending a line laterally from this central point
onto the skin of the lateral abdominal wall. Care is taken to be sure
that the apex point of this mark is the same height on each side to
ensure symmetry in the final appearance of the scar. Additionally,
by canting this line so that it follows the relaxed skin tension
lines of the skin of the lateral abdominal wall, the likelihood of a
smooth and contoured lateral closure is enhanced. Ensuring sym-
metry in the location of the scar can greatly enhance the quality of
the overall result; an asymmetrically and irregular postoperative
scar proves distracting to the final result (Fig. 91.12f). In selected
cases, the exact location of this lower mark can become import-
ant, because many patients will have a very sharply defined fold
running across the lower abdomen as the panniculus folds over
from above. The skin and fatty layer at this fold and below can be
Fig. 91.11 (a,b) Preoperative appearance of a 50-year-old woman in preparation for full abdominoplasty with muscle plication. The degree of
abdominal bulging with loss of muscle tone can readily be seen. (c) Preoperative marks. (d) Intraoperative view demonstrating three vertical lines of
suture reinforcement of the abdominal wall. One suture line is placed in the midline, and a second one is placed at each lateral margin of the rectus
abdominis muscles. (e,f) The postoperative result at 6 months reveals an aesthetic abdomen with total correction of the abdominal bulging and a flat
abdominal contour.

91 Abdominoplasty
1419
Fig. 91.12 (a–c) Preoperative appearance of a 31-year-old woman in preparation for abdominoplasty with planned abdominal wall plication
secondary to extreme musculofascial laxity and the presence of a diastasis recti deformity. (d,e) A midline line is drawn for orientation, and the
lowermost portion of the pattern is drawn in at a point 5 to 7 cm above the labial cleft. (f) This lower incision mark is extended away from the midline
in a symmetric fashion running the orientation along the relaxed skin tension lines as they course laterally around to the back. An estimation is made
of how far posteriorly this line must go to ensure that a dog-ear is not left behind after the redundant tissue is removed. It is a better option to extend
this line posteriorly as much as is necessary than to risk dog-ear formation secondary to a resection pattern that ends too quickly, thereby obviating
any chance for a smooth closure. When the lower incision mark is made directly in the groin crease, the thickness of the superior flap will exceed that
of the lower flap, which can be quite thin, particularly in male patients. If no adjustment is made in the location of this mark, a persistent fold will
remain after wound closure and excision of the redundant tissue. (g,h) As the lateral portion of the lower mark is drawn in, an effort is made to orient
this mark just above the crease. Doing so will ensure that the lower flap will be of sufficient thickness to meet the dimensions of the upper flap and
create a smooth contour after closure. In the figure, every effort is made to avoid placing the incision line in the region identified with the X marks.
(i–k) A separate mark is made just above the umbilicus in the midline. This mark is an estimation of where the upper incision will be made, although
the final position of this line will be determined intraoperatively once the upper abdominal panniculus has been elevated. This mark is then carried
laterally in a smooth arc until it reaches the apex of the lower mark. By measuring from the midline around to the most lateral extent of the pattern,
symmetry in the application of the pattern can be ensured. In this case, the distance from the midline to the lateral extent of the pattern was 33 cm
on each side. (l) The areas in the posterior hips that will be treated with liposuction are outlined. (m) The final appearance of the marking pattern,
including the proposed three-line abdominal wall plication technique for repair of the abdominal wall.

1420
XII Body Contouring
quite thin, while the skin and fatty layer in the flap above can be
proportionately thicker, leading to a tissue thickness mismatch at
the time of closure. Such a mismatch creates an unavoidable and
persistent postoperative contour break along the lower scar, with
the tissues above folding over the scar (Fig. 91.12f). Particularly in
heavier patients, such an occurrence negates the presurgical goal
of creating a smooth and aesthetic contour to the lower abdomen
after abdominoplasty. To prevent such an occurrence, care must
be taken during the marking sequence to avoid placing the scar
directly in this fold. By angling the scar slightly up onto the thicker
lower flap, even only a centimeter or two, a thick enough lower
flap contour will be created that then can be smoothly approxi-
mated to an upper flap of similar thickness (Fig. 91.12g,h).
Once the lower mark is set, an estimate is made of how much
tissue will be removed after undermining the panniculus, and a
contoured incision line is marked from a point variably above the
umbilicus joining the lateral extent of the lower line in a symmet-
rical fashion (Fig. 91.12i–k). Any areas of fatty deposition that will
be treated with liposuction are then delineated using the standard
topographical map style of marking. Typically this includes the
posterior hips as well as any fatty accumulations in the upper
abdominal flap (Fig. 91.12l). Finally the proposed lines of muscle
and fascia plication are drawn in to reinforce the surgical plan for
tightening and repair of the abdominal wall (Fig. 91.12m). This
completes the marking sequence.
7eFKniTue
The procedure proceeds under general anesthesia. The patient
is placed supine on the operating room table with the operative
field prepared from the nipple line down to the midthigh. An
operating table capable of placing the patient in a semiflexed
position is required to allow tension-free closure at the conclu-
sion of the case. Pneumatic compression stockings are applied
to the lower extremities as mechanical prophylaxis against
postoperative DVT. During this portion of the procedure, muscle
relaxation delivered by the anesthesiologist is not required,
although temporary paralytic agents will be administered later
during plication of the abdominal wall.
In cases where areas of fatty deposition will be addressed with
liposuction, these areas are infiltrated with a standard tumescent
solution and then treated to the desired effect before any aspect
of the abdominoplasty is begun. Once the body contouring with
liposuction has been completed, the initial umbilical incision is
made using a 2.5 to 3.5 cm long horizontal elliptical pattern. The
superior rim of the umbilical stalk is trimmed slightly to make
room for the eventual abdominal turn-down flap that will be cre-
ated at the time of insetting of the umbilicus (Fig. 91.13a–e). Once
the umbilicus is dissected free from the abdominal panniculus,
the lower incision is made across the entire lower aspect of the
pattern after infiltrating the skin with a diluted solution of lido-
caine with epinephrine. The dissection is carried straight down
to the abdominal wall until the fascia is identified. If necessary,
a slight beveling technique directed superiorly can be used to be
certain that the lower flap is thick enough to meet the upper flap
at the time of closure without creating a thickness discrepancy
that could lead to incision line irregularities (Fig. 91.13f).
The upper panniculus is undermined up to the umbilical
stalk using a dissection strategy of keeping the fine network of
lymphatics that lies just at the junction of the fat with the fascia
of the abdominal wall intact and attached to the abdomen. By
avoiding damage to this fine lymphatic network, seroma forma-
tion postoperatively can potentially be minimized (Fig. 91.13g,h).
A more aggressive approach advocated by many is to perform this
initial lateral flap elevation at a plane just under Scarpa’s fascia in
order to leave behind the deep layer of fat. This will serve to even
more aggressively maintain an intact lymphatic network. In many
instances, a strategy that includes the use of no postoperative
drains is employed with this dissection approach (Fig. 91.13i).
Once the umbilical stalk is reached, the lower panniculus can be
divided in the midline as needed. This allows the umbilical stalk
to be accurately released from the surrounding soft tissues and
also eases the further undermining of the flap up to the margin
of the ribs laterally and the xiphoid process superiorly. Laterally
there is no reason to undermine any further than the rib margin,
as this degree of dissection will allow the upper flap to advance
down to the lower incision without tension. However, centrally,
the upper panniculus is dissected free up to the level of the
xiphoid process. This degree of central undermining is performed
simply to allow the rectus fascia to be plicated as part of the repair
of the abdominal wall (Fig. 91.13j,k).
Once the undermining has been completed, the abdominal
wall is reinforced. It is helpful at this point to use paralytic drugs
to obtain full relaxation of the muscles as this will allow a more
aggressive repair of the abdominal wall to be accomplished with
reduced risk of tearing or otherwise injuring the fascia or muscles
in the process. The primary component of abdominal wall rein-
forcement involves repair of the midline diastasis that is present
to a greater or lesser degree in many patients (Fig. 91.13l). Repair
of this separation between the medial edges of the rectus abdom-
inis muscles serves to restore competence to the muscles of the
abdominal wall, allowing the entire musculoaponeurotic com-
plex to flatten the abdominal wall contour. Although absorbable
sutures can be used to accomplish this task, permanent suture
material affords a more certain degree of protection regarding
postoperative suture failure potentially enhancing the stability of
the long-term result.
Using a no. 1 Prolene suture, plication of the medial edges of the
rectus fascia is initiated at the level of the xiphoid process. Using
a running locking technique, the fascial edges are approximated,
adjusting each pass to create a firm reinforcement of the abdom-
inal wall. This running suture is passed halfway down toward the
umbilicus and stopped (Fig. 91.13m,n). A second no. 1 Prolene
suture is placed just at the superior margin of the umbilicus and
in a similar fashion run superiorly toward the first suture, where
the two loose ends are tied together to complete the supraum-
bilical repair (Fig. 91.13o,p). By using this two-strand technique,
a more secure knot results than by using one continuous strand
that is then tied to itself. The same technique is then applied in a
similar fashion running from the inferior aspect of the umbilicus
down to the pubis (Fig. 91.13q). If necessary, the skin and fat in
the midline of the lower flap can be slightly undermined to allow
the plication to reach all the way down to the pubis. Care must be
taken to avoid cinching the opening for the umbilicus too aggres-
sively so as to avoid any tendency for ischemia to develop in the
umbilical stalk. Once this first suture line is secured, the effect on
the abdominal wall is assessed. If, in the judgment of the surgeon,
sufficient support of the abdominal wall has been rendered, no

91 Abdominoplasty
1421
Fig. 91.13 (a,b) The margins of the umbilicus can be identified by applying pressure to the abdominal wall causing the borders of the umbilical defect
to be more sharply defined. (c) A horizontally oriented ellipse 2.5 to 3.5 cm in length is diagrammed around the margins of the umbilicus. (d) The
incisions are made at right angles through the skin margins, and a small rim along the upper margin is resected to allow the eventual inset of the
upper flap from the abdomen into this defect. (e) Appearance of the umbilicus after it is completely released from the upper abdominal panniculus.
(f) The incision along the lower margin of the pattern is made at right angles to the skin edge, avoiding any tendency to undermine the lower flap.
(g,h) When elevating the upper abdominal panniculus away from the abdominal wall, a dissection strategy that leaves behind the thin, areolar
lymphatic layer is used to limit the potential for postoperative seroma formation. (i) An alternative method of flap elevation is to leave behind the
full layer of subscarpal fat along the lateral aspects of the dissection plane. This strategy is used to further reduce the possibility of postoperative
seroma formation and is even used as a technique for avoiding the necessity for a drain postoperatively. (j,k) The upper abdominal panniculus is
elevated to the level of the ribs laterally with dissection extending to the xiphoid process centrally. (l) In cases where the midline rectus fascia is
thin or attenuated and the rectus muscles have spread apart, the proposed fascial repair extending from the xiphoid process down to the pubis is
outlined. (m,n) Orientation lines are drawn on the proposed fascial repair to guide an even closure, and the fascial plication is begun, extending from
the xiphoid process inferiorly using a running no. 1 Prolene suture. This repair is run halfway down to the umbilicus. (o) A second suture is begun just
at the superior margin of the umbilicus. (Continued)

1422
XII Body Contouring
further treatment is required. However, in many patients, even
with this midline suture support of the abdomen, persistent
laxity of the remaining abdominal wall may be present, leading
to an incomplete correction of the problem. In these patients,
additional suture support can enhance the overall result.
To further reinforce the abdominal wall, two basic approaches
can be used. One strategy, termed high-definition abdomino-
plasty, involves running two additional suture lines on either side
of the lateral aspect of the rectus abdominis muscles where these
muscles join with the external oblique. This suture line incorpo-
rates fascia and muscle and runs from just below the rib margin,
down the lateral aspect of the rectus abdominis, and then angles
obliquely toward the midline where it again ends at the pubis. As
before, two separate suture strands are placed, one starting above
and one starting below, to allow a secure closure. This three-line
approach to abdominal wall reinforcement provides a tight and
secure flattening of the abdominal wall contour while at the same
time distributing the tension of the closure evenly over the entire
abdomen. There is firm reinforcement of the relatively weak mus-
culofascial complex that is present in the lower abdomen. This
maneuver also tends to narrow the waist due to medialization
of the external oblique attachments to the rectus sheath (Fig.
91.13r–t).
At this point, firm support of the abdomen should be noted.
In unusual circumstances, there can still be persistent laxity to
the substance of the external oblique itself, leading to persistent
laxity in the abdominal wall. Here, it can be helpful to run a suture
line obliquely along the line of the midsubstance of the external
oblique to further narrow the waist.
These accessory lines of suture reinforcement are used only
when indicated. However, by maximally reinforcing the integrity
of the entire musculoaponeurotic framework of the abdominal
wall, an outstanding aesthetic contour can be created that only
enhances the effect of removing the redundant skin and fat.
Once the abdominal wall has been reinforced, it will be noted
that the umbilical stalk has invaginated into the cleft created by
the plication of the rectus fascia. This is advantageous, because one
of the hallmarks of an aesthetic umbilicus after abdominoplasty
is a mild umbilical depression. This creates a pleasing umbilical
contour and tends to hide the scar along the inner aspect of the
Fig. 91.13 (Continued) (p) This suture is then run from the top of the umbilicus superiorly and tied to the first suture. This provides a secure knot and a
reliable fascial repair. T In a similar fashion, a suture repair of the fascia below the umbilicus and extending down to the pubis is performed. (r) If any
redundancy in the abdominal wall remains, the loose fascia at the lateral margins of each rectus muscle is marked for plication. (s) Appearance of the
abdominal wall after repair of the lateral margin of the right rectus abdominis muscle. (t) Appearance of the abdominal wall after repair of the midline
defect along with the lateral margin of each rectus muscle. (u) The umbilical stalk is tethered to the abdominal wall at the 6 and 12 o’clock positions
to assist in creating a pleasing umbilical depression after full inset of the umbilicus. (v,w) After repair of the abdominal wall is completed, the patient
is placed in the reflex position, and the redundant upper abdominal panniculus is pulled maximally inferiorly and then split in the middle to identify
the amount of soft tissue to be resected. (x) Appearance of the resected specimen.