Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

161
Chapter | 16  Transverse upper body lift
lost during the procedure itself but the indelible tattoo
remains to facilitate realignment.
An incision is made into but not through the dermis.
Electrocautery is used to deepen the incision through the
dermis, which allows for sealing of the subdermal plexus
to minimize bleeding. Dissection is performed straight
down to the loose areolar plane above the muscle fascia
without any undermining or bevelling (Fig. 16.7). Leaving
this layer of tissue will facilitate closure allowing for space-
obliterating sutures. This is accomplished by placing a
3-point suture from the superficial fascial system at each
side of the wound to the muscle fascia, obviating the need
for drains. Should this procedure be performed in combina­
tion with a mastopexy, breast reduction, or reverse abdomi­
noplasty, a temporary V-Y closure can be performed and
then released when the patient is turned supine. As an
tapered into the inframammary fold at the level of the ante­
rior axillary line to avoid a dog ear. Realignment marks are
then made across the area for resection to allow for precise
realignment intraoperatively (Fig. 16.5). The markings are
made with the arms at the patient’s side, allowing for the
maximum amount of tissue to be gathered to achieve an
optimal result.
SURGICAL TECHNIQUE
In prone position, the arms are placed on arm boards with
elbows flexed and the upper arms only moderately abducted.
This reduces tension on closure in the midaxillary line.
A penetrating towel clip is used to confirm preoperative
markings at multiple points (Fig. 16.6). If the champ is
difficult to close, the tension is too great and the lines for
resection are remarked in a more conservative fashion. This
is admittedly a subjective measurement, but the experi­
enced surgeon can accurately assess appropriate tension
using this maneuver. For the surgeon with less experience,
a more conservative resection is suggested initially, and as
experience is gained, more tension can be employed to
maximize results.
Lidocaine with epinephrine is used to infiltrate the inci­
sion lines. A dilute tumescent infiltration can also be per­
formed in the loose areolar tissue above the muscle as well
as the incision lines. Full prepping and draping is per­
formed. Methylene blue skin tattooing is performed at both
ends of the proposed excision as well as at the realignment
marks. This is important because the realignment marks are
FIG. 16.5  A standard resection pattern for the transverse upper body lift
is noted. Because of the strong zone of adherence in the midline, the width
of resection in the midline is the least. The resection is tapered strongly
to a point at the inframammary fold in the anterior axillary line. This will
avoid a dog ear. Realignment marks (green) are placed across the entire
area of resection, which facilitate realignment and avoid tissue shifting.
This is extremely important because of the marked tissue laxity in this
patient population.
FIG. 16.6  (A) A penetrating towel clamp is used prior to infiltration to
reassess the width of the resection at multiple points across the entire
transverse upper body lift. This will ensure that there is proper healing and
reduce the possibility of wound dehiscence or scar widening. (B) In the
operating room, final markings are often made inside of the preoperative
marks if tension appears too great.
A
B

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PART | 4  Upper trunk contouring
revision is offered no sooner than 3 months after
healing to allow for full relaxation of tissues. Rarely,
patients will complain of undercorrection. In these
cases, additional resection can usually be performed under
local anesthesia. If tissue is not gathered from the lateral
aspect and moved centrally, a dog ear can be left later­
ally. This will normally settle out over several months,
but revision under local is sometimes required. Local
wound healing complications should be managed with
debridement and secondary intention healing or delayed
primary closure. Seroma, hematoma, and infection have
not been experienced in our series; however, they are
still discussed as part of the informed consent process,
and should they occur, standard surgical techniques
including drainage, debridement and wound care are
recommended.
isolated procedure, the Bra Line Back Lift can be done
entirely in the prone position.
The resection is completed and skin edges are temporar­
ily aligned with penetrating towel clamps using the realign­
ment marks as reference points. A three layer closure is then
performed starting laterally and progressing toward the
spine. Based on the tension, either 0 or number 1 polygla­
ctin (Vicryl) suture is used for space obliteration (Fig. 16.8).
Deep dermal sutures are then employed using 3-0 polydiox­
anone (PDS) suture in a buried fashion, and a final 4-0
poliglecaprone (Monocryl) suture is used for the intracu­
ticular closure. The incision line is subsequently treated
with either tissue adhesive or taping. When taping is
applied, it must be split periodically to allow for swelling
and avoid shearing forces that create blistering and subse­
quent hyperpigmentation.
POSTOPERATIVE CARE
Patients can shower on postoperative day one, but are
reminded to leave arms abducted when shampooing hair.
Range of motion and arm abduction are increased gradually
based on patient comfort. If abducting the arms is painful
or creates undue tension, patients are counselled to scale
back activity. Common sense is employed and we stress
this to patients and their families. We remove the skin tape
between the third and fifth postoperative days and begin
scar therapy, which entails applying a topical hydrocorti­
sone, vitamin E, and silicone cream three times daily.
COMPLICATIONS AND MANAGEMENT
The most common complication after transverse upper
body lifting is scar widening. Should this occur, a scar
FIG. 16.7  Electrocautery is used to separate the skin and subcutaneous
fat from the underlying chest wall. The muscular fascia and loose areolar
tissue is left intact and serves as an anchoring point at the base of the
wound for space-obliterating sutures.
FIG. 16.8  (A) The superficial fascia has been marked with methylene
blue for the purposes of demonstration. It is at this level that all tension
is placed. (B) Space-obliterating sutures are placed by approximating the
SFS at each side of the wound and anchoring to the muscle fascia
(grasped). This eliminates the need for a drain.
A
B

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Chapter | 16  Transverse upper body lift
FIG. 16.9  (A, C, E) 32-year-old, 100 kg (221 lb) female concerned with multiple skin folds of the upper back and flanks. (B, D, F) After Bra Line
Back Lift, a smooth contour is achieved with the final scar easily concealed beneath the bra line. A 22 cm resection was performed.
A
B
C
D
E
F

164
PART | 4  Upper trunk contouring
FIG. 16.10  (A) 47-year-old, 73 kg (160 lb) female after massive weight loss exhibiting lax, hanging skin and residual adiposity. (B) After transverse
body lift, a smooth upper back contour is achieved, completely eliminating the multiple zones of adherence and tissue folding. The patient underwent
simultaneous brachioplasty.
A
B
FIG. 16.11  (A, C, E) 30-year-old, 70 kg (155 lb) female after successful massive weight loss. She developed a dramatic excess of skin and subcutane­
ous tissue in the flank and back. (B, D, F) The transverse upper body lift achieved a complete correction of this deformity. The vertical resection width
measured 26 cm.
A
B
C
D

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Chapter | 16  Transverse upper body lift
E
F
FIG. 16.11  Continued
CONCLUSION
The transverse upper body lift that we refer to as the Bra
Line Back Lift is a powerful tool that delivers consistent
results. It has proven useful for both massive weight loss
patients and normal weight patients who have experienced
weight fluctuation and laxity. The procedure eliminates skin
excess and adiposity from the upper back. This anatomic
area has been somewhat underserved in the plastic surgery
literature, but with this rewarding procedure, the deformi­
ties of the upper back can be consistently and reliably
addressed. The final scar is concealed beneath the bra line
and tolerated well by patients (Figs. 16.9-16.11). Complica­
tions are rare and can normally be managed with wound
care and the occasional revision under local anesthesia. The
overall patient satisfaction with this operation in our prac­
tice has been universally high. Mastering the Bra Line Back
Lift has a gentle learning curve and serves as a useful tool
in the armamentarium of any plastic surgeon interested in
excisional body contouring.
REFERENCES
1. Huemer GM. Upper body reshaping for the woman with massive
weight loss: an algorithmic approach. Aesth Plast Surg 2010;34(5):
561–9.
2. Strauch B, Rohde C, Patel MK, et al. Back contouring in weight loss
patients. Plast Reconstr Surg 2007;120(6):1692–6.
3. Strauch B, Herman C, Rohde C, et al. Mid-body contouring in the
post-bariatric surgery patient. Plast Reconstr Surg 2006;117(7):
2200–11.
4. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current
concepts in massive weight loss surgery. Aesthc Surg J 2008;28(4):
452–5.
5. Aly AS. 2006. Upper body lift. In: Aly AS, editor. Body Contouring
after Massive Weight Loss. St Louis, MO: Quality Medical Publish­
ing Inc.; 2006.
6. Rubin JP, Aly AS, Eaves III FF. Approaches to upper body rolls. In:
Rubin JP, Matarasso A, editors. Aesthetic Surgery after Massive
Weight Loss. Philadelphia, PA: Elsevier; 2007.
7. Aly As, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: The University of Iowa experience. Plast Reconstr
Surg 2003;111:398.
8. Cannistra C, Rodrigo V, Marmuse JP. Torsoplasty after important
weight loss. Aesth Plast Surg 2006;30:667.
9. Gonzalez-Ulloa M. Belt lipectomy. Br J Plast Surg 1961;13:179.
10. Hamra ST. Circumferential body lift. Aesth Surg J 1999;19:244.
11. Hunstad JP. Addressing difficult areas in body contouring with
emphasis on combined tumescent and syringe techniques. Clin Plast
Surg 1996;23:57.
12. Hunstad JP. Body contouring in the obese patient. Clin Plast Surg
1996;23:647.
13. Baroudi R. Flankplasty: A specific treatment to improve body con­
touring. Ann Plast Surg 1991;27:404.
14. Carwell GR. Circumferential torsoplasty. Ann Plast Surg 1997;
38:213.
15. Hurwitz DJ. Single stage total body lift after massive weight loss.
Ann Plast Surg 2004;52:435.
16. Hunstad JP, Repta R. Bra-Line Back Lift. Plast Reconst Surg 2008;
122(4):1225–8.

166
© 2013 Elsevier Inc
Chapter 17 
Key Points
●
Upper body lift. This combination of single procedures
is described and compared to single stage techniques.
●
The main technical aspects are highlighted and
described in the clinical context.
●
Prevention, reduction and management of
complications are demonstrated for this specific
procedure.
●
Different intraoperative steps are explained to enable
procedure enhancement.
●
The combination of liposuction and upper body
contouring procedures has to be performed cautiously
and restricted. Therefore, limitations are emphasized.
Upper body lift with lateral excision
Dirk F. Richter and Alexander Stoff
INTRODUCTION
After massive weight loss patients often present varying
skin and tissue redundancy in the different body regions.
Besides the typical lower body deformities, tissue redun­
dancy is frequently present in the area of the upper arm, the
lateral and dorsal thorax, as well as characteristic deformi­
ties of the breast, including a significant volume loss in
combination with skin redundancy and extreme nipple–
areola complex ptosis and medialization.
In the past, reconstructive operations such as breast
reshaping, arm- and back-lifts were performed as single-
stage procedures, especially for patients after massive
weight loss. As part of a progression in this specific subfield
of plastic surgery, modern treatment concepts have been
established, such as the upper body lift, with or without a
circumferential upper thoracic lift.1–7 Besides the recon­
struction of the breast with implants or alternatively with
autologous tissues from the upper abdomen and/or lateral
thorax, these regions can be sufficiently tightened in a
single procedure, positioning the scar as a continuation of
the submammary fold, ascending to the axillary crease.
Patients with mild to moderate skin and tissue excess in the
dorsal thoracic region can benefit from a sufficient skin
tightening in this area by this approach. The upper arm
reconstruction can easily be continued, without any interac­
tion with the axillary reconstruction. In individual cases
with severe skin excess at the dorsal thorax, a direct
approach in terms of a bra-line lift can be performed4
(Fig. 17.1).
Due to the poor skin quality with its consequently
reduced retraction capabilities in this patient subgroup,
liposuction techniques have not been able to provide an
alternative treatment option. However, its indispensability
as an adjunct procedure has to be emphasized.
The upper body lift is a combined approach for the
breasts and arms and eliminating skin excess in the axillary
and back regions in a single-stage operation. It further
allows the autoaugmentation of volume deficient breasts in
female patients by tissue transfer from the lateral thoracic
and upper abdominal regions.
PREOPERATIVE PREPARATION
For general information please refer to Chapter 38.
The decision for an upper body lift is made on the extent
of skin and soft tissue excess at the lateral and dorsal tho­
racic wall. The classification of the lateral folds after
massive weight loss is designated by Strauch et al into an
upper breast roll, followed by a lower scapular roll or a
deeper lower chest/thoracic roll. An analogous classifica­
tion is made for the iliac area as hip rolls. The folds can be
seen individually, often with a fluent passage.8 The two
upper folds often can be treated by various surgical options
and are only peripherally influenced by the lower body lift
alone, whereas the two lower folds can only effectively be
treated by a lower body lift or a belt lipectomy (Fig. 17.2).
In case of an indication for a breast and arm lift the
lateral and dorsal thoracic wall has to be evaluated. The
ideal indication for an upper body lift is the presence of
lateral and dorsal thoracic skin folds, which can be elimi­
nated by a lateral thoracic approach. It has to be considered
that the lateral soft tissue excess can be used as an autolo­
gous tissue augmentation for breast reshaping procedures
in female patients. On the contrary, in male patients this
tissue excess has to be resected without exception.
Part 4  Upper trunk contouring

167
Chapter | 17  Upper body lift with lateral excision
A
B
C
D
FIG. 17.1  Markings of the bra-line backlift include the upper and lower incision line (red line), which should result in the estimated scar line
(dotted line) by means of a pinch test.
Continued

168
PART | 4  Upper trunk contouring
In females, the markings of the lateral thorax start with
an extension of the upper horizontal breast incision of the
lateral pillar that sweeps towards the axillary crease. In
male patients, the upper breast incision line runs from
slightly lateral of the chest meridian laterally and continues
to the axillary crease. The lower line is assessed by careful
pinching of the lateral and dorsal thoracic tissue.
This maneuver allows a transposition and rotation of the
lateral and dorsal soft-tissue cranial and anterior, with a
resulting scar that is located at the medial or posterior axil­
lary line. The lateral tension from the back may cause a
lateralization of the breast which must be considered during
the markings for the breast. The position of the nipple–
areola complex should always be double-checked after fin­
ishing the upper lateral-thoracic-lift.4–6
SURGICAL TECHNIQUE
Brachioplasty/Mammaplasty/Bra-line Backlift
For a detailed description of the single techniques please
refer to the corresponding chapters in Parts 2 and 3.
Markings
Marking of the breast procedure is performed so that it is
personalized to the patient. Regarding the new nipple–
areola complex position, we emphasize the measurement
of it proportional to the submammary fold and the
upper breast border. Since women with low submammary
folds have an appropriately low upper breast border, a
high nipple–areola complex may lead to an early postopera­
tive bottoming out. We prefer the central pedicle with
dermal suspension as presented by Rubin and the double-
ellipse technique for the arm reconstruction as published
by Aly.2,9
The back rolls should be carefully marked prior to the
operation with the patient both lying and standing. Once
the patient lies on the operation table the folds disappear
and a proper treatment of the soft-tissue excess is nearly
impossible. Because of the poor shrinkage capability of the
thick skin of the back and the subjacent fibrous tissue,
markings for extensive superficial liposuction of the entire
back should be made.
E
F
FIG. 17.1  Continued

169
Chapter | 17  Upper body lift with lateral excision
FIG. 17.2  Schematic demonstration of abdominal, lateral and back rolls. Operative planning in patients with multiple trunk rolls has to include
additional approaches, such as fleur-de-lis, upper lateral thoracic lift or bra-line backlift.
A
B
C
D

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PART | 4  Upper trunk contouring
Upper Lateral Thoracic Lift
The conventional surgical treatment of the upper two back
and lateral rolls by direct excision at the aspect of the dorsal
thorax often leads to wide, unsightly and permanent visible
scars. Respecting the different interfering units of the upper
body, and in terms of reduction of operating and recovery
time and improving patient outcome, we combine the upper
arm lift with breast reshaping and the upper-lateral thoracic
lift as an integrated treatment in appropriate cases. Using
the combination technique, a continuous approach is per­
formed from the medial submammary fold via an anterior
and posterior axillary incision line distally to the elbow. In
this regard, the circumferential vectors eliminate the upper
breast and lower scapular rolls and a horizontal tension to
the central zone over the vertebral column is ensured
(Fig. 17.3).
Starting with the upper arm lift, which is mostly
performed in terms of the double-ellipse technique as
described by Aly,2 we continue passing the axillary crease.
The upper-lateral thoracic lift is followed in terms of a
direct and indirect excisional procedure, mobilizing the
dorsal and lateral thorax region. In female patients, we
preferably address the breast deformities in a 45–60°
upright patient positioning, performing the Rubin tech­
nique with a central pedicle and cranial fixation to
preserve volume and prevent bottoming out, which is a
common complication in this patient group due to the
extremely thin atonic skin quality. In male patients, we
generally perform the excisional technique with a pedicled
breast reduction with simultaneous liposuction, resulting
in best achievable results in this patient group. This intra­
operative sequence ensures that the nipple–areola complex
is not set too laterally and that you are able to compensate
for the lateral pull being created with the upper-lateral
thoracic lift. In the axillary crease the running scar may
be disrupted with a Z plasty to prevent postoperative scar
contraction.
In summary, it can be emphasized that the upper lateral
thoracic lift is a safe and effective procedure to simultane­
ously reduce upper lateral thoracic and upper back rolls
without placing a single scar to the back region. It can be
performed as a single procedure or an integrated part of a
combined technique for restoration of the upper arm, lateral
as well as dorsal thorax, and the breast.
After carefully pinching and setting clamps and staplers
for tailor tacking we can control the lateralization of the
breast and may adjust the position of the nipple–areola
complex. Usually we leave the staplers in place and start
with the arm first. We stop our incision at the level of the
axilla. We continue with the mastopexy procedure and stop
our incision at the anterior axillary line.
A
B
FIG. 17.3  Preoperative posterior, lateral and anterior view of a 39-year-old woman after 100 kg weight loss due to gastric bypass.
C

171
Chapter | 17  Upper body lift with lateral excision
Then we start incising at the curved ventral line of the
lateral thoracic region. As there is no clear definition of the
superficial fascia at this level we do not perform preparation
too deep and we preserve a thin layer of fat epifascial to
the deep fascia. This reduces the risk of injuring underlying
nerves such as the lateral-thoracic nerve and lower inter­
costobrachial branches.
Once the incision has been made and the preparation has
been completed up to the dorsal resection line we carefully
pull the ventral wound edges dorsally, estimating if the
breast shows a tendency to move laterally. In cases of
extended lateralization we suture the deep layer of the ventral
wound edges down to the deep muscle fascia, using PDS 2-0
sutures (Ethicon, USA). Then we pull the dorsal flap over the
ventral wound edge and complete the resection. Before tem­
porary closure with staples and suturing of the wound, we
fixate the dorsal wound edge to the deep fascia for definition
of the submammary fold, using PDS 2-0 sutures.
We do not primarily apply a Z plasty at the axillary crease
in every case. However, if contraction at this level becomes
evident during the postoperative period, this procedure can
be considered in cases of conservative treatment failure.
OPTIMIZING OUTCOMES
Since patients after massive weight loss often present with
skin and soft-tissue redundancy in the upper arm, lateral
thorax, and the breast regions, most of these patients
desire corrections in these adjoining parts of the upper
body. In Germany, body contouring cases after massive
weight loss may be reimbursed by general or private
insurance based on the DRG-system. Since the breast and
lateral chest regions are interacting regions that, for
example, may provide soft tissue for autoaugmentation of
the breast, a combined reconstruction of these regions is
unavoidable. Hence, a staged reconstructive procedure of
the upper arm may be performed without affecting the
upper trunk region.
Due to steady technical improvements, upper body lift
procedures enable plastic surgeons to treat the upper truncal
contour sufficiently to rapidly reach patients' goals and
expectations, with a reduced total recovery time. The upper
body lift has gained wide popularity in the group of massive
weight loss patients, nowadays performed as a routine part
of a body reconstruction concept after weight loss.
In general, dependent on the preoperative BMI and
existing folds, indications for direct excisional procedures
of the back are rarely seen in patients with mild to moderate
weight loss, but occasionally in patients after massive
weight loss. Although satisfactory results can be achieved
with this approach, unfavourably located scar placement
and scar quality restrict the implementation of this proce­
dure, especially in male patients.
A more common and favorable procedure for contour
improvement of the dorsal thoracic region is the upper-
lateral thoracic lift, intended for patients after massive
weight loss with consequent skin and soft-tissue redun­
dancy in the lateral and dorsal thoracic region with or
without lateral and back folds. It enables sufficient tissue
elimination in different neighboring regions, convention­
ally seen as different anatomical units, by optimal scar
placement. Optionally, this can be performed alone or as an
integral part of a combined contouring procedure of the
upper arm, the lateral and dorsal thoracic wall, as well as
the female or male breast. In female patients it is usually
combined with an inverted-T pattern breast reshaping, elon­
gating the submammary incision to the axillary crease. In
male patients we perform the direct excisional procedure
for breast reshaping after massive weight loss, optionally
with a free nipple graft, as popularized by Aly or as a
pedicled transfer as recently described by Gusenoff or
Stoff.2,10,11 The submammary scar is ideally placed at the
inferior boundary of the pectoralis major muscle, continu­
ing well hidden at the lateral thoracic wall to the axillary
crease.
Scar formation in upper body contouring is well accepted
by patients, though results differ widely in quality and
appearance due to atonic skin quality with poor elasticity
after significant damage to extracellular matrix components
during obesity and bariatric surgery.12 In this regard, patients
should be told clearly about revisional surgery, since the
rate for secondary corrections in this patient group is rela­
tively high due to secondary skin and tissue relaxation.
Some representative case studies are shown in Figs
17.4–17.8.
POSTOPERATIVE CARE
The postoperative management after upper body lift
procedures is similar to lower body lift procedures (see
Chapter 38). However, patients are not monitored on the
intensive care unit. Early patient mobilization from day 1
with adequate thrombosis prophylaxis from low molecular
weight heparin and a specially adjusted compression
garment for 8 weeks postoperatively are mandatory.
In all cases we support postoperative wound healing and
reduction of lymphatic swelling, particularly in the area of
the lower arms, through early lymphatic drainage.
For further details please refer to Chapter 38.
COMPLICATIONS AND THEIR
MANAGEMENT
Complications can be differentiated into minor and major
as well as early and long-term complications. Compared to
body contouring procedures of the lower body regions,

172
PART | 4  Upper trunk contouring
A
B
FIG. 17.4  12-months postoperative posterior, lateral and anterior view after circumferential lower truncal dermatolipectomy, breast and
bra-line lift.
C
FIG. 17.5  Marking of the lateral thoracic lift incision lines by lateral pinching. The lower incision line should extend to the back region to
allow maximal tightening of the back and lateral rolls. The dotted line presents the estimated scar course.
A
B

173
Chapter | 17  Upper body lift with lateral excision
FIG. 17.6  Preoperative posterior, lateral and front view of a 42-year-old patient after 70 kg weight loss.
A
B
C
D

174
PART | 4  Upper trunk contouring
A
B
FIG. 17.7  3-months Postoperative posterior, lateral and anterior view after circumferential lower truncal dermatolipectomy with skin folds
remaining in the upper lateral and dorsal trunk.
seroma formation is observed less frequently in the area of
the breast and arms. In the lateral chest and axillary region
seroma formation may occur more often in cases of radical
fat tissue resection, especially the deeper fatty layer overly­
ing the latissimus dorsi muscle. We emphasize the preserva­
tion of the deep layer of fat in the area of the lateral chest
and perform resection superficially in the axillary region.
Further, we recommend applying wound drains in the
breast and lateral chest area. We refrain from drains in the
arm regions due to the minimal dead space and low risk of
seroma formation.
Minor wound dehiscences and wound healing disorders
are frequently observed after major surgical procedures
such as the upper body lift. This can occur in the early
postoperative phase as well as during the later phase. The
causes of wound dehiscence can be assumed to be impaired
wound healing, such as in smokers or, in cases of local
wound infections, nutritional deficiency or incompatibility
with suture material. Further, an undetected seroma can
gain a size that leads to wound separation and spontaneous
evacuation. Another important aspect for prevention of
wound healing disturbances is the placement of subcutane­
ous suture knots at an adequately deep level. Alternatively,
the use of subcutaneous barbed sutures in a running manner
may be recommended. One has to be aware that this closure
technique requires a learning curve in terms of stability and
suturing time.
The key to good scar formation is well-defined skin
preparation and the careful tissue handling, an optimized
suturing technique and the patient’s compatibility with the
suture material. We recommend performing skin closure
to a maximal degree of everted wound edges, which will
result in reduced tension during the epidermal skin
regeneration.
The axillary region presents a slightly higher risk of
complications such as wound healing disorders, since

175
Chapter | 17  Upper body lift with lateral excision
FIG. 17.8  12-months postoperative posterior, lateral and anterior view after circumferential lower truncal dermatolipectomy, breast reshaping
and upper lateral thoracic lift.
A
B
C
D

176
PART | 4  Upper trunk contouring
mobility and consequent shearing forces in this particular
region are higher and hygiene is poorer due to the larger
number of sweat glands. Seroma formation can occur par­
ticularly in this region due to the risk of damage to the
lymphatic system. Again, we therefore emphasize avoiding
total resection of the fatty tissue overlying the lateral border
of the pectoralis major muscle and anterior border of the
latissimus dorsi muscle.
Secondary relaxation, especially in the breast region,
is very commonly seen and has to be clarified on the
patient’s part. Understanding this postoperative charac­
teristic is essential to achieve adequate patient satisfaction.
To avoid the appearance of a postoperative bottoming
out we emphasize the positioning of the new nipple–
areola complex in relation to the submammary breast fold.
In this context, the new sternal–areolar distance may
range from 21 and higher, defined in relation to the
sternal–submammary distance. Postoperative bottoming
out therefore derives from an inadequate sternal–areolar
distance.
For further information please refer to Chapter 39.
CONCLUSION
The upper body lift procedure allows a simultaneous
reshaping of the upper arms, axillary region, lateral chest,
lateral back, breast and upper abdomen in selected cases.
The combination of these procedures enables a significant
reduction of patients' total recovery and down time, with a
consequently reduced financial burden to the health and
welfare system.
Operation time can be significantly reduced through
precise preoperative marking and a standardized peri- and
intraoperative setting. Ideally, the operative implementation
should be managed by two surgical teams, reducing prepa­
ration and wound closure time. Postoperative standards in
patient care should guarantee optimal progress and patient
safety.
In cases of breast hypoplasia after massive weight loss
it is mandatory for the plastic surgeon to inform patients
about the increased risks of complications caused by sili­
cone implants. In a high number of patients after massive
weight loss the recruitment of excess tissue from the
lateral chest and upper abdomen allows a significant volume
augmentation without the side effects of silicone implants.
The combination of tissue tightening in the adjoining
regions of the breast, upper abdomen and lateral chest
with simultaneous autoaugmentation of the breasts is best
accomplished during the upper body lift procedure.
REFERENCES
1. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: The University of Iowa experience. Plast Reconstr
Surg 2003;111:398.
2. Aly AS. Body Contouring after Massive Weight Loss. St. Louis:
Quality Medical Publishing; 2006.
3. Hurwitz DJ. Single-staged total body lift after massive weight loss.
Ann Plast Surg 2004;52(5):435–41; discussion 441.
4. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative
approach to correct excess tissue of the upper arm, axilla, and lateral
chest. Plast Reconstr Surg 2006;117(2):403–11; discussion 412–3.
5. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast
reshaping: the spiral flap. Ann Plast Surg 2006;56(5):481–6; discus­
sion 486.
6. Richter DF, Stoff A. The upper lateral thoracic lift. Plastic Surgery
Pulse News. Volume 2, No 2. St. Louis: Quality Medical Publishing;
2010.
7. Richter DF, Stoff A. Back and lateral fold contouring. In: Nahai F,
editor. The Art of Aesthetic Plastic Surgery. St. Louis: Quality
Medical Publishing; 2010.
8. Strauch B, Herman C, Rohde C, et al. Mid-body contouring in the
post-bariatric surgery patient. Plast Reconstr Surg 2006;117(7):
2200–11.
9. Rubin JP. Mastopexy after massive weight loss: dermal suspension
and total parenchymal reshaping. Aesthet Surg J 2006;26(2):
214–22.
10. Stoff A, Velasco-Laguardia FJ, Richter DF. Central pedicled breast
reduction technique in male patients after massive weight loss. Obes
Surg 2012;22(3):445–51.
11. Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after massive
weight loss: detectability of technique, patient satisfaction, and clas­
sification. Plast Reconstr Surg 2008;122(5):1301–11.
12. Rohrich RJ, Gosman AA, Conrad MH, et al. Simplifying circumfer­
ential body contouring: the central body lift evolution. Plast Reconstr
Surg 2006;118(2):525–35; discussion 536–538.
FURTHER READING
Hunstad JP, Repta R. Bra-line back lift. Plast Reconstr Surg 2008;
122(4):1225–8.
Orpheu SC, Coltro PS, Scopel GP, et al. Collagen and elastic content of
abdominal skin after surgical weight loss. Obes Surg 2010;20(4):
480–6.
Rubin JP, Nguyen V, Schwentker A. Perioperative management of the
post-gastric-bypass patient presenting for body contour surgery. Clin
Plast Surg 2004;31(4):601–10, vi. Review.

177
© 2013 Elsevier Inc
Part 5  Abdominal contouring procedures
Key Points
●
Abdominal contour surgery represents a group of
procedure options available for esthetic improvement
of the abdomen.
●
The abdominolipoplasty system of classification and
treatment (type I-suction-assisted lipectomy (SAL); Type
II & III – limited abdominoplasties; Type IV
abdominoplasty with or without liposuction) provides
the framework on which procedure selection is based
(Fig. 18.1 and Table 18.1).
●
The appropriate procedure is based on reconciling the
patient’s anatomic findings with their goals; and taking
into considering such factors as their tolerance for the
length of the lower abdominal scar and an umbilical
scar.
●
Overall, liposuction of the abdomen is the most
frequent abdominal contour procedure. As surgeons
have become familiar with incorporating liposuction
with a full abdominoplasty, abdominoplasty with
liposuction referred to as Lipoabdominoplasty has
become more mainstream. This and abdominoplasty
alone without liposuction (conventional
abdominoplasty) represent the most common types of
“open” options for the abdomen.
●
Lipoabdominoplasty is an operation based on the
principles of preserving the maximum blood supply to
the anterior abdominal wall (Fig. 18.2) and of creating
a narrow tunnel of undermining (zone of complete
undermining) to the xiphoid in order to access the
rectus diastasis with a surrounding zone of selective
undermining and a zone of discontinuous undermining
(Fig. 18.3).
Aesthetic classification of the abdomen
Alan Matarasso
Within the full abdominoplasty category (Type IV) group
there are 11“special” circumstances, that merit attention
in traditional planning.
1. Abdominoplasty in the presence of nonmidline pre-
existing upper abdominal scars or flank scars.
2. When the goal is also to achieve a narrower
waistline.
3. Downstaging to a less invasive alternative in patients
not willing or able to have a more invasive
operation.
4. Obese patients who require a panniculectomy with
extensive SAL (also known as liposuction with lower
skin resection or lower abdominoplasty or modified
abdominoplasty).
5. Abdominoplasty in a patient who previously had
liposuction.
6. Secondary full abdominoplasty.
7. Removing the old umbilical site in long-waisted
individuals.
8. Converting a prior limited (possibly that had an umbil­
ical float) abdominoplasty to a full abdominoplasty.
9. Bariatric plastic surgery (massive weight loss patients).
10. Reverse abdominoplasty.
11. Abdominoplasty in males.
INTRODUCTION
The goal of abdominal contour surgery is the esthetic
improvement of the abdomen with the least conspicuous
scar feasible. Depending on the procedure performed,
improvement can be achieved in varying degrees to the
appearance of loose, damaged skin, rectus muscle diastasis,
and excess fatty deposits, in order to create a firmer, flatter
abdomen.
More than ever, today’s society emphasizes youth­
fulness and vitality, particularly as the first wave of the
populous “Baby Boomer” generation passes 65. They are
a population that has attempted to defy aging by being
more health-conscious than any preceding demographic.
However, from the age of the mid 30s onward in males
and beginning in the premenopausal years in females the
abdomen begins to change with the accumulation of
intra-abdominal fat (apple), loosening skin, and widening
of the rectus muscle diastasis. These problems are magni­
fied following pregnancy in women, or in both genders
with massive weight loss or fluctuations and are only
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Chapter 18

178
PART | 5  Abdominal contouring procedures
TABLE 18.1  Abdominolipoplasty system of classification and treatment2
Category
Skin
Fat
Musculofacial System
Treatment
Type I
Minimal laxity
Variable
Minimal diastasis
Suction-assisted lipectomy
Type II
Mild laxity
Variable
Lower diastasis
Mini-abdominoplasty
Type III
Moderate laxity
Variable
Lower ± upper diastasis
Modified abdominoplasty
Type IV
Severe laxity
Variable
Complete diastasis
Standard abdominoplasty with suction lipectomy
FIG. 18.1  The abdominoplasty system of treatment and classifica­
tion is based on evaluating the treatable soft tissue layers of the
abdomen. Type I (upper lift) is liposuction alone; Type II (upper right)
is mini-abdominoplasty; Type III (lower left) modified abdomino­
plasty (or lower abdominoplasty or marriage abdominoplasty); Type
IV (lower right) a full abdominoplasty without or with (lipoabdomi­
noplasty) liposuction. (Pink = liposuction, yellow = undermining,
green = excision).1
Type I
SAL
SAL
SAL
U
E
U
E
U
E
Type II
Type III
Type IV
self-controlled or rectified by the patient to a limited degree.
For example, a fit male runner running 20 miles per week
in his 20s would need to run over 50 miles a week in his
50s just to maintain his prior weight and appearance (even
with maintenance most people report that their abdomen
never looks the same as in earlier years). Otherwise, they
might expect to gain approximately 1.5 kg (3.3 pounds) per
decade and 1.5 cm (3 4 of an inch) on their waistlines.
Women over 40 years old would need to exercise over 1
hour a day to just retain the appearance of their earlier
figure.
Females, in addition to the inevitable consequences of
aging, are plagued by the changes that occur from preg­
nancy, which invariably and almost universally ravage the
abdomen and breasts. (Hence the idea of breast and abdom­
inal surgery being referred to as the “mommy makeover”.
The male equivalent for improving the abdominal and chest
area has been dubbed the “daddy do over”.)
In males and females the abdomen represents the region
with the largest surface area of the body and a patient’s
perception of its appearance often acts as a surrogate
barometer for how an individual perceives their ideal
weight, their level of fitness, their overall health and their
physical appearance or attractiveness.
PREOPERATIVE PREPARATION
Suitable candidates for abdominal contour surgery have had
an in-depth discussion with their surgeon regarding their
concerns and the appropriate procedures available to them
based on those anatomic characteristics that can be improved
(skin, subcutaneous fat, and rectus muscle diastasis) and
those factors that cannot be (quality of the remaining
skin, visceral fat, scars, spinal or uterine issues that affect
the appearance of the abdomen). Factored into this dis­
cussion is their tolerance for risk and recovery, their
expected goals and outcome, and their willingness to accept
lower abdominal or periumbilical scars. Based on this
information an appropriate procedure is selected, with a
firm understanding that different techniques will yield dif­
ferent outcomes.
For example, liposuction is often the first choice of
patients, though liposuction does not tighten skin, but rather
skin can be expected to contract, albeit to an unpredictable
degree, after fat removal, in contrast to the excisional pro­
cedures that actually remove loose skin. Moreover, it should
be recognized that the more skin that is removed the larger
the incision that is required and that the remaining skin is

179
Chapter | 18  Aesthetic classification of the abdomen
Segmental perforators
Segmental perforators
Musculophrenic artery
Ascending branch of deep
circumflex iliac artery
Deep circumflex iliac artery
Superficial circumflex iliac artery
Deep circumflex iliac artery
Superficial circumflex iliac artery
Deep superior epigastric artery
Deep inferior epigastric artery
Superficial superior epigastric artery
Superficial inferior epigastric artery
Superficial external pudendal artery
I
II
III
FIG. 18.2  Left side. The blood supply of the unoperated abdomen. Right side. The blood supply to the operated abdominoplasty. Note Huger
zones I–III.
not improved but just pulled tighter. Preoperative prepara­
tion begins from the time of the initial consultation and is
an evolving process that is based on a series of conversa­
tions with the physician, their staff, the anesthesiologist and
any ancillary personnel and the patient.
Patients receive an extensive informational package
at the time of the consultation and are mailed a detailed
perioperative package that includes a copious list of prod­
ucts that affect coagulation. For all abdominal contour
surgery procedures patients are instructed to cease nicotine-
containing products and compounds that affect clotting
prior to the procedure. All patients are evaluated by an inter­
nist, and have appropriate blood or diagnostic testing. Con­
sideration is given to “special” hematology testing for
prothrombogenic factors because patients that are geneti­
cally susceptible dramatically increase their potential for
blood clots. Abdominoplasty, in general, has the highest
incidence of thromboembolism of all esthetic procedures.
Half or more of deep vein thromboses (DVT) result in
pulmonary embolism fatalities frequently. Patients begin
antimicrobial skin washes, including the area above and
beyond the surgical site, 3 days preoperatively. No shaving
of body hair is done. Broad-spectrum perioperative antibiot­
ics are employed and often continued until any drains that
are used are removed. However, evidence-based informa­
tion, which confirms that antibiotics may reduce surgical
site infections in abdominoplasty, suggests that a single
preoperative antibiotic is as effective as pre- and postopera­
tive doses.
Surgical markings are made in conjunction with the
patient so that stab wound incisions for liposuction are well
hidden and abdominoplasty incisions are confined to the
limits of their undergarments. The abdominal excision is
essentially an ellipse of tissue removal between the umbi­
licus and the mons pubis (Fig. 18.4). The length of the
abdominoplasty incision is determined by locating the ends
of the pannus’ skin creases, which are determined in a
sitting position and noting the ends of the skin folds.

180
PART | 5  Abdominal contouring procedures
FIG. 18.4  Preoperatively grasping excess lower tissue and joining
the examiner’s finger tips (Matarasso Miami beach chair
manoeuvre).
FIG. 18.5  Surgical markings are made confining the incision to
reasonable undergarments. This is verified intraoperatively with
underlying criss-crossed silk sutures. Marking for excision. The upper
markings demonstrate the suction areas (red = terrible triangle – the
area most in danger of devascularization; yellow, safer; green, safest.
Endpoint of natural
skin crease when
sitting
5–6 cm
(Excise old scars?)
Long silk suture (black line)
Undergarment
lines
Long silk suture (black line)
Zone of complete
undermining
Zone of selective
undermining
Zone of discontinuous
undermining
Area of excision
Zones of
liposuction
FIG. 18.3  Lipoabdominoplasty is based on the principle of undermin­
ing to the xiphoid in a narrowed tunnel leaving intact intercostal (Huger
zone III) blood supply. Surrounding this is a zone of selective undermin­
ing that is done sharply to free any excessive skin bunching that occurs
after rectus fascia plication. The zone of discontinuous undermining
results from the blunt dissection of the liposuction cannula.3
joining the lower incision and completing the ellipse. The
ability to remove the lower abdominal skin pannus from
umbilicus to pubis is verified by the surgeon grasping the
skin and their fingers meeting. In an abdominoplasty it is
preferable to remove enough tissue so that the old umbili­
cus site is removed with it. In the operating room the mark­
ings are verified by placing long silk sutures (after any
liposuction is performed) in the midline at the xiphoid and
pubis and overlapping them at multiple points on the upper
and lower incision in order to ascertain symmetry between
sides of the incision (Fig. 18.5).
All procedures are undertaken with systemic anesthesia
(spontaneous ventilation GA, or spinal/epidural) adminis­
tered by an anesthesiologist. The operative field is injected
with approximately 1 liter of super-wet anesthesia (1 liter
of Ringer’s lactate, 20 ml of 1% lidocaine, 1 ml of 1 : 1000
epinephrine). Limiting the wetting solution allows safe
injections to any additional operative sites, by avoiding
potentially toxic doses of lidocaine or epinephrine (0.07 mg/
kg of 1 : 1000 epinephrine) and excess fluid would ulti­
mately encumber electrocautery use during surgery. In
“open” procedures 20 ml of 1% Marcaine is injected at
various points in the muscle layer. A Foley catheter is
inserted for open (non-SAL only) procedures. The arms are
symmetrically placed on arm boards while avoiding pres­
sure points and secured with curlex wraps. Preoperatively
the bed is checked to verify that it can reach a maximum
beach chair position, which is necessary for wound closure
and removing the old umbilical site (Fig. 18.6).
The lower incision is then marked between those two
points, approximately 6 to 7 cm superior to the vulva cleft
and incorporating removal of any lower (Pfannenstiel,
cesarean, etc.) scars. The upper incision is then drawn
across the top of the umbilicus from hip-point to hip-point,

181
Chapter | 18  Aesthetic classification of the abdomen
Abdominal contour surgery procedures are generally
performed as an outpatient and usually they are the last part
if a multisurgical operation (e.g., breast surgery, liposuc­
tion, facialplasty, etc.) operation is performed.
All patients receive TED stockings and sequential pneu­
matic compression devices (SCD). Pharmacologic inter­
vention is considered on a case-by-case basis and is
determined with the assistance of the Davidson–Caprini
model or Venturi modification and considering the unique
circumstances of each patient and procedure.
SURGICAL TECHNIQUE
This description focuses on the most commonly encoun­
tered abdominoplasty candidate, which is a healthy ASA I,
multiparous, pre- or postmenopausal female. The abdomen
manifests itself with the “typical” postpartum changes:
loose, damaged and excess skin of the abdomen and flank
(“muffin top”); widening in the bony pelvic girth; rectus
muscle stretching, attenuation, and diastasis; fatty deposits
in all or some of the seven esthetic units of the female
abdomen; and mons pubis distortion, widening, and ptosis.
The patient is prepared and marked for surgery as
described. Systemic anesthesia is administered, and super­
wet anesthesia infused. Liposuction is performed as indi­
cated on the esthetic units of the abdomen. The surgeon
then verifies the abdominal markings with the overlapping
silk sutures (see Fig. 18.5) and changes to fresh surgical
gloves to begin the open portion of the abdominoplasty.
The abdominoplasty proceeds by incising and freeing
the umbilicus. The pannus is then prepared for pre-excision
in a vest-over-pants fashion (after J. Planas). Surgery then
proceeds as previously described (Fig. 18.8A,B,C).
Box 18.2 lists different scenarios in which the technique
of a full abdominoplasty or lipoabdominoplasty might be
“adjusted”.
FIG. 18.6  The final Miami Beach Chair position at the completion
of the case. The position allows for wound closure.
1. The presence of nonmidline pre-existing upper abdom­
inal scar or flank scars.
2. When the goal is also to achieve a narrower
waistline.
3. Downstaging to a less invasive alternative in patients
not willing or able to have a more invasive
operation.
4. Obese patients who require a panniculectomy with
extensive SAL (also known as liposuction with lower
skin resection or lower abdominoplasty or modified
abdominoplasty).
5. Abdominoplasty in a patient who previously had
liposuction.
6. Secondary full abdominoplasty.
7. Removing the old umbilical site in long-waisted
individuals.
8. Converting a prior limited (possibly that had an umbili­
cal float) abdominoplasty to a full abdominoplasty.
9. Bariatric plastic surgery (massive weight loss patients).
10. Reverse abdominoplasty.
11. Abdominoplasty in males.
BOX 18.2  Special Situations Encountered
in Abdominoplasty
BOX 18.3  Optimizing Outcomes
1. Choosing the appropriate technique (Table 18.3) which
is based on:
a. Anatomy (Table 18.2)
b. Extraneous factors that influence patients’ decisions
(Table 18.2).
2. The principles of lipoabdominoplasty are based on
maximal preservation of the vascular anatomy of the
abdominal wall and the narrow undermining of the flap
above the umbilicus with zones of complete, selective,
and discontinuous undermining.
3. Awareness and avoidance of complications associated
with abdominoplasty and instituting measures to dimin­
ish their occurrence is desirable. Complications can be
described as local or systemic; or early versus late; or
type of surgery they had (e.g., type I–IV).
4. Complications can now be reported by various methods
including: an individual surgeon’s case series (Table
18.4), surveys of an organization’s membership, TOPS®,
Cosmet Assure, the Doctors Insurance Company, MOC,
and AAAASF. (Box 18.4, Table 18.5).
TABLE 18.4, 18.5 APPEARS ONLINE ONLY
OPTIMIZING OUTCOMES
See Box 18.3. Traditionally, pulmonary issues (e.g., atelec­
tasis) were considered the most common complications of
abdominoplasty. However, data on complications is now
available from many different reporting agencies (Box 18.4)

181.e1
Chapter | 18  Aesthetic classification of the abdomen
OPTIONS
Table 18.2 illustrates the patient’s potential anatomic issues
that can affect procedure selection.
Box 18.1 illustrates some of the issues that influence
patient decisions about which abdominal contour procedure
they are interested in undertaking.
Table 18.3 lists the procedures that are available to the
abdominal contour patient. The * procedures do not require
an umbilical scar. The ** procedures have a shorter lower
tranverse scar (Fig. 18.7).
TABLE 18.2  Anatomic Characteristics
Skin
Laxity, striae gravidum, tone, thickness
Fat
Subcutaneous, visceral
Muscle
Extent of rectus muscle diastasis and the
quality of the muscle
Hernia (peri/umbilical or hernias elsewhere)
Prior surgery
Circumscribed umbilicus, limited
abdominoplasty with a floated umbilicus,
liposuction, presence of nonmidline
upper abdominal scars, flank scars or
inframammary scars
Length of recovery
Risk of procedure
Type of anesthesia required
Type of operating room facility required
How future pregnancy will affect the outcome
Amount of discomfort
Length of lower scar
Need for periumbilical scar
What type of clothing they can wear postoperatively.
BOX 18.1  Sample of Factors that Commonly
Influence the Procedure that Patients Select

181.e2
PART | 5  Abdominal Contouring Procedures
TABLE 18.4  A Comparison of Complications in Abdominoplasty of Major Case Series4–8
Matarasso et al4
Hester et al5
Grazer and
Goldwyn6
Pitanguy7
Teimourian
and Rogers8
No. of procedures
11016
563
10490
539
25562
Local, %
Necrosis Minor
4.4
0.9% (minimal
slough)
5.4 (wound
dehiscence)
1.4
Necrosis major
1.0
0.3
Seroma
2.5%
5.8
8.58
Infection
1.1
1.1
7.3
Blood loss
<1.0
14.2
Hypertrophic scars
<1.0
3.7
Hematoma
1.4
6
Wound infection
1%
Dehiscence
1%
0.3
Umbilical abnormality
1.2
0.3
Dissatisfied patient
2.2
Need for second
operation
3.4
Scar revision
4.9
Contour irregularity
5.0
Systemic, %
Deep vein thrombosis
0.04
1.1
0.29
Pulmonary embolism
0.02
1.1
0.8
0.25
Pulmonary fat embolism
0
0.02
Blood transfusion
0.04
0.04
Death
0
0.16
0.04
Anesthesia complications
0
0.01
Readmission to hospital
0.05
Malpractice action
0.01
0.18

181.e3
Chapter | 18  Aesthetic classification of the abdomen
TABLE 18.5  Data on Complications for
Cosmet Assure
Infection
1.63%
Hemorrhage
1.17%
Fluid overload
0.33%
Rule Out (R/O) DVT
0.30%
Hypoxia
0.24%
Pulmonary dysfunction
0.22%
R/O PE
0.22%
PE
0.19%
Severe hypertension
0.16%
DVT
0.16%
Overall c/o rate of abdominoplasties
4.7% v 1.37%
Versus other cosmetic procedures
1.37%
Abdominoplasty alone
37%
Abdominoplasty with multiple
procedures
63%
*About half of suspected (R/O) DVTs confirmed & almost all suspected
(R/O) PEs were positive.

182
PART | 5  Abdominal contouring procedures
lawsuits. Cosmet Assure’s most recent data on abdomino­
plasty reveal that, based on those surgeons that use Cosmet
Assure, (1) age over 40; (2) female gender; and (3) BMI
over 25 kg/m2 were risk factors. Interestingly, in their cohort
seromas are not captured, and smoking does not represent a
risk (probably because ischemia/limited wound healing
problems may be managed in an office and Cosmet Assure
does not look at complications treated in an office). Finally,
abdominoplasty with another cosmetic procedure performed
concurrently, in contrast to other reporting agencies (e.g.,
American Association for the Accreditation of Ambulatory
Surgical Facilities (AAAASF)) in Cosmet Assure’s data did
not result in more complications. They speculate that this
may be due to surgeons’ improved ability to select appropri­
ate patients for combined surgery.
BOX 18.4 APPEARS ONLINE ONLY
Maintenance of Certification (MOC) data report the
most common complications to be infection, seromas, and
DVT/pulmonary embolism (PE). Tracking Operations and
Outcomes for Plastic Surgery (TOPS™) data report the
most common adverse event recorded by ASPS members
as: infection (3.5%). And finally, Comet Assure’s database
is listed in Table 18.5. In their data about half of the sus­
pected DVTs turned out to be DVTs and almost all of the
suspected PEs were in fact PEs. They also state an overall
FIG. 18.8  A 39-year-old gravida 3 para 3. (A) preoperative. (B) after an abdominoplasty and breast reduction (left 370 g/right 375 g).
(C) following a second stage of 9600 cm3 of liposuction of the buttocks, legs, thighs, arms, anterior and posterior axillary folds, back rolls,
anterior thighs and knees.
A
B
C
FIG. 18.7  Different incision alternatives for abdominal contour pro­
cedures. Based on preference for length of incisions and umbilical
scarring.
Standard
abdominoplasty
or
Panniculectomy
w/ umbilical
circumscription
(green)
Panniculectomy
without umbilical
circumscription
(yellow)
Lower
abdominoplasty
(purple)
Mini-
abdominoplasty
(red)
although some of the data may overlap or conflict based on
their source. In the final analysis it is absolutely essential to
bear in mind that because of the way data are captured the
complications and risks factors that are generated will have
an inherent bias and differ based on their universe. For
example, The Doctors Insurance yields data that result in

182.e1
Chapter | 18  Aesthetic classification of the abdomen
Case Series of a surgeon.
Surveys of groups of plastic surgeons (e.g., ASPS, ASAPS).
TOPSTM (Tracking Operations and Outcomes for Plastic
Surgery). This is a national database of plastic surgery
procedures and outcomes self reported by members of
ASPS.
Cosmet Assure – A medical insurance program covering 17
elective cosmetic procedures performed by active or
candidate members of American Society of Plastic Sur­
geons. Coverage includes complications treated in an
emergency room, those requiring hospital admission, or
intervention in an accredited surgical centre within 30
days of the procedure. It does not include complications
treated on an outpatient basis, such as seromas drain­
age, wound care, or oral antibiotics, which TOPS
should include.
The Doctors Insurance Company – These data are based
on claims that the insured physicians medical malprac­
tice covers.
Maintenance of Certification (MOC) is data collected by
the American Board of Plastic Surgeons for board
certification.
American Association for the Accreditation of Ambulatory
Surgical Facilities – (AAASF) is data collected from out­
patient accredited surgery centers.
BOX 18.4  Databases for Abdominoplasty
Complications

183
Chapter | 18  Aesthetic classification of the abdomen
complication rate of 4.7%, more than double (1.57%) the
rate from other cosmetic procedures. Thirty-seven percent
were abdominoplasty alone and 63% had multiple proce­
dures. Their average age was 44 years, with an average
BMI of 27 kg/m2. In the patients having complications
12/163 (7%) were smokers and 7/163 (4%) were diabetic;
single complications occurred in 155/163 (95%) and mul­
tiple 8/163 (5%). Cosmet Assure data confirm that abdomi­
noplasty carries the highest risk of complications of all
esthetic plastic surgery. Indeed, doing body surgery is more
risky than any facial esthetic plastic surgery.
MOC data advises a single dose of antibiotics to reduce
infections. For reducing seromas they suggest modifying
the level of dissection to leave a loose areola plane of tissue
on the muscle fascia, progressive tension sutures or drains.
The author has published a protocol to treat chronic seromas
in an attempt to reduce their sequela or pseudobursa forma­
tion. According to Grazer and Goldwyn, thromboembolism
is the most dreaded complication and accounts for approxi­
mately half of all fatalities in abdominoplasty. With regards
to DVT/PE, the MOC implications for practice state to
consider the patient’s risk level, weigh the benefits of DVT
prophylaxis with the risk of bleeding and consider enoxa­
parin postoperatively. If enoxaparin is used it is currently
recommended to commence 12 hours postoperatively.
Ideally, patients should begin ambulating on the day of
surgery.
Proper patient evaluation, appropriate surgical marking,
and intraoperative bed positioning (beach chair) are neces­
sary to ensure removal of the old umbilical site – which is
a highly desirable patient preference.
Preparing patients for their postoperative course, man­
aging their expectations, and addressing the anticipated
outcome are measures that assist in optimizing outcomes in
the highly subjective preview of esthetic surgery.
COMPLICATIONS AND THEIR
PREVENTION, DIAGNOSIS,
AND MANAGEMENT
In addition to what has been discussed previously, cellulitis,
tissue ischemia/necrosis, hematoma, scars (umbilical, inci­
sion line, or “dog-ears”), contour irregularities, hypesthesia/
pain, or “unsatisfactory” results can occur.
Adding liposuction to an abdominoplasty is the most
common adjunctive procedure performed in conjunction
with abdominoplasty. Liposuction is valuable because it
contours surrounding areas and aids in creating a more
harmonious and symmetric appearance. It should be empha­
sized that adding some liposuction to an abdominoplasty is
different, in terms of added risk, than adding an abdomino­
plasty to a planned liposuction procedure. Furthermore, the
location where liposuction is added often dictates what the
TABLE 18.3  Menu of Abdominal Contour Surgery
Options (Using the Abdominolipoplasty System of
Classification and Treatment as a Template)
(see Fig. 18.1 & Table 18.1)
*/**Type I-SAL – liposuction of the abdomen, or;
Type 1a-Extended liposuction (larger volume, extent of
liposuction-locations, and degree: deep and superficial
liposuction).
*/**Type II – mini-abdominoplasty begins with liposuction of
the abdomen, then a Pfannenstiel type lower incision with
a small skin excision and lower rectus muscle plication
(from umbilicus down). There is a natural tendency
towards a lower abdominal bulge due to areas of the
posterior rectus fascia below the accurate line of Douglas.
Type 2 – open mini-abdominoplasty that uses a pre-existing
lower midline scar to perform the mini-abdominoplasty.
*/**Type III – modified abdominoplasty (or lower
abdominoplasty). A longer lower incision is used which
allows more skin to be removed (approximately1/4 of the
total abdominal skin or1/2 below the umbilicus), therefore
a slightly shorter lower skin incision than a traditional
abdominoplasty may be possible and there is no
periumbilical scar. This option allows unrestricted upper
abdominal (above the umbilicus) liposuction and can
safely be done in the presence of upper abdominal scars.
If the umbilicus is floated additional access can be gained
to the rectus diastasis above the umbilicus.
*/**Type III a – endoscopic abdominoplasty when a minimal
access incision is suitable. It is designed for the rare
situation when there is good quality skin, varying amount
of fat and in the presence of an upper and lower
abdominal diastasis.
Type IV – full abdominoplasty with liposuction
(lipoabdominoplasty) or without liposuction (conventional
abdominoplasty) – see text for details.
Panniculectomy with extensive liposuction with (Fig. 18.10,
green) or without (*) (Fig. 18.10, yellow) umbilical
circumscription is a variation of a full, modified
abdominoplasty, or lower abdominoplasty. Unrestricted
upper abdominal liposuction is performed with minimal
undermining of the upper flap (just sufficient to achieve
wound closure after excising the skin below the umbilicus
– either circumscribing the umbilicus or not, depending on
what is needed to get the planned skin excision closed).
Minimal if any upper rectus muscle plication is done. This is
a good option for patients with umbilical hernias (because
the hernia can more safely be repaired if the umbilicus is
not circumscribed), in patients that are less than ideal for
a full abdominoplasty (e.g., obese), or patients with upper
abdominal nonmidline scars. The incision can also be
designed to excise more skin than in a lower
abdominoplasty.
*shorter/absent low transverse abdominal incision.
**no external umbilical scar.

183.e1
Chapter | 18  Aesthetic classification of the abdomen
●
Patients should ambulate on the day of surgery. In
general they should avoid prolonged immobilization,
and make a conscious attempt to bend their ankles and
knees while stationary.
●
For up to approximately 40 days patients and surgeons
should be vigilant for the potential development of VTE.
The Davison Caprini model indicates that the higher the
score the more at risk for DVT/PE a patient is and for
the longer a period of time postoperatively. Any sys­
temic signs such as leg pain or swelling, shortness of
breath, decreased oxygen saturation, EKG changes,
chest pain, and an ominous feeling on the part of the
patient, confusion, or other signs of symptoms of DVT
or PE should be expeditiously evaluated. This can
include venous Doppler scans (also periodically recom­
mended just as a screening tool), spiral CT scans, or
D-dimer assays.
●
Drains should be used appropriately until drainage sub­
sides. Drains are removed when clinically (color of
output, length of time they are in place, etc.) and objec­
tively (output volume 30–40 ml over 24 hours)
appropriate.
●
Maintain a high degree of suspicion for postoperative
seromas and evaluate the patient in the weeks following
drain removal for the presence of contour irregularities
or ballotable fluid waves (seromas) or the development
of a pseudobursa which manifests itself as a persistent
contour irregularity.
●
Incorporate postoperative ancillary maneuvers such as
scar treatment (gels, tapes, etc.), lymphatic massage,
ultrasound treatment, and compression binders.
BOX 18.5  Postoperative Care
POSTOPERATIVE CARE
See Box 18.5.

184
PART | 5  Abdominal contouring procedures
potential added risk is. For example, the most common
concern when liposuctioning the elevated flap is tissue isch­
emia, when liposuctioning the adjacent flank it is seroma,
and when liposuctioning the torso extensively it is the
increased risk of thromboembolism.
Tissue ischemia is often related to the extent of liposuc­
tion, the amount of tension on wound closure and the nature
of the flap undermining (other causes can include excess
flap thinning or “racking” the flap with the retractors, tissue
handling, inappropriate undermining). These three factors
should be reconciled to diminish ischemia/necrosis, which
happens most commonly in the “terrible abdominal trian­
gle” located between the umbilicus and the mons pubis.
Reversible causes such as tension (removing or loosening
sutures) or delayed wound (secondary) closure or delayed
exteriorization of the umbilicus can assist by preserving
blood supply; fluid collections or infections should be ruled
out. The author uses a solution of DMSO/RMSO (Gaylord
Chemical, Slidell, LA) topically applied to the affected
ischemic areas. Wounds that progress to necrosis can be
debrided, but that should be delayed until final tissue demar­
cation is evident in order to avoid retrograde thrombosis.
The individual surgeon’s preferred and appropriate wound
management techniques are suggested for necrotic areas.
Hematomas requiring surgical evacuation can occur
rapidly in the immediate postoperative period or gradually
in the early (7–10 days) postoperative period. They should
be drained by opening the wound and exploring it in a
sterile setting and copiously irrigating the cavity. Drains are
then reinserted. Hematomas can occur in any location sub­
cutaneously below the skin flap, often above level of the
umbilicus; or deeply below the rectus fascia; or under the
mons pubis area.
Scars are an inevitable consequence of surgery. The
nature of a scar or a patient’s reaction to their appearance
is unpredictable. The only guarantee that can be made is
that scars will appear and that they will mature in stages
over months and years.
Contour irregularities occur from excess or insufficient
liposuction, failure to plicate or taper the rectus muscle
plication to the xiphoid process, from pseudobursas, and
uneven undermining, among other things.
Paresthesias that resolve are an expected event in
abdominoplasty, though periodically patients report persis­
tent “deep” intense itching “inside” long after an abdomi­
noplasty has healed. Nerve entrapment syndromes such as
the lateral femoral cutaneous nerve can be avoided by
leaving some subcutaneous tissue within 6 cm of the ante­
rior superior iliac spine while dissecting. Other nerve
entrapments (genitofemoral, ilioinguinal and iliohypogas­
tric nerves) manifest themselves in classic patterns consis­
tent with their innervation. Surgeons should avoid an
excessively deep bite of the rectus fascia when performing
rectus muscle plication (Figs 18.9 and 18.10).
CONCLUSION
Esthetic surgery of the abdomen continues to be in great
demand and has evolved substantially in less than two
generations, beginning in the late 1970s with the rise in
popularity of the classic abdominoplasty.
When liposuction was introduced in the 1980s it perma­
nently and radically altered the landscape of body contour
surgery in general. Rapidly, liposuction of the abdomen as
a sole procedure became the most common abdominal
contour surgery operation. In the late 1980s and early 1990s
limited incision abdominoplasties arose by introducing
liposuction to operations with smaller skin excisions and
restricted rectus muscle plication. They are recognized to
be appropriate for a selected group of patients. Concur­
rently, surgeons established principles in traditional abdom­
inoplasty that allowed the incorporation of safe liposuction
to the undermined flap of a full abdominoplasty (lipoab­
dominoplasty) and the surrounding regions. Simultane­
ously, procedures that avoid umbilical scarring, such as
lower abdominoplasty, became available. Finally, with the
rise in popularity of bariatric surgery over the last decade,
techniques for abdominal and circumferential abdomino­
plasty in the arena of bariatric plastic surgery have been
FIG. 18.9  Anatomy of potential nerve entrapments that can occur
from abdominoplasty (with permission from Dr. Susan McKinnon).
Quadratus lumborom
Iliohypogastric nerve
Iliohypogastric nerve
Iliohypogastric nerve
(terminal branch)
Ilioinguinal nerve
Ilioinguinal nerve
(terminal branch)
Lateral femoral cutaneous nerve
Genitofemoral nerve
Genital branch of
the genitofemoral nerve
(terminal branch)
Psoas
B
A

185
Chapter | 18  Aesthetic classification of the abdomen
refined and represent an entirely new dimension in the
esthetic improvement of the abdomen.
FURTHER READING
Matarasso A. Abdominolipoplasty. Clinics in Plastic Surgery. Philadel­
phia, PA: W.B. Saunders and Company; 1989. 16:2, (Cited in Selected
Readings in Plastic Surgery, 1992).
Matarasso A. Abdominoplasty and abdominolipoplasty. In: Cohen M,
editor. Mastery in Plastic Surgery, vol. 3. Boston, MA: Little, Brown
& Company; 1994. p. 1385.
Saldanha OR, Azevedo SF, Delboni PS, et al. Lipoabdominoplasty: the
Saldanha technique. Clin Plast Surg 2010;37(3):469–81.
Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal
contour surgery: a national plastic surgery survey. Plast Reconstr Surg
2006;117(6):1797–808.
Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with
emphasis on complications. Plast Reconstr Surg 1977;59:513.
Teimourian B, Rogers WB III. A national survey of complications associ­
ated with suction lipectomy: A comparative study. Plast Reconstr Surg
1989;84:628.
Pitanguy I. Abdominal lipectomy. Clin Plast Surg 1975;2:401.
Hester TR Jr, Baird W, Bostwick J III, et al. Abdominoplasty combined
with other major surgical procedures: Safe or sorry? Plast Reconstr
Surg 1989;83:997.
Matarasso A. Abdominoplasty. In: Achauer BM, Eriksson E, Guyuron B,
et al, editors. Plastic Surgery. Indications, Operations, and Outcomes,
Vol. V, Aesthetic Surgery, vol 5. St. Louis, MO: Mosby; 2000. p. 2783–821.
Bercial ME, Sabino Neto M, Calil JA, et al. Suction drains, quilting
sutures, and fibrin sealant in the prevention of seroma formation in
abdominoplasty: which is the best strategy? Aesth Plast Surg 2011;
36(3):370–3.
Mangano A. Seroma in lipoabdominoplasty and abdominoplasty: a com­
parative study using ultrasound–a note about statistics. Plast Reconstr
Surg 2011;128(2):600–1.
Matarasso A. The male abdominoplasty. Clin Plast Surg 2004;31(4):
555–69.
Matarasso A, Rubin JP, editors. Aesthetic Surgery after Massive Weight
Loss. Edinburgh: Elsevier Ltd.; 2007.
Matarasso A. Minimal-access variations in abdominoplasty. Ann Plast
Surg 1995 (Cited as an abstract in Yearbook of Plastic Surgery, 1996,
and in Selected Readings in Plastic Surgery, 1999);34:255.
Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast
Reconstr Surg 1995;5:829.
Matarasso A, Matarasso S. When does your liposuction patient require an
abdominoplasty? Dermatol Surg 1997;23(12):1151–60.
Matarasso A. Superwet anesthesia redefines large volume liposuction.
Aesth Surg J 1997;17(6):358–64.
Najera RM, Asheld W, Sayeed SM, et al. Comparison of seroma formation
following abdominoplasty with or without liposuction. Plast Reconstr
Surg 2011;127(1):417–22.
Buck DW 2nd, Mustoe TA. An evidence-based approach to abdomino­
plasty. Plast Reconstr Surg 2010;126(6):2189–95.
Ali A, Essam A. Abdominoplasty combined with Cesarean delivery: eval­
uation of the practice. Aesth Plast Surg 2011;35(1):80–6, Epub 2010
Aug 31.
Karthikesalingam A, Kitcat M, Malata CM. Abdominoplasty in patients
with and without pre-existing scars: a retrospective comparison.
J Plast Reconstr Aesthet Surg 2011;64(3):369–74.
Pollock TA, Pollock H. No-drain abdominoplasty with progressive tension
sutures. Clin Plast Surg 2010;37(3):515–24, Epub 2010 May 23.
Shestak KC. Short scar abdominoplasty update. Clin Plast Surg 2010;
37(3):505–13, Epub 2010 Jun 9.
Nahai FR. Anatomic considerations in abdominoplasty. Clin Plast Surg
2010;37(3):407–14.
Friedman T, O’Brien Coon D, Michaels J, et al. Fleur-de-Lis abdomino­
plasty: a safe alternative to traditional abdominoplasty for the massive
weight loss patient. Plast Reconstr Surg 2010;125(5):1525–35.
Shermak MA, Mallalieu J, Chang D. Do preexisting abdominal scars
threaten wound healing in abdominoplasty? Eplasty 2010;10:e14.
Hatef DA, Trussler AP, Kenkel JM. Procedural risk for venous thrombo­
embolism in abdominal contouring surgery: a systematic review of
the literature. Plast Reconstr Surg 2010;125(1):352–62.
Chin SH, Martin WJ, Matarasso A. Do waistline and umbilical position
really change after abdominoplasty? Plast Reconstr Surg 2010;
125(1):27e–8e.
Warner JP, Gutowski KA. Abdominoplasty with progressive tension
closure using a barbed suture technique. Aesth Surg J 2009;29(3):
221–5.
Tables 18.2, 18.4, 18.5; Boxes 18.1, 18.4, 18.5 can be found online.
Bonus images for this chapter can be found online at

Iliohypogastric nerve
Genitofemoral nerve
Genitofemoral nerve/
Ilioinguinal nerve
Ilioinguinal nerve
Lateral femoral
cutaneous nerve
FIG. 18.10  The difficulty encountered from different nerve entrap­
ments (with permission from Dr. Susan McKinnon).

186
© 2013 Elsevier Inc
Chapter 19 
Key Points
●
Subcutaneous and myoaponeurotic abdominal
deformities must be identified.
●
Surgery must be planned accordingly to the patient’s
deformity, diagnosed either pre- or intraoperatively.
●
Look for congenital rectus diastasis intraoperatively to
avoid recurrence of rectus diastasis.
●
If there is still myoaponeurotic laxity after the
approximation of the rectus edges, plication of the
external oblique aponeurosis should be performed.
●
Supraumbilical undermining should be performed at
the minimum width of the supraumbilical area in
order to preserve the perforator arteries of the rectus
muscle.
Anatomy of the abdominal wall
and aesthetic classification
Fabio X. Nahas and Lydia M. Ferreira
INTRODUCTION
Knowledge of the abdominal wall anatomy and its deformi­
ties provides the plastic surgeon with a clear view of which
aspects should be addressed during abdominoplasty. All
patients are different, their deformities vary and, therefore,
there is not a one-size-fits-all abdominoplasty. Because of
this, this chapter provides a review of the surgical anatomy
of the abdominal wall with a special focus on the different
types of acquired and congenital deformities; thus creating
a classification of abdominal wall deformities based on skin,
the subcutaneous and the myoaponeurotic layers. Specific
surgical techniques are suggested for each of these
deformities.
ANATOMY OF THE ANTERIOR
ABDOMINAL WALL AND ITS SURGICAL
IMPLICATIONS ON ABDOMINOPLASTY
Fine Contour and Anatomical Unities of
the Abdomen
There are some anatomical landmarks that should be
defined before any description of the anatomy of the
abdominal wall. This might serve as the main guideline
providing orientation for plastic surgeons in order to obtain
a good cosmetic result.
Plastic surgeons should try to create the details of the
fine contour of the abdomen when operating on this
area. Ideally, there should be a slight depression in the
midline at the upper abdomen. Two paramedian depres­
sions (folds) should exist at the lateral edges of the recti
muscles. In most patients these folds begin at the infraum­
bilical level, reaching 3–4 cm above the umbilicus. The
folds can be created either by myoaponeurotic plications or
by liposculpture.
Subcutaneous Anatomy of the Anterior
Abdominal Wall
The subcutaneous tissue of the anterior abdomen is divided
into two layers: the superficial (areolar) and the deep
(lamellar) layer. The superficial fascia, also called Scarpa’s
fascia, separates these two planes. Adipose tissue is thick
and dense in the superficial layer, which is evenly distrib­
uted over the whole abdomen. The fat tissue in the deep
layer is loose. In the infraumbilical area, these layers are
very well defined, whereas in the supraumbilical region this
separation is not very clear.1 In the infraumbilical area there
is a wide variety of thickness of adipose tissue depending
on the patient’s weight. It is important to know this anatomy
when there is a difference in subcutaneous thickness
between the flap and the area inferiorly to the abdominal
incision. In such cases, the removal of the lamellar layer
deep to Scarpa’s fascia can be a good option. This removal
can be performed up to the umbilicus2 or in all the extension
of the abdominal flap.
Blood Supply of the Abdominal Wall
The abdominal skin is supplied by a subdermal arterial
plexus originated from a complex network of superficial
vessels. Most of these vessels are supplied by the superficial
Part 5  Abdominal contouring procedures

187
Chapter | 19  Anatomy of the abdominal wall and aesthetic classification
Lymphatic System
The lymphatic system of the subcutaneous tissue of
the supraumbilical area drains to the axillary lymph
nodes, whereas the infraumbilical system drains to the
superficial inguinal lymph nodes.6 The periumbilical area
may also drain to deep abdominal periaortal lymph nodes.
Inefficient lymphatic drainage can be one of the causes
of seroma.
Myoaponeurotic Anatomy
The rectus abdominis muscle is enfolded by two aponeuro­
sis: the anterior and the posterior rectus sheath.
The anterior rectus sheath covers all the anterior surface
of the rectus abdominis muscle. Its composition is different
depending on its position. Above the arcuate line the ante­
rior sheath is formed by aponeurotic fibers that originate
from the external and internal oblique muscles. Below the
arcuate line, the external, internal oblique and transverse
aponeurosis blend to form the anterior rectus sheath. The
arcuate line is in a variable position between the umbilicus
and the pubis.
The posterior rectus sheath does not cover the entire
posterior surface of the rectus muscle. It is interrupted
below the arcuate line. Above this level, this sheath is
formed by aponeurotic fibers of the internal oblique and
transverse muscles. Below the arcuate line there is no apo­
neurosis and the muscle is separated from the peritoneum
by the transversalis fascia.
After describing the rectus sheath anatomy, it is easy to
understand why the plication of the anterior rectus sheath
is a reliable procedure. As there is a dense attachment
between the anterior sheath and the muscle, the plication
will effectively bring these muscles together.7–11 However,
if these muscles present a lateral origin in the rib cage,
recurrence of the plication may occur, as repeated muscle
contraction may lead to suture disruption in the upper
abdomen.12
The muscles of the flank of the abdomen are the external
oblique, internal oblique, and the transverse muscle. The
fibers of the oblique muscles are perpendicular to the inter­
nal oblique fibers and there is a loose connective tissue
between them. This is taken into account if a plication of
the external oblique aponeurosis is performed; there is a
real decrease of the distance between the origin and inser­
tion of the muscle, thus promoting a more efficient contrac­
tion of the muscle and a positive cosmetic effect. It is also
important to stress that the arterial supply to the external
oblique muscle and its innervation penetrates the muscle
laterally to the anterior axillary line.13 Therefore, when the
advancement of the external oblique muscle is performed,
the undermining on the loose connective tissue above the
epigastric artery, the superficial circumflex iliac artery, and
also from perforators of the superior and inferior epigastric
artery. Superficial branches of the intercostal arteries and
lumbar branches are also part of this arterial supply.3 When
describing the arterial anatomy of the abdominal wall, it
is important to define the zones of blood supply which
will have an important role in necrosis prevention. There
are three areas of blood supply4 that have been described
from the perspective of the surgeon. Knowledge of these
areas guides the surgeon during abdominal flap under­
mining (Fig. 19.1). Zone I is the most important area and
should be preserved as much as possible during flap under­
mining. It is located at the supraumbilical region, in which
the main arterial flow comes from the perforators of the
deep superior epigastric artery. By performing a more local­
ized undermining, surgeons can preserve some of these
arteries.
Sensitive Innervation of the Abdominal Wall
The intercostal, subcostal, iliohypogastric and ilioinguinal
nerves are responsible for the sensitivity innervation
of the anterior abdominal wall.5 The intercostal nerves
are branches originating from T7 to T11. The subcostal
nerves originate from T12 whereas the iliohypogastric
and ilioinguinal nerves originate from L1. Branches from
T7 to T9 innervate the supraumbilical area, T10 inner­
vates the periumbilical area and the branches originating
from T12 and L1 provide innervation to the infraumbili­
cal area.
FIG. 19.1  Illustration showing the areas of blood supply of the
abdominal wall as described by Hugher. Zone 1 is the most important
area and should be carefully undermined during abdominoplasty, in order
to preserve part of the superior epigastric perforators. (Modified from
Persichetti P. et al. Anchor line abdominoplasty. Plast Reconstr Surg.
116(1): 289–294, 2005.)
1
2
3
3

188
PART | 5  Abdominal contouring procedures
classifications can be used, depending on the patient’s
deformity.
Classification Based on the Excess Skin and
Subcutaneous Tissue
In this classification, deformities are categorized into four
different types: 0, I, II and III.
Type 0
Deformity – these patients present an abdominal defor­
mity exclusively due to excessive subcutaneous tissue.
There is no excess skin, although some patients may
present a little excess skin caused by previous preg­
nancy or weight loss.
Management – correction of the deformity is achieved
by suction lipectomy only (Fig. 19.2).
Type I
Deformity – these patients present little or mild excess
skin and a high positioned umbilicus.
Management – an incision usually slightly smaller than
those used on classical abdominoplasties is performed
tangentially to the suprapubic hairline. The abdominal
flap is elevated, exposing the linea alba from the pubis
to the xiphoid process. The umbilical pedicle is sec­
tioned and the umbilical skin is maintained with the
abdominal flap. The muscular defect is corrected and
the excess skin is resected on an area marked with the
shape of an Indian canoe. The umbilicus is reattached
in the aponeurosis not lower than 2 or 3 cm below its
original position (Fig. 19.3).
Type II
Deformity – these are patients with mild excess skin and
a well positioned umbilicus. Patients with moderate
excess skin with a well or high positioned umbilicus are
also included in this group. In such cases, the surgeon
is unable to resect the whole area of skin between the
umbilicus and the pubic region because there will be not
enough skin left with the flap to cover this area. In those
patients, two surgical options can be used, depending
on patient characteristics.
Management Type II Vertical – indicated in type II
patients who present a stable body weight, in those
patients with a low abdominal fold and also in patients
who present a median supraumbilical scar. In such cases,
some of the infraumbilical skin is preserved. There will
be a resulting midline scar in the lower abdomen,
continuously with the transverse abdominal suprapubic
scar. After the undermining, the excess skin is removed
under adequate tension. At the end of the operation, the
internal oblique muscle can be performed safely laterally
to the anterior axillary line.
The Umbilicus
The attractive umbilicus should have a central depression,
a superior skin hood and should also be more vertically
shaped. The most accepted position of the umbilicus is at
the level above the iliac crests.14 It is not an easy task to
achieve all these goals when performing an abdomino­
plasty. To obtain an attractive umbilicus will depend on the
design of the incisions used in the skin and in the umbilicus,
on the skin closure tension, and on the abdominal level
chosen to place the umbilicus.
PREOPERATIVE PREPARATION
Candidates for abdominoplasty should have a stable weight
by the time of the operation to obtain the best possible
result. If the patient is overweight and there is some diffi­
culty advancing the flap on the pinch test, weight loss will
benefit the patient’s result. Women should be past all their
pregnancies before abdominoplasty; however, if a patient
gets pregnant after this operation, there is a chance that the
musculoaponeurotic deformity will not recur.9 A compres­
sive abdominal garment is used for 1 week before the
surgery to adapt the abdominal wall to the myoaponeurotic
correction. Smoking and birth control medication should be
discontinued for at least 15 days preoperatively.
Blood cell count, coagulation test, serum glucoses,
sodium, potassium, urea and creatinine are basic blood
exams that should be done for these patients. Ultrasound of
the abdominal wall may be performed in cases where the
plastic surgeon suspects abdominal wall hernias.
Diagnosis of the Abdominal Wall
Deformities and Surgical Technique
Esthetic Classification of Abdominal
Wall Deformities
Deformities of the abdominal wall vary. Each individual
will present a specific deformity, depending on inherited
characteristics, age and – for women – previous pregnan­
cies. Therefore, a different surgical solution is applicable to
each of the abdominal deformities. So that surgeons can
easily understand which technique would be more suitable
for correcting a specific deformity, two classifications have
been described. The first one evaluates excess skin and
subcutaneous tissue,15 whereas the other evaluates malpo­
sitioning and laxity of the myoaponeurotic layer.16 For each
degree of deformity, a specific technique is suggested.
Therefore, a combination of the methods described on both

189
Chapter | 19  Anatomy of the abdominal wall and aesthetic classification
FIG. 19.3  Type I patients present mild excess skin and a high positioned umbilicus. In these cases the umbilical pedicle is sectioned and it is reat­
tached 2 or 3 cm below its actual position. The excess skin of the lower abdomen is removed. Type II patients are those who present mild excess skin
and a well positioned umbilicus. In these cases two surgical options can be performed: Type II Vertical – To preserve some of the skin of the lower
abdomen close to the umbilicus, thus forming a small vertical incision; or Type II High – To preserve some of the skin of the lower abdomen close to
the inferior abdominal fold by placing the transverse incision on a more superior position. Type III patients are those who present severe excess skin.
In such patients a fusiform of skin and subcutaneous tissue is removed from the suprapubic area to the umbilicus. Note that the arrow indicates a pro­
gressive excess skin.
2-3 cms
Type I
Type II
Vertical
Type II
High
Type III
Excess skin
FIG. 19.2  (A) Preoperative aspect of a type 0 patient (26-year-old white female) who presented excess fat in the anterior abdomen, flanks and lumbar
area. (B) Six-month postoperative aspect showing the result, in which 1.4 liters of fat was removed by syringe liposuction.
A
B

190
PART | 5  Abdominal contouring procedures
FIG. 19.4  (A) Preoperative aspect of a type II Vertical/B patient (42-year-old white female) who presented moderate excess skin and a well positioned
umbilicus. The patient presented a low abdominal fold, weight stability and laxity of the myoaponeurotic layer. (B) Six-month postoperative aspect.
Note the effect of the L plication of the external oblique aponeurosis associated with the plication of the anterior rectus sheath. Note also the fine contour
obtained by using these techniques to correct the myoaponeurotic layer.
A
B
FIG. 19.5  Two-year postoperative aspect of the scar of a Type II
High patient. Note the inconspicuous scar resulted from a well placed
high positioned incision.
abdomen will present an anchor-shaped scar with a small
median vertical scar (Fig. 19.4).
Management Type II High – indicated in type II patients
who present a high abdominal fold or for those with
weight variations throughout their lives. Patients with
a high abdominal fold will have a tendency to have a
more discreet scar (Fig. 19.5). This occurs because the
incision is placed between the esthetic unities of the
abdomen. Also, if patients gain weight after the surgery,
a vertical scar may retract, thus dividing the lower
abdomen in two areas of subcutaneous projection. In
these cases, a high positioned incision is preferable. It
is placed from 2 to 3 cm above the pubic hairline, at
the patient’s abdominal skin fold. This incision is
extended across the whole abdominal width. The under­
mining exposes the fascia from 1 to 2 cm laterally to
the medial edge of the recti muscles and the medial
portion of the external oblique muscles. After trimming

191
Chapter | 19  Anatomy of the abdominal wall and aesthetic classification
Classification Based on the
Myoaponeurotic Deformity
In this classification, deformities are categorized into four
different types: A, B, C and D (Fig. 19.7).
Type A
Deformity – these patients present a typical fusiform
rectus diastasis secondary to pregnancy. Both recti
muscles are inserted on the costal margins close to the
midline.
Management – rectus diastasis is corrected by the plica­
tion of the anterior rectus sheath. Plication is performed
with a two-layer 2-0 nylon suture. The first layer is done
using inverted stitches every 0.4 cm and the second
layer is a continuous suture. The plication addresses
only the correction of the diastasis (Fig.19.6). If the
myoaponeurotic layer is still flaccid, the deformity will
FIG. 19.6  (A) Preoperative view of a type III/A patient (54-year-old white female). This patient presented a large excess skin and subcutaneous tissue
and rectus diastasis. (B) One-year postoperative aspect. The skin between the umbilicus and the suprapubic area was removed. Although the patient
presented a high BMI (34), after the plication of the anterior rectus sheath there was no laxity of the myoaponeurotic layer, therefore only the correction
of the diastasis was performed.
A
B
the excess skin and fat, the remaining abdominal flap
can be thinned by removing the fat tissue underneath
Scarpa’s fascia whenever the flap is thicker than the
suprapubic area. The fascia is kept intact within the
flap.
Type III
Deformity – patients included in this group are those
with severe excessive skin in the abdomen and with the
umbilicus at a high or normal position.
Management – in these cases removal of a fusiform
area of skin and subcutaneous tissue from the umbilicus
to the pubic hairline is performed (Fig. 19.6). The
area undermined in the supraumbilical region is
similar to the one described in type II patients.
The abdominal flap can also be thinned by removing
the fat tissue underneath Scarpa’s fascia whenever
necessary.

192
PART | 5  Abdominal contouring procedures
2-0 nylon inverted sutures and the recti muscles, still
attached to the anterior sheath, are advanced towards
the midline and anchored to the invaginated linea alba
with the same sutures (Fig. 19.9). By using this tech­
nique a tension decrease is obtained at the aponeurotic
suture.17 A more effective correction is achieved at the
upper abdomen (Fig. 19.10).
Type D
Deformity – these patients present musculoaponeurotic
laxity of the area of the flank with a poorly defined
waistline associated with rectus diastasis secondary to
pregnancy.
Management – the external oblique aponeurosis is
incised along the semilunaris line, having as the supe­
rior limit the costal margins and as the inferior limit
the reflected inguinal ligament. The external oblique
muscle is undermined laterally towards the anterior
axillary line where its neurovascular pedicle penetrates
the muscle. An aponeurotic incision is made parallel to
the reflected inguinal ligament. This muscle is advanced
to the midline and, if possible, sutured to the contralat­
eral one.
OPTIMIZING OUTCOMES
1. Evaluate excess skin and fat separately from the myo­
aponeurotic deformity.
2. In order to decrease skin tension between the umbilicus
and the skin of the abdominal flap it is sometimes
be classified as type B and another technique is used to
correct it.
Type B
Deformity – Type B patients are those who present a
persistent bulging of the musculoaponeurotic layer after
the correction of diastasis. These patients may present
a vertical elongation of the abdominal wall. Patients
who need some improvement to the waistline may also
benefit from this technique.
Management – an L-shaped plication of the external
oblique aponeurosis should be performed in addition to
the plication of the anterior rectus sheath. This plication
of the external oblique aponeurosis is done in the same
fashion as described for the correction of the rectus
diastasis (Fig. 19.8).
Type C
Deformity – Type C patients present a congenital rectus
diastasis. In these cases the recti muscles are inserted
laterally in the costal margins. These are patients clas­
sified by general surgeons as having an epigastric hernia.
Although they may not always present hernias, it is a
frequently associated defect.
Management – the aponeurotic sheath of the recti
muscles should be advanced in these cases. To correct
congenital rectus diastasis, an incision is performed
along the anterior rectus sheath, close to the linea alba.
The rectus muscle is undermined from its posterior
sheath. At this point, the linea alba is invaginated using
FIG. 19.7  Type A patients present rectus diastasis secondary to pregnancy, in which the recti muscles are inserted close together in the midline at the
costal margin. Plication of the anterior rectus sheath is performed in these cases. Type B patients are those who present laxity of the musculoaponeurotic
layer after the correction of rectus diastasis and, in addition to the plication of the anterior rectus sheath, these patients will undergo plication of the
external oblique aponeurosis. Type C patients present congenital rectus diastasis, on which the insertion of the recti muscles is lateral in the costal
margins. To correct this deformity, an advancement of the recti muscles is performed. Type D patients are those who present a poorly defined waistline
and these patients will have their external oblique muscles advanced. Note that the arrow indicates a progressive myoaponeurotic laxity.
A
B
C
Laxity
D

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Chapter | 19  Anatomy of the abdominal wall and aesthetic classification
the first postoperative day when they are mobilized. A com­
pressive garment is used at the end of the operation and
throughout the first postoperative month.
Penrose drains are indicated when quilting suturing
is performed and should be removed within 48 hours
after the surgery. In the few cases when these stitches
are not used, a suction drain is placed and removed
when the collected fluid amounts to less than 30 ml in
24 hours.
Patients are kept in the Fowler’s position during the
sleeping period for the first postoperative week. When in
the standing position they are oriented to bend their trunk
forward and slightly bend their knees for the first week.
They are allowed to drive 3 weeks after the operation and
exercise after the first postoperative month. Sit ups and any
exercises that include contraction of the abdominal muscles
are allowed 45 days after the operation when aponeurotic
plications are performed. A 90-day period free of abdomi­
nal exercises is required for patients with abdominal muscle
advancements.
FIG. 19.8  (A) Oblique view of a 24-year-old white female patient with a type II High/B deformity. (B) One-year postoperative aspect showing a
blended high positioned scar and two paramedian folds where the external oblique plications were performed.
A
B
necessary to advance the umbilical pedicle anteriorly by
anchoring it to the aponeurosis, so that tension can be
decreased.
3. Quilting sutures are important to reduce seroma, hema­
toma and tension of the abdominal flap, thus reducing
flap necrosis.
4. Avoid performing wide rectus plication in cases
where the anterior rectus plication was not sufficient to
correct the myoaponeurotic deformity. Wide rectus pli­
cation can erase the fine contour of the abdominal wall.
In such cases, plication of the external oblique aponeu­
rosis is indicated and should be performed.
5. Identify congenital rectus diastasis. In these cases
advancement of the rectus muscle should be performed
to avoid recurrence of this deformity.
POSTOPERATIVE CARE
Patients should use intermittent calf compression devices
during the operation and in the postoperative period until

194
PART | 5  Abdominal contouring procedures
FIG. 19.9  Illustration demonstrating the correc­
tion of type D myoaponeurotic deformity. (A) Inci­
sion of the anterior rectus sheath and exposure of the
posterior rectus sheath. A 2-0 nylon suture is passed in
the posterior sheath on each side. (B) The posterior
aponeurosis is sutured, thus invaginating the linea alba.
(C) The anterior aponeurosis is sutured and anchored to
the midline at the posterior sheath. (D) The final aspect
is shown.
A
B
C
D
A
B
C
D
FIG. 19.10  (A) Preoperative lateral view of a 44-year-old white female who presented a type C deformity with congenital lateral insertion of the recti
muscles at the costal margin. At the clinical evaluation she presented an anterior projection of the upper abdomen. (B) Six-month postoperative lateral
view showing correction of the projection of the upper abdomen.
A
B

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Chapter | 19  Anatomy of the abdominal wall and aesthetic classification
3–4 days until there is a decrease in volume to less than
20–40 ml. If seroma is not recognized or if it is not aspi­
rated, its absorption can be delayed and a capsule will be
formed around it. A deformity of the abdomen will occur
and an extensive undermining is usually necessary to
correct this secondary complication.24
Abdominal flap necrosis can be a dramatic complication
depending on its extension. The most common causes of
necrosis after abdominoplasty are excessive tension and
extensive undermining. Preoperative planning based on
the type of skin and subcutaneous deformity can help to
prevent excessive tension of the abdominal flap.15 The area
of undermining can be decreased at the upper abdomen. A
narrow undermining tunnel can preserve some of the rectus
perforator arteries, thus increasing the arterial flow of the
flap. Mayr et al25 demonstrated that there is a decrease in
blood flow in the infraumbilical area of the abdominal flap
to 17.2% as compared to the normal blood flow after a more
extensive flap undermining during abdominoplasty. There­
fore liposuction of the abdominal flap should be carefully
done. Lipectomy of the flap can be a better choice when it
is necessary to decrease flap thickness.2 Quilting sutures
can also decrease flap tension. These sutures are progres­
sively placed attaching the skin flap to the aponeurosis, thus
decreasing tension on the skin edge.26
The risk of hematoma is secondary to many factors.
However, dead space is an important issue when blood loss
is considered. Therefore, quilting sutures can be helpful
when this complication occurs. In small hematomas con­
servative management is probably the best way to deal with
this complication. In such cases, seroma can occur second­
arily and ultrasound exam is a useful tool. It usually occurs
12–15 days after the surgery. Sequential aspirations of the
secondary seroma with blood content should be done. In
large hematomas, reoperation is indicated to remove blood
clots and to avoid secondary fibrosis.
Recurrence of myoaponeurotic deformities is another
complication that will force the surgeon to perform an exten­
sive surgery to correct it. It usually occurs when the most
appropriate technique to correct a specific defect was not
used. Patients with type C myoaponeurotic deformities may
present recurrence of rectus diastasis in the upper abdomen
if plication of the anterior rectus sheath is performed.12 As
mentioned before, this complication occurs because the recti
muscles present a lateral insertion on the costal margin.
However, patients with weak aponeurosis may also present
recurrence of the deformities, depending on aponeurotic
composition and the predominance of collagen.27
CONCLUSION
It is essential to diagnose the type of abdominal deformity
and use a specific technique to correct it. Knowledge of
the local anatomy is paramount to evaluate and treat the
LOCAL COMPLICATIONS AND
THEIR MANAGEMENT
Although the number of complications following abdomi­
noplasty has fallen drastically in the last 30 years,18 this
operation still has a large range of complications. Scar
widening, dyschromic and hypertrophic scars, and dog-ears
are common complications that occur after abdominoplasty.
Different treatments are used to control these conditions
such as chemical peels for hyperchromic scars, intralesional
steroid injections for hypertrophic scars, the removal of
excess skin in cases of dog-ears and scar excision for the
correction of wide scars. Dog-ears can be prevented by
sitting the patient up during the operation. The quality of
the scar can be improved by good planning and with the
use of micropore strips over the scar or silicone. These
preventive measures will not avoid all complications but
can certainly decrease their incidence.
Sensitivity of the abdominal skin may decrease after
abdominoplasty. Usually the most affected areas are the
region between the umbilicus and the pubic area and the
pubic region itself. The main modalities of sensitivity loss
are to pressure and heat.5 Therefore, these patients are more
exposed to contact burn accidents on hot surfaces such as
hot ovens and barbecue grills. When lipoabdominoplasty is
used, the innervation of the abdominal flap is kept intact,
thus preserving skin sensibility in these areas.19
Umbilical constriction is not a frequent complication,
but it may be troublesome. Most plastic surgeons try to
obtain a small umbilicus, which is a sign of youth and
esthetically pleasing. However, if there is excessive tension
at the edges of the skin to be sutured to the umbilicus,
dehiscence can occur and a circular scar will constrict the
umbilical area. There is an expected shortening of the
umbilical pedicle after the plication of the anterior rectus
sheath. The umbilical pedicle fixation to the anterior rectus
fascia permits the surgeon to control the pedicle height and
consequently the tension at the skin edges during the suture.
Therefore, in some cases, the skin pedicle should be
advanced superficially, using the aponeurosis as a step to
obtain tension decrease of the skin suture between the
umbilical skin and the abdominal flap.20
Seroma is the most frequent complication of abdomino­
plasty. Baroudi and Ferreira in 199821 described the use of
quilting sutures to avoid this complication. Nahas et al22
have verified that this technique is efficient in patients with
risk factors for developing seroma, for example those
who are overweight, those who have presented massive
weight loss, and those with supraumbilical scars. Di Martino
et al23 have shown that the use of quilting sutures during
abdominoplasty was more successful in preventing seroma
than when lipoabdominoplasty was performed. Therefore,
seroma can be prevented in most cases. However, when
seroma occurs, aspiration of this fluid should be done every

196
PART | 5  Abdominal contouring procedures
deformity. The diagnosis of the correct abdominal defor­
mity will help plastic surgeons to prevent complications.
Good preoperative planning will avoid excessive flap
tension and will help to decrease the risk of recurrence of
myoaponeurotic deformities.
REFERENCES
1. Pitman GH. Liposuction and body contouring. In: Aston SJ, Beasley
RW, Thorne CHM, editors. Grabb and Smith’s Plastic Surgery. New
York: Lippincot-Raven; 1997. p. 669–91.
2. Nahas FX. Refinamentos em abdominoplastia. Rev Bras Cir 2002;93:
58–60.
3. Lowe JB, Lowe JB, Baty JD, et al. Risks associated with “compo­
nents separation” for closure of complex abdominal wall defects.
Plast Reconstr Surg 2003;111(3):1276–83.
4. Persichetti P, Simone P, Scuderi N. Anchor line abdominoplasty.
Plast Reconstr Surg 2005;116(1):289–94.
5. Farah AB, Nahas FX, Ferreira LM, et al. Sensibility of the abdomen
after abdominoplasty. Plast Reconstr Surg 2004;114(2):577–82.
6. Rubinstein E. Vascularização da parede abdominal. In: Petroianu A,
editor. Anatomia Cirúrgica. Guanabara Koogan: Rio de Janeiro;
1999. p. 375–8.
7. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be cor­
rected? Aesth Plast Surg 1997;21(4):285–9.
8. Nahas FX, Augusto SM, Ghelfond C. Nylon versus polydioxanone
in the correction of rectus diastasis. Plast Reconstr Surg 2001;107(3):
700–6.
9. Nahas FX. Pregnancy after abdominoplasty. Aesth Plast Surg 2002;
26(4):284–6.
10. Nahas FX, Ferreira LM, Augusto SM, et al. Long-term follow-up
of correction of rectus diastasis. Plast Reconstr Surg 2005;115(6):
1736–41.
11. Nahas FX, Ferreira LM, Ely PB, et al. Rectus diastasis corrected
with absorbable suture: a long-term evaluation. Aesth Plast Surg
2011;35(1):43–8.
12. Nahas FX, Ferreira LM, Mendes J de A. An efficient way to correct
recurrent rectus diastasis. Aesth Plast Surg 2004;28(4):189–96.
13. Nahas FX. Advancement of the external oblique muscle flap to
improve the waistline: a study in cadavers. Plast Reconstr Surg 2001;
108(2):550–5.
14. Barbosa MV, Nahas FX, Sabia Neto MA, et al. Strategies in umbili­
cal reconstruction. J Plast Reconstr Aesth Surg 2009;62(6):
e147–150.
15. Nahas FX. A pragmatic way to treat abdominal deformities based
on skin and subcutaneous excess. Aesth Plast Surg 2001;25(5):
365–71.
16. Nahas FX. An aesthetic classification of the abdomen based on the
myoaponeurotic layer. Plast Reconstr Surg 2001;108(6):1787–95;
discussion 1796–1797.
17. Nahas FX, Ishida J, Gemperli R, et al. Abdominal wall closure after
selective aponeurotic incision and undermining. Ann Plast Surg 1998
Dec;41(6):606–13.
18. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal
contour surgery: a national plastic surgery survey. Plast Reconstr
Surg 2006;117(6):1797–808.
19. Bello EML, Mitre LF, Nahas FX, et al. Avaliação da sensibilidade
cutânea abdominal pós-lipoabdominoplastia. In: Saldanha O, editor.
Lipoabdominoplastia. São Paulo: Di Livros; 2004. p. 85.
20. Nahas FX. How to deal with the umbilical stalk during abdomino­
plasty. Plast Reconstr Surg 2000;106(5):1220–1.
21. Baroudi R, Ferreira C. Seroma: how to avoid it and how to treat it.
Aesth Surg 1998;18:439.
22. Nahas FX, Ferreira LM, Ghelfond C. Does quilting suture prevent
seroma in abdominoplasty? Plast Reconstr Surg 2007;119(3):
1060–4.
23. Di Martino M, Nahas FX, Barbosa MV, et al. Seroma in lipoabdomi­
noplasty and abdominoplasty: a comparative study using ultrasound.
Plast Reconstr Surg 2010;126(5):1742–51.
24. Zecha PJ, Missotten FEM. Pseudocyst formation after abdomino­
plasty. Br J Plast Surg 1999;52:500–2.
25. Mayr M, Holm C, Höfter E, et al. Effects of aesthetic abdomino­
plasty on abdominal wall perfusion: a quantitative evaluation. Plast
Reconstr Surg 2004;114(6):1586–94.
26. Pollok H, Pollok T. Progressive tension sutures: a technique to
reduce local complications in abdominoplasty. Plast Reconstr Surg
2000;105(7):2583–6.
27. Nahas FX, Ferreira LM. Concepts on correction of the musculoapo­
neurotic layer in abdominoplasty. Clin Plast Surg 2010 Jul;37(3):
527–38.

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© 2013 Elsevier Inc
Part 5  Abdominal contouring procedures
Chapter 20 
Key Points
●
Morphological and histological analysis demonstrates
differences in the superficial layer, regarding the layout
of lobes, the shape disposition of interlobular septa
tissue (collagen), and thickness of the different body
parts.
●
Marking before surgery is considered a key step for
successful surgery. This should always be performed
with the patient standing in front of the mirror. This
ensures three-dimensional mobility and the patient can
monitor all the surgeon’s movements and tracings.
●
Ultrasonic energy (UAL) and vibroliposuction (VL) are
useful as aids to conventional liposuction, but not for
skin retraction.
●
Liposuction must respect the histological peculiarities
of the superficial layer of fat in order to stimulate skin
retraction, and follow the muscle fibers’ direction; this
makes it possible to carve the fat on the muscle,
avoiding criss crossing.
Lipomyosculpture
Ewaldo Bolivar Souza Pinto Sr., Pablo Silva Frizzera Delboni and Matheus Monseff Vieira Borela
INTRODUCTION
Since the first half of the twentieth century, many surgeons
have been trying to change body contours in accordance
with changing concepts of beauty. Since its introduction by
Illouz, liposuction has become the best option for body
contouring surgery. Improvements in conventional surgery
became possible with the development of new liposuction
equipments and methods.
In this chapter we describe a new body contouring tech­
nique, based on the direction of muscle fibers and collagen,
rather than the more traditional crossing tunnels. Excellent
results have been achieved, with less trauma and better skin
retraction.
PREOPERATIVE PREPARATION
The clinical evaluation should be as thorough as possible,
based on detailed history and physical examination.
It is important to have data on: age, sex, comorbidities,
medications, allergies, gastroesophageal reflux, any history
of tranfusions and their reactions, abuse of legal and illegal
drugs, anesthesia complications, the possibility of preg­
nancy, and functional capacity.
A complete physical examination should be performed,
with emphasis on cardiovascular disorders and volume
status.
Supplementary examinations should not be carried out
randomly and indiscrimately, but in accordance with the
clinical evaluation in order to recommend and implement
pre- and postoperative care aimed at reducing the surgical
risk.
MORPHO-HISTOLOGY OF
SUBCUTANEOUS ADIPOSE TISSUE
The subcutaneous tissue is divided into two layers. Its mor­
phological and histological analysis demonstrates differ­
ences in the superficial layer, regarding the layout of lobes,
shape, disposition of interlobular septa tissue (collagen),
and thickness of different body parts (Fig. 20.1).
● Upper abdomen: irregular (50%), elliptical (40%) and
rounded (10%) lobes with a parallel arrangement to the
epidermis, thick (50%) and thin (50%) septa with a
parallel arrangement in relation to the lobes (Fig. 20.2).
● Lower abdomen: irregular (50%), elliptical (30%) and
rounded (20%) lobes with a parallel arrangement to the
epidermis, thick (70%) and thin (30%) septa with a
parallel arrangement in relation to the lobes (Fig. 20.3).
● Lateral thigh: irregular (80%), elliptical (10%) and
rounded (10%) lobes with a parallel arrangement to the
epidermis, thick (70%) and thin (30%) septa surround­
ing the lobes (Fig. 20.4).
● Anterior thigh: irregular (60%), elliptical (30%) and
rounded (10%) lobes with a parallel arrangement to the
epidermis, thick (50%) and thin (50%) septa surround­
ing and penetrating the lobes (Fig. 20.5).
● Medial thigh: irregular (90%) and elliptical (10%) lobes
with a parallel and perpendicular arrangement to the
epidermis, thick (30%) and thin (70%) septa surround­
ing and perforating the lobes (Fig. 20.6).

198
PART | 5  Abdominal contouring procedures
FIG. 20.1  Layout of fat cells in different areas of the body. Topography of the areas studied.
Sub-mental region
Lower abdomen
Anterior face of
the thigh
Upper abdomen
Flank
Dorsal region
Sacral region
Medial face of
the thigh
Gluteal region
Lateral face of
the thigh
A
B
FIG. 20.2  Upper abdomen: thick and parallel septa tissue.
FIG. 20.3  Lower abdomen: thick and surrounding septa tissue,
irregular lobes of adipose tissue.

199
Chapter | 20  Lipomyosculpture
● Dorsal region: irregular (80%), elliptical (10%) and
rounded (10%) lobes with a parallel arrangement to
the epidermis, thick (80%) and thin (20%) septa (Fig.
20.7).
● Flank: irregular (70%), elliptical (20%) and rounded
(10%) lobes with a perpendicular arrangement to the
epidermis, thick (50%) and thin (50%) septa surround­
ing and perforating the lobes (Fig. 20.8).
● Gluteal region: irregular (80%), elliptical (10%) and
rounded (10%) lobes with a parallel arrangement to the
epidermis, thick (90%) and thin (10%) septa surround­
ing and perforating the lobes (Fig. 20.9).
● Sacral promontory: irregular (80%), elliptical (10%)
and rounded (10%) lobes with a parallel arrangement to
the epidermis, thick (90%) and thin (10%) septa perpen­
dicular to the lobes (Fig. 20.10).
● Submental region: irregular (90%) and elliptical (10%)
lobes with a perpendicular arrangement to the epider­
mis, thick (40%) and thin (60%) septa surrounding the
lobes (Fig. 20.11).
FIG 20.4–20.11 APPEARS ONLINE ONLY
Comparing this analysis to results from clinical obser­
vations after liposuction there is an increased skin retrac­
tion in those topographies, in which the septa, consisting
mostly of collagen, are thicker. Recently, we have been
studying a new concept in liposuction – noncrossing
tunnels – during the procedure. This new technique follows
the muscle fiber directions in each aspirated region, pre­
serving the integrity of the collagen fibers, which are
responsible for greater skin retraction in the postoperative
period.
SURGICAL TECHNIQUE
Marking
Marking before surgery is considered a key step for suc­
cessful surgery. Marking is always performed with the
patient standing, without the administration of preanes­
thetic and in front of the mirror. While ensuring three-
dimensional mobility, the patient can monitor all the
surgeon’s movements and tracings, and is able to give his/
her opinion and indicate the areas that bother most and that
may go unnoticed. Thus, patient and surgeon can match
expectations and actual surgical possibilities. After defining
the areas to be sucked, the direction of the muscle fibers is
drawn to help in following the technique of lipomyosculp­
ture (Figs 20.12–20.14).
Patient Position
It is essential to provide comfort and safety to patients.
The position, depending on the region to be treated, should
FIG. 20.12  Marking following the muscle fibers – front.
FIG. 20.13  Marking following the muscle fibers – profile.

199.e1
Chapter | 20  Lipomyosculpture
FIG. 20.4  Lateral thigh: thick and perforating septa tissue.
FIG. 20.5  Anterior thigh: thick and surrounding septa tissue, irreg­
ular lobes of adipose tissue.
FIG. 20.6  Medial thigh: thin and surrounding septa tissue, irregular
lobes.

199.e2
PART | 5  Abdominal contouring procedures
FIG. 20.10  Sacral promontory: thick and perforating septa tissue,
elliptical lobe of adipose tissue.
FIG. 20.11  Submental region: thin and surrounding septa tissue.
FIG. 20.9  Gluteal region: thick and perforating septa tissue, irregu­
lar lobes of adipose tissue.
FIG. 20.8  Flank: surrounding septa tissue, irregular lobes of adipose
tissue.
FIG. 20.7  Back: thick and perforating septa tissue.

200
PART | 5  Abdominal contouring procedures
FIG. 20.14  Marking following the muscle fibers – back.
superficial layer is treated according to the peculiarities of
each region.
Submental
In this region of loose collagen and irregular cells, we use
a 3 mm cannula in the superficial layer, through a submen­
tal incision. This follows the fibers of the platysma muscle,
just to standardize it without removing excessive fat, which
prevents sagging.
Arm
In this area, the liposuction is performed in the superficial
layer with a 3 mm cannula, following the direction of the
triceps brachii muscle. The incision may be proximal or
distal.
Upper Abdomen
This region has more irregular globules and looser collagen
than the lower abdomen, creating an area more susceptible
to irregularities. In this region we use a 3 mm cannula with
conventional liposuction for the refinement of this layer,
after aspiration of the deeper layer with UAL and VL
through an incision at the level of the xiphoid process, fol­
lowing the fibers of the rectus abdominis muscle.
Lower Abdomen
By having a greater amount of collagen, the superficial
layer becomes more compact and thicker than in the upper
abdomen. So, we use UAL and VL in both layers, superfi­
cial and deep, and a posterior refinement is performed
with a 3 mm cannula. When treating the lateral region of
this area we use two incisions at the level of the pubis,
equidistant from the midline, directing the cannula based
on the rectus abdominis muscle and external oblique
muscle.
Back
In an area of irregular globules and dense collagen, we use
UAL and VL to facilitate the removal of this resistant tissue,
and then a 3 mm cannula for the refinement. We follow the
direction of the trapezius muscle and the latissimus dorsi
muscle, by incisions in the superior or inferior area of the
tracing, or both. We insert a silicon drain in the dorsal
region, which is removed after 24 hours.
Flank, Sacral Promontory, and Lateral Thigh
The irregular globules with dense collagen give these
regions a stronger consistency. So we use UAL and VL in
these layers, as we do in the deep layer, facilitating
its removal. Finally, we perform the refinement of the
favor the tubes’ orientation, allowing a wide approach to
the area to facilitate the liposuction.
The patient can be positioned on the operating table in
the prone, supine, or right and left lateral positions.
Liposuction
The incisions are 5 mm thick, usually perpendicular to the
power lines and located in the peripheral area of the region
to be treated, allowing the cannula to be correctly aligned.
Subcutaneous fat layers with variable thickness should
always be left, depending on the treated area, to avoid
excess sagging skin and to maintain a correct body anatomy,
particularly in women, who need this fat to maintain estro­
gen homeostasis.
In all areas, regardless of the tube thickness or the use
of ultrasound-assisted liposuction (UAL) or vibroliposuc­
tion (VL), liposuction is performed following the anatomi­
cal direction of the muscle fibers, as an essential part of the
lipomyosculpture technique.
Liposuction begins at the deep layer of subcutaneous
tissue. This layer, because of the lack of histological differ­
ences in the different body areas studied, is treated in the
same way with UAL and VL. This aids conventional lipo­
suction, which is performed later (except in regions such as
the buttocks, submental, arm, anterior thigh, and medial
thigh, where superficial dermal lesions may be caused). The

201
Chapter | 20  Lipomyosculpture
superficial layer with a 3 mm cannula. We follow the fibers
of the external oblique muscle and latissimus dorsi muscle,
and the fibers of the tensor fascia lata muscle and vastus
lateralis muscle on the lateral thigh, and latissimus dorsi
muscle on the promontory. An incision in the intergluteal
groove gives access to both promontory and flank, and
other incisions can be made as needed, in order to facilitate
access. In the flank, the incision is made in the tracing
proximal or distal periphery, or both.
Buttocks
The subcutaneous tissue in the projection of the gluteal
muscles is respected, and only the superior insertion out­
lines are aspirated.
Anterior Thigh
We treat only the irregular globules of the superficial layer,
using a 3 mm cannula to harmonize the surface, and a ring
cannula to rearrange the fat between the collagen fibers,
preventing imperfections. The incision is also made in the
tracing proximal or distal periphery, following the fibers of
the rectus femoris muscle and vastus medialis muscle.
Medial Thigh
Irregular lobes of fat, interspersed with collagen, form a
fragile structure with the thin skin that overlaps. The treat­
ment of our choice is liposuction only in the superficial
layer, with a 3 mm cannula, or up to a 4 mm cannula in
cases where the patient has a greater subdermal layer, and
maintain the deep layer to support the region. This prevents
postoperative sagging. We follow the fibers of the gracilis,
adductor longus and adductor magnus muscles, through an
incision near the groin.
Knee
The inner side of the knee should be aspirated cautiously
with a 3 mm cannula, due to a high risk of irregularities,
with direction based on the distal region of the sartorius and
gracilis muscle fibers, through an incision in the medial
popliteal groove.
POSTOPERATIVE CARE
After the surgery, the treated areas are protected with com­
pression bandages and a medium compression mesh, for a
minimum of 30 days. Later precautions involve lymphatic
drainage, the goal of which is the dissolution of residual
nodules and global stimulation of this system.
COMPLICATIONS
Complications of lipomyosculpture are almost the same as
those in conventional liposuction. They can be local or
systemic. However, we observed that lipomyosculpture
has fewer local complications such as bruises, seroma and
irregularities.
CONCLUSION
The superficial body anatomy is formed mainly by its
muscles, so the perfect body would be the one with visible
muscle structures, giving the desired shape. Based on
subcutaneous tissue histology and muscle fiber arrange­
ment, the technique of lipomyosculpture was developed.
This consists of performing liposuction, while respecting
the histological peculiarities of the superficial layer of fat
in order to stimulate skin retraction, and following the
muscle fibers’ direction, thereby seeking to carve the fat
onto the muscle.
Through this technique we can also minimize some
common complications in conventional liposuction, such as
intraoperative bleeding and muscle damage. This happens
because the location of the subcutaneous neurovascular
bundle follows the same direction as the muscle fibers, so
there is less chance of bleeding (Fig. 20.15). Muscular
trauma and its consequences are diminished when fibers are
divided, instead of breaking them incidentally with the
cannula.
FIG. 20.15  Fat resulting from lipomyosculpture.
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PART | 5  Abdominal contouring procedures
A
B
C
FIG. 20.16  (A–D) 33-year-old patient – 15 days postoperative.