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

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PART | 5  Abdominal contouring procedures
B
C
A
FIG. 20.18  (A–C) 31-year-old patient – 6 months postoperative.

205
Chapter | 20  Lipomyosculpture
A
B
C
FIG. 20.19  (A–C) 20-year-old patient – 30 days postoperative.

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PART | 5  Abdominal contouring procedures
FIG. 20.20  (A–C) 33-year-old patient – 60 days postoperative.
A
B
C

207
Chapter | 20  Lipomyosculpture
FIG. 20.21  (A) Patient aged 54, 2 years postoperative of primary conventional liposuction (left); 3 months postoperative of secondary liposuc­
tion (lipomyosculpture) (right). (B) Patient aged 54 showing skin retraction after lipomyosculpture.
A
B

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PART | 5  Abdominal contouring procedures
The technique achieves both layers, superficial and deep
subcutaneous tissue, in order to obtain a good skin retrac­
tion and a smooth removal of fat tissue. This requires a
careful surgical sequence to obtain the desired results. See
case studies shown in Figs 20.16–20.21.
FURTHER READING
da Rocha RP. Atlas de cirurgia estética para o residente. Revinter Ltda
2005;1:29.
Ferner H, Staubes J., Sobotta J. – Atlas de anatomia humana. 18th ed.
Editora: Guanabara Koogan SA; 1984.
Souza Pinto EB. Nossa experiência em lipoaspiração. Brasília/Brazil:
Anais do Congresso Brasileiro de Cirurgia Plástica; 1983.
Souza Pinto EB. Lipoaspiração superficial. Revinter: Rio de Janeiro;
1999.
Souza Pinto EB. Morphohistologic analysis of fat tissue in áreas treated
with lipoplasty. Aesth Plast Surg J 2002;513–8.
Souza Pinto EB, Federico R, Pessoa de Melo SP, et al. Lipomioplasty with
Vaser: A new approach to body contouring. Innovations in Plastic and
Aesthetic Surgery 2008;54:433–42.
Figs 20.4–20.11 can be found online.
Bonus images for this chapter can be found online at

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© 2013 Elsevier Inc
Chapter 21 
Key Points
●
The classic abdominoplasty which encompasses
excision of excess skin and abdominal wall tightening
offers excellent surgical outcomes and patient
satisfaction with contour improvements.
●
Correct surgical planning and measurements permit an
inconspicuous scar that will be hidden in a bikini-style
swimsuit.
●
The use of adhesion stitches to abolish dead space
between the layers has proven effective in reducing
the incidence of postoperative seroma.
●
Attention to the technical aspects of umbilical inset
and contouring will produce a natural-appearing
outcome.
Classic abdominoplasty with adhesion
tension sutures
Ricardo Baroudi
INTRODUCTION
The history of abdominoplasty starts at the end of the 19th
century. Since then new approaches have been introduced
continuously by various authors. Its history was published
by Hakme,1 Baroudi,2 and Sinder3 in Brazil, and also by
other plastic surgeons. This chapter will focus on our
experience of five decades in the transverse pubic type
of incision. For historical purposes, Monard4 in 1930 was
the first to do this type of surgery with umbilicus transposi­
tion. Liposuction was used by Illouz5 in abdominoplasty.
Pitanguy6 and Bozola7 published their classifications
involving both male and female patients. These academic
classifications orient the surgeons to select their technique
according to the type of esthetic deformity and functional
problems. Two patients were selected to illustrate the pro­
posed technique, with different degrees of subcutaneous
volume, flaccid skin, and recti diastases. In general the
results are different, even performing the same procedures,
based on the aspects of the trunk shape, skin quality, the
patient’s age, and whether or not liposuction was performed
at the same surgical stage, and also by the surgeon’s
qualifications. We did not include morbidly obese or post-
bariatric patients, but just those with an unesthetic abdomi­
nal shape.
SURGICAL TECHNIQUE
We prefer general endotracheal anesthesia. The abdominal
skin markings are always done after the surgical prep.
When liposuction is to be used, the patient is marked in the
standing position.
Three main situations occur in this type of abdomino­
plasty as described by Baroudi and Ferreira.8
1. The umbilical hole at the skin abdominal flap crosses
the transverse pubic incision.
The skin demarcations are shown in Figure 21.1A–D.
The surgery starts after previous skin infiltration with saline
solution and epinephrine 1: 400 000 in all the demarcated
areas. The skin is incised at the pubic level and the incision
is extended towards the iliac spines, in general from 35 to
45 cm in length, deep to the superficial fascia level. The
skin is undermined at the deep fascia plane up to the umbili­
cal stalk, which is dissected from the skin flap. The dissec­
tion concludes near the xiphoid. Above the umbilicus, the
dissection narrows to the lateral limits aside the recti
muscles in order not to decrease the blood supply to the
flap (Fig. 21.2A, B).
The recti fascia plication is performed in two levels.
From the xiphoid to the pubis with isolated nonabsorbable
2-0 stitches with the knot faced downward. Next, a second
running suture is applied, also from the xiphoid area to the
pubis with a 2-0 nonabsorbable suture. This suture is inter­
rupted 3 cm above the umbilical pedicle and starts again
3 cm below it. Never cross over the umbilical stalk, in order
to avoid possible contamination of the nonabsorbable suture
(Fig. 21.3A–D).
The patient is then positioned with the trunk and the
inferior limbs slightly elevated (each at 20°). The under­
mined skin flap is then stretched caudally; the umbilical
Part 5  Abdominal contouring procedures

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PART | 5  Abdominal contouring procedures
Fig. 21.1  Schematic aspects of the pubic low transversal incision. (A) The resection involves an elliptical transverse skin shape from the hypogas­
trium. The demarcation starts with a vertical median (x-x′) xiphopubic line, followed by two transverse lines placed at the level of the pubis above 7 cm
from the vulvar commissure and (B) at the umbilicus upper limit. At the crossing line A and the xiphopubic, points (1) and (2) are placed bilaterally at
an equal distance, measuring 10 to 14 cm according to the pubis volume. From points (1) and (2) two lazy curved lines reach the anterior superior iliac
spine bilaterally. This is compared to a bicycle-handlebar shape. The points (1) and (2) are placed at the line (B) bilaterally, receiving the numbers (5)
and (6) and from each one two small parallel and perpendicular lines are delineated. Finally, from the umbilicus upper limit two convex lines are placed,
also bilaterally directed to the iliac spine. These two lines cross the two vertical lines from points (5) and (6) at the points (3) and (4). It is important
that 1–3–5 = 2–4–6, to obtain an equal amount of skin excess resection and a symmetric suture line. The photo (B) shows the patient’s anterior abdominal
wall after the skin demarcations, similar to the schematic drawing, where (R) and (U) represent skin resection and undermining respectively. (C) Close-up
of the skin demarcations. Routinely provisional stitches are placed at points 1, 2, 5, and 6 to avoid loss of the demarcations during the surgery. (D) The
distance from the vulvar commissure and the transversal pubic demarcation goes from 6 to 7 cm. The small dark arc demarcation is selectively resected
at the end of the surgery to reduce the distance vulva to pubis when it is over 8 cm in length.
A
B
C
D

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Chapter | 21  Classic abdominoplasty with adhesion tension sutures
should number 40 to 45. From the xiphoid to the umbilical
line the skin flap is always stretched slightly after each
stitch line is applied.
Next, the umbilicoplasty described by Baroudi9 is per­
formed in the following stages:
● Dissection of the stalk, leaving 1 cm of a round skin
island at its free extremity. Whatever the pedicle length,
two isolated 2-0 nonabsorbable material stitches are
inserted at 12 and 6 o’clock, passed through the dermis
of the umbilicus and fixed at the fascia level.
● A 2 cm transversal incision transfixes the abdominal
skin flap at the level of the umbilicus. Four cardinal
position nonabsorbable 2-0 stitches transfix the skin
edge flap incision, then the recti fascia below, the skin
island, and merge through the open skin flap incision
again (Fig. 21.6A–C).
Pinch tests stretching the four stitches check the correct
position in the xiphopubic line (Fig. 21.5). They remain
loose until the abdominal flap is partially sutured into its
definitive position. After the umbilicoplasty steps, the adhe­
sion stitches continue to be placed according to the previous
orientation until they reach the lower edge incision of the
skin. In each line of stitches the skin flap is stretched cau­
dally to estimate its position along the lower transversal
incision of the skin. The final suture between the skin flap
and the low incision edge is always with absorbable 3-0
sutures. The superficial fascia is repaired as part of the
wound closure and finished with dermal and subcuticular
sutures. After this step, the umbilicoplasty is concluded
with the previous 2-0 stitches tightened and complementary
isolated 4-0 nonabsorbable stitches are placed between
them. A gauze pad with ointment is fixed by two of the
uncut stitches (Fig. 21.7). A sterile porous adhesive material
covers the whole suture line and the patient wears an elastic
girdle from the submammary line down to the superior half
of the thighs. Since 1998 no suction drains have been used
in the abdominoplasty. Figure 21.8A–C illustrates the
results obtained.
2. The umbilical hole at the skin abdominal flap partially
crosses the transverse pubic incision.
The specific detail relates to the umbilical hole at the
abdominal skin flap, which is not eliminated completely
and an inverted T compensation (from 1–4 cm in length)
needs to be performed at the pubic midline. A technical
detail involves the suture of the subcutaneous tissue below
the T area to the fascia below to avoid dead space.
3. The umbilical hole at the skin abdominal flap does not
reach the transverse pubic incision.
Patients in this group must have the original umbilical
hole sutured in three planes (subcutaneous, dermis and
Fig. 21.2  (A) No more extended skin flap undermining, but
(B) limited to avoid unnecessary dead space.
A
X
B
hole always surpasses the pubic transverse incision and the
excesses are resected. Routinely, several bilateral tunnels
are made with scissors along the undermined skin flap
limits to release its adhesion and augment its slide caudally,
to preserve the flap blood supply (Fig. 21.4). The skin flap
is then divided longitudinally in two equal halves and a
provisional stitch anchors the flap to the median portion of
the pubis. Each skin part is divided again and another two
provisional stitches fix the flap to the points (1) and (2) on
Fig. 21.4. Finally, all the skin excesses are resected. The
provisional stitches are removed and the skin flap elevated
with a skin retractor. The adhesion suture (quilting stitch)
is applied with absorbable 3-0 stitches in lines and columns
from the xiphoid down to the pubis. The distance between
them should not be over 4 cm and the amount of stitches

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PART | 5  Abdominal contouring procedures
Fig. 21.3  (A, B) Schematic aspects of the recti fascia plication with isolated nonabsorbable 2-0 stitches from the xiphoid down to the pubis.
The 1 cm umbilicus skin island dermis is sutured to the fascia (C, D). A 2-0 second running suture line from the xiphoid to the pubis. The suture
stops 3 cm above the umbilicus and starts 3 cm below it to avoid eventual contamination though the umbilicus suture line. The umbilicus is
positioned inside the white square line.
A
B
C
D
cuticular) leaving a vertical midline suture up to 4 cm in
length, between the new umbilicus and the pubis. The prim­
itive umbilicus pedicle is implanted in its normal position
(Fig. 21.9).
SEVEN COMMENTS
1. From the time of its invention in 1947, the bikini has
become a popular style of swimwear in most countries.
The reduction of the bikini to the “tanga” and thong
styles became another headache for plastic surgeons in
placing their abdominoplasty scars. From 1988 we have
been working with an incision that should be placed very
low at the pubis and higher towards the anterior–superior
iliac spine bilaterally. In 1995, Baroudi and Ferreira8
published their results. Since then no specific aspects of
the incision have been changed. The scar position remains
covered by the normal bikini and never by a tanga or
thong. This incision and the final scar remain similar to
what we called a “bicycle handlebar” incision.
2. The adhesion stitches or kilting sutures open up an
effective gap in plastic surgery as a procedure to reduce
and avoid hematoma and seroma.8,10,11 Basically, the
idea is to reduce the dead space to avoid the skin flap

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Chapter | 21  Classic abdominoplasty with adhesion tension sutures
Fig. 21.4  (A and B) With long scissors several tunnels are created
bilaterally at the limit of the undermined skin flap to facilitate the flap
slide maintaining its blood supply.
Fig. 21.5  (A, B) Schematic aspects of the skin flap stretched caudally with the umbilicus skin hole trespassing the pubic line, incised at its
midline with a provisional stitch.
A
B
bursa exposed, and multiple isolated adhesion stitches
with absorbable 3-0 material biting both sides of
the membrane made the dead space collapse without
recurrence.
This experiment was successful and we have applied
it to abdominoplasty. In the first 2 years the drainage and
adhesion stitches were studied. Before the adhesion
stitches the drainage average in our cases with suction
drains was around 120 to 180 ml in the first 24 hours,
reducing to 80 ml on the second day and 50 ml on the
third day of the postoperative period after being removed.
During the first 2 years, 1986–1987, using suction
drains and adhesion stitches, the drainage was around
50 to 60 ml on the first day, reducing to 30 ml on the
second day, when they were removed. No clinical
seromas were detected using the described procedures.
From 1998 on, no more suction or any other type of
drains have been used. The results still remain at zero
incidence of postoperative seroma.
We have been applying these adhesion stitches in
all types of surgeries with dead space in all regions
of the body. This includes TRAM and latissimus dorsi
donor sites for breast reconstruction, axillary pits
after radical mastectomy, brachio- and thighplasty,
sliding over the connected planes. By the end of 1987,
this was applied for the first time in a male patient
with a hematoma, 4 months post-trauma at the lateral
aspect of the thigh with an organized pseudo bursa
without collapse after nonoperative treatment. In this
patient the skin over the area was incised, the pseudo

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PART | 5  Abdominal contouring procedures
hypogastrium, almost at the mid distance between the
umbilicus and the anterior vulvar commissure.
Another item is the asymmetry of the scar, with one
side longer than the other and at different levels. The
final suture at the mons pubis must be placed 7 cm from
the vulvar commissure at the end of the surgery. Even
so, the continuous local tension in the following 6
months will stretch it upward. When placed at 7 cm, the
scar is elevated 1–3 cm, remaining distant 9 to 10 cm
from the vulva. If the surgery finishes with 9 to 11 cm,
its final position will be around 12 to 14 cm, in other
words, at the mid-hypogastrium level. Another final
detail is still related to the pubic local skin suture
tension. Quite often it became broad at around 10 to
15 mm in this area. Some patients complain about this
and a scar revision is performed as needed to improve
scar quality. Interestingly, at the lateral extent of the scar
where there is minimal tension, the scars are thin and
pale. In conclusion, we recommend that the surgeon
measure the distance from the vulva commissure and
the pubic suture line at the end of the surgery before the
last cuticular running suture is applied.
4. After Baroudi12 studied 40 Caucasian women without
previous abdominoplasty, the average distances of the
Fig. 21.6  (A–C) Schematic aspects of the umbilical pedicle after its dissection. Whatever its length, 1 cm of skin island is sutured to the fascia
after its plication.
A
B
C
Fig. 21.7  Final suture aspect, with low position of pubic suture line
and the two lateral branches toward the iliac spine. At the navel two
long stitches aligned at 12 and 6 o’clock tie the gauze pad with oint­
ment for 48 hours.
facelift around the pre- and postauricular areas, and skin
flaps.
3. Why all the measures before the start of the abdomino­
plasty? It takes a minimum 10 to 15 minutes for marking
and planning, but also gives us and the patient satisfac­
tion with the scar shape, symmetry, and position in the
lower portion of the abdomen, covered by a normal
bikini. Very often we have seen the reverse – a high-
positioned transverse scar placed horizontally along the

215
Chapter | 21  Classic abdominoplasty with adhesion tension sutures
Fig. 21.8  (A–C) Pre- and 10 months postoperative front view of a 61-year-old female patient operated in 2002, combined with liposuction of
the abdomen and flanks after 6 months, with the scar still reddish and completely covered by small underwear.
A
B
C

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PART | 5  Abdominal contouring procedures
the bikini leaving 1–3 cm of a vertical scar at the pubic
area. In 5% of the abdominoplasties with up to 4 cm of
vertical umbilical scar placed between the new position
of the umbilicus and the pubis, we did not receive any
complaints from our patients.
5. Umbilicoplasty and neo-umbilicoplasty as described by
Baroudi9,13 have two technical details to be considered.
The umbilicus is the only scar of the body that when
absent or distorted, becomes unacceptable by people of
both sexes. Its technical evolution is a nonstop system
towards a better esthetic. Several techniques have been
published. If there are problems of necrosis, stenosis,
broad umbilicus, lack of deepness, scarring, etc., the
solution involves its complete resection followed by a
neo-umbilicoplasty.
This is based on the complete resection of the umbil­
ical stalk, the application of several isolated nonabsorb­
able 4-0 stitches all round the raw edge fixed to the
fascia, which are then covered with gauze and ointment.
The gauze is removed after 3 days, the raw area cleaned
daily, the stitches removed after 12 days and all the
epithelialization completed around 4 weeks (Fig.
21.10A–D). For those interested in umbilicoplasty
without external scar, Amud14 and Abreu15 have recently
published their technique and results.
6. Liposuction and abdominoplasty in the same surgical
procedure became accepted and applied as routine after
the pioneer procedures of Avelar16 and Saldanha.17,18
The great goal and safety of the technique is the narrow
umbilicus from the vulvar anterior commissure were
between 18 and 21.5 cm. After abdominoplasty by low
pubic transverse incision the average distance was
17 cm, which still gives a good esthetic result. These
parameters have been used routinely to measure these
distances before and after surgery. The three described
groups of patients underwent an abdominoplasty. In the
first group the umbilical hole surpassed the transverse
skin pubic incision in 77% of those operated on; 18%
received a T compensation at the pubic area, of 1 to
4 cm length, and in 5% the umbilical hole did not reach
the pubis. The logic is to maintain the scar hidden under
Fig. 21.9  Eight months and 2 years postoperative with the umbilical
skin hole sutured vertically at the mid portion of the hypogastrium
leaving a 4 cm scar with minimal evidence.
Fig. 21.10  (A–D) Patient with a scar after total necrosis of the umbilicus after an abdominoplasty healed by secondary intention. Neo-
umbilicoplasty was performed removing the scar and immediately isolated nonabsorbable stitches were applied all around the skin edge fixed
directly to the fascia below, leaving a small 15 mm diameter exposed raw area, that took around 4 weeks to complete epithelialization.
A
B
C
D

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Chapter | 21  Classic abdominoplasty with adhesion tension sutures
Fig. 21.11  (A–C) Abdominoplasty transoperative routine used since 1982, to trim the fat excesses with scissors at the lamellar level, preserving
the superficial fascia.
A
B
C
Fig. 21.12  (A, B) Pre- and postoperative profile views in a patient with projected epigastric region previously hidden by the protruded lower
abdomen, becoming more evident after the surgery. The patient complained that she never had a stomach before.
A
B

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PART | 5  Abdominal contouring procedures
Fig. 21.13  (A, B) Pre- and postoperative aspects of an abdominoplasty. Despite the good result the patient complained (C) about excess flank
volume previously hidden by the abdomen volume, with the comment that “she never had these bulges before the surgery”.
A
B
C
undermining of the abdominal skin flap along the epi­
gastric region up to the xiphoid. According to these
authors the undermining should not go beyond the
lateral edges of the rectus abdominus when preparing a
tunnel for muscle plication. This technique safely allows
for the preservation of blood supply to the entire flap by
not delaminating the flap from the deeper layers.
Avelar16 reported a 5% revision rate for abdomino­
plasty and Saldanha17,18 reported 11%. In our series, we
had a 22% revision rate with my technique. These were
primarily small problems, such as scar revisions, small
necrosis at the inverted T junction, localized scar line
infections, scar broadness, secondary localized liposuc­
tion in specific regions of the anterior abdominal wall,
primary flank-plasty after previous abdominoplasty,
and umbilicus scar revision. I still prefer to perform the
surgical fat resection in the abdominal flap with scissors
to trim the fat thickness of the abdominal skin flap (Fig.
21.11A–C). In conclusion, there are two options. Each
represents an excellent choice to produce outcomes that
satisfy patients. Both my technique and that of lipoab­
dominoplasty are capable of producing excellent long-
term results and minimizing the risk of complications
such as seroma and skin necrosis.
7. There are two groups of patients that I see in my clinic.
Each group has different outcomes, even though the
same abdominoplasty technique is used. The first group
has normal thoracic cage contour and projection, where
the epi- and hypogastrium remain at the same line
projection after the surgery. The second group is

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Chapter | 21  Classic abdominoplasty with adhesion tension sutures
more problematic, based on the nonevident thorax pro­
jection, partially hidden by the forward voluminous fat
and looseness in the hypogastrium. After the surgery,
these patients complain, saying, for example “Dr, I
never had a stomach before, and now look how pro­
truded it is… ?” The reality is that the hypogastrium is
in a retro position exposing a bulged epigastrium after
the surgery. There is no solution for these cases
(Fig. 21.12A, B). A second common detail regards the
flank fat deposits, also not so evident before the surgery
as they are based on one single block around the hip
including the hypogastrium. After the surgery a similar
complaint is “Dr, I never had these lateral bulges
before”. For these specific problems liposuction can
be performed, and in more extensive situations
flank-abdominoplasty is performed at the same stage8,19
(Fig. 21.13A–C).
When these situations exist, it is important to discuss
these factors that limit the outcomes from abdominoplasty
before surgery. Otherwise, it appears that the surgeon is
making excuses for a less than perfect outcome.
REFERENCES
1. Hakme F. Evolução Histórica das abdominoplastias e contribuição
pessoal. In: Avelar MJ, editor. Anais do Simpósio Brasileiro de
Abdominoplastias. Patrocínio. Brazil: Sociedade Brasileira de
Cirurgia Plástica – Regional de São Paulo; 1982.
2. Baroudi R. Abdominoplasty: historical review and personal refer­
ences. Newsletter. Lipoplasty Society North America 1983;10(3):
8–13.
3. Sinder R. Historical evolution of abdominoplasty. In Avelar MJ,
editor. Abdominoplasty without Panniculous Undermining and
Resection. São Paulo: Hipócrates; 2002. p. 21–40.
4. Monard P. La resection esthetique du ventre en tablier avec trans­
plantation de l’ombelique. In: Paucher V, editor. La Practique Chirur­
gicale Illustrée, vol. XIV. Paris: Gaston Doin; 1930.
5. Illouz YG. Une nouvelle technique pour les lipodystrophies locali­
sées. Rev Chir Esth Franc 1980;6(19).
6. Pitanguy I, et al. Abdominoplastias: classificação e técnica cirúrgica.
Ver Bras Cir 1995;85:23–44.
7. Bozola A, Psillakis JM. Abdominoplasty: a new concept and clas­
sification for treatment. Plast Reconstr Surg 1998;77:779.
8. Baroudi R, Ferreira CAA. Contouring the hip and the abdomen. Clin
Plast Surg 1996;23:551–73.
9. Baroudi R. Umbilicoplasty. Clin Plast Surg 1975;2:431–48.
10. Baroudi R, Moraes M. A “bicycle-handlebar” type of incision for
primary and secondary abdominoplasty. Aesth Plast Surg 1995;19:
307–20.
11. Baroudi R, Ferreira CAA. Seroma: how to avoid and to solve it.
Aesth Surg J 1988;18:439–41.
12. Baroudi R. Inovazone nel disegno della addominoplastiche:
Tecnica e Resultati. Tese di Laurea. Università Degli Studi di
Cagliari; 1975.
13. Baroudi R, Carvalho CGS. Neoumbilicoplastias: Un procedimiento
nel transcorso de las abdominoplastias. Cir Plast Iberolatinoamer­
cana 1981;7:391–402.
14. Amud RJM. Neo-onfaloplastia sem cicatriz. Rev Soc Bras Cir Plast
2008;23(1):37–40.
15. Abreu Ng JA. Abdominoplastias: neo-onfaloplastia sem cicatriz e
sem excisão de gordura. Rev Bras Cir Plast 2010;25(3):499–503.
16. Avelar JM. Abdominoplasty: A new technique without undermining
and fat removal. Arq Catarinense Med 2000;29:147–9.
17. Saldanha OR. Lipoabdominoplasty without undermining. Aesth
Surg J 2001;21:518–26.
18. Saldanha OR. Lipoabdominoplastia. Rio de Janeiro: DiLivro; 2004.
19. Baroudi R. Reoperation after liposuction and body contour surgery.
In: Grotting CG, editor. Reoperative Aesthetic & Reconstructive
Plastic Surgery, vol. II. 2nd ed. St. Louis: Quality Med Publishing;
2007. p. 1635–99.

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© 2013 Elsevier Inc
Chapter 22 
Key Points
●
Lipoabdominoplasty with previous flap resection is a
complete method for the correction of esthetic
abdominal deformities by removing excess skin and
subcutaneous fat whilst also repairing the rectus
diastasis and tissue laxity.
●
Abdominal surgery has been extensively revised and
published since Dermars and Marx in 1890 and Kelly1
in 1899.
●
It is important to note the following:
1. Accurate evaluation of the patient and precise
demarcation are key points to this procedure.
2. Concurrent liposuction enhances the body contour
and removes excess fat in selected areas.
3. The previous flap resection is as a single block and
the absolute control of bleeding shortens the
procedure and reduces operative time.
4. The drastic reduction of the undermined area
preserves the perforating vessels, improving
surgical safety and efficiency, and maintains total
viability of the flap.
5. The outcome is predictable and consistent and the
patient recovery time is reduced.
Lipoabdominoplasty with previous
flap resection
Arnaldo L. Miró
INTRODUCTION
Many surgeons over the last century have increased our
understanding of abdominal surgical anatomy, especially
with regard to the vascularization and lymphatic drainage of
the abdominal wall. These advances have resulted in sur­
geons able to perform safer, more efficient and faster abdom­
inoplasty procedures with good and consistent results.
Surgeons such as Callia,2 Pitanguy,3 Pontes,4 Baroudi,5
Avelar,6 Matarasso,7 Lockwood,8 Guerrero Santos,9 and
many others around the world have contributed to the
development of surgery in the abdominal area.
Concerning vascularization studies, contributions from
El Mrakbey,10 Boyd and Taylor11 and others have high­
lighted the associated morbidity related to the extension of
the undermining in these procedures.
The classifications of the pathology, according to Pitan­
guy12 and Bozola,13 allowed more precise and correct surgi­
cal indication by choosing the technical options and the
extension of each procedure.
Baroudi’s5 stitch technique greatly diminished the
occurrence of seroma formation by plicating the abdominal
flap to the aponeurosis. Seroma formation, together with
infection and skin necrosis, are the major complications of
this procedure in the postoperative period.
Bozola13 described the umbilical position, which can be
measured in a geometric proportion of 1 for the infraumbili­
cal portion and 1.5 for the supraumbilical area, giving a
harmonic relationship to the abdomen (Fig. 22.1). The
umbilical position will be the parameter for our assessment
concerning the removal of the infraumbilical flap, so we
must be extremely careful with those patients having a high
umbilical scar position.
However, the greatest advancement in the evolution of
abdominoplasty was the use of liposuction. The liposuction
studies by Illouz,14 Avelar,6 Saldanha,15 Hunstad16 and
Klein17 highlighted the safety of this procedure in regular
association with traditional abdominoplasty. Liposuction
decreases fat thickness and reduces the undermining
required. This results in both harmonious and satisfactory
outcomes for the patients and their respective surgeons.
In our clinical practice we are in favor of the previous
resection of the abdominal flap as proposed by Pontes4
since 1964. The ease of the resection, the absolute control
of bleeding, scar symmetry, and improved speed and effi­
ciency of the procedure are our critical points to advocate
the abdominoplasty with previous flap resection as our
routine technique. In addition, improved flap handling is
another distinct advantage and further emphasizes our pref­
erence for this procedure.
PREOPERATIVE PREPARATION
Once the patients have disclosed their expectations about
the surgery, we carefully analyze the deformity to indicate
the best technical option for the case. The surgery must be
Part 5  Abdominal contouring procedures

221
Chapter | 22  Lipoabdominoplasty with previous flap resection
Type VI: Marked generalized abdominal lipodystrophy
and flaccidity. These patients are generally not consid­
ered good candidates for an esthetic surgical procedure.
Patients in this group should undergo a strict clinical
treatment to lose weight, frequently needing the atten­
tion of a multidisciplinary team (e.g., endo­crinologist,
physiotherapist, nutritionist, physiologist, etc.).
So, with precise analysis we can choose the exact
surgery type for each case.
In this chapter we are going to focus on patients with
types IV and V abdominal deformities. These are patients
who present with skin excess in the inferior and superior
part of the abdominal wall, flaccidity of the muscle aponeu­
rotic layer, diastasis of rectus abdominis muscles and the
presence or absence of fat.
These patients require a selective liposuction in the
supraumbilical area, waist and hips, resection of the infra­
umbilical flap as a block, plication of rectus abdominis
muscle aponeurosis, caudal sliding of the flap, transposition
of the umbilical scar, and closure by anatomical planes.
Other preoperative considerations are the routine clini­
cal examination and clinical history, especially for those
patients with a history of previous deep venous thrombosis,
obesity, and massive weight loss, diabetes, and cardiac
abnormalities. All these patients require closer and special
attention throughout the pre and post-operative periods.
SURGICAL TECHNIQUE
In a standing position we draw an area corresponding to a
bikini shape (Fig. 22.2). The lateral lines are parallel to
the inguinal crease, reaching a point demarcated on the
natural crease of the abdomen on the hips (Figs 22.3
and 22.4).
The central inferior line delineates the upper pubis and
is located approximately 5–6 cm from the vulvar commis­
sure, with a soft caudal concavity.
The opposite side will be drawn in the same way and
confirmed with a ruler and a compass.
FIG. 22.1  Geometrical position of the umbilical scar described by
Bozola.
1.5
1
1.5
1
FIG. 22.2  Marking the area corresponding to a bikini shape.
clearly discussed with the patient beforehand so as to avoid
any misunderstandings with regards to scarring and the
final esthetic results.
Patient Selection
The procedure selection is accomplished using the Pitanguy
classification for abdominal deformities and the eight types
of abdominal deformities listed below:
Type I: Abdominal lipodystrophy without skin flaccid­
ity, absence of diastasis or hernia, umbilical scar in
normal anatomical position.
Type II: Infraumbilical abdominal lipodystrophy with
discrete cutaneous flaccidity, presence or absence of
diastasis, umbilical scar in normal anatomical
position.
Type III: Generalized abdominal lipodystrophy with
moderate cutaneous flaccidity, and presence or absence
of diastasis.
Type IIIA: Umbilical scar in normal anatomical
position.
Type IIIB: Umbilical scar in excessively high anatomi­
cal position.
Type IV: Abdominal lipodystrophy with marked cutane­
ous flaccidity, the presence of muscular diastasis or
eventrations with or without associated umbilical scar
in a normal anatomical position.
Type V: Marked abdominal cutaneous flaccidity with or
without lipodystrophy; presence of scar at the midline
of the abdomen. The umbilical position is in a normal
or altered anatomical position.

222
PART | 5  Abdominal contouring procedures
In sequence we draw a semicircle bordering the inferior
pole of the umbilical scar, and another one passing the
superior border, creating a safety area (Fig. 22.5).
At the moment of traction and suture of the flap to the
pubic area, we assess the tension of the flap.
If the superior border is considered the ideal one, the
remaining skin in the safety area will be resected. This situ­
ation corresponds to about 95% of the cases.
If there is too much skin tension we can change
our surgical plan, closing the umbilical scar and stretch­
ing it to the suprapubic region, leaving a small 2–3  cm
longer vertical scar as a release tension maneuver
(Fig. 22.6).
All the measurements are checked and tattooed in the
key points with methylene blue ink.
Under epidural anesthesia, for the majority of cases, we
infiltrate with a solution composed of 500 ml saline solu­
tion 0.9% and epinephrine (adrenaline) concentration
of 1/500 000 using 3.0 or 3.5 mm cannulas in the upper
abdomen, flanks, and waist.
In the submammary region the cannula runs down­
ward using a small incision in the mammary sulcus;
sometimes this area does not require fat removal but
FIG. 22.3  Marking the natural crease of the abdomen on hips.
FIG. 22.4  The lateral lines are parallel to the inguinal crease into the
area limits.
FIG. 22.5  Final demarcation forming an elliptical design, the safety
area (above the umbilical scar) and the regions for liposuction.
FIG. 22.6  An eventual suprapubic vertical scar.
must be undermined in tunnels using a 3.0 mm cannula,
with no suction. This is to allow easier sliding of the
flap.
Following this, the skin and fat will be cut inferiorly and
in the superior line below the umbilical scar, forming a flap

223
Chapter | 22  Lipoabdominoplasty with previous flap resection
placement will be pointed using Pitanguy’s demarcator
(Fig. 22.10).
Baroudi’s quilting sutures are performed with absorbable
sutures, fixing the entire flap to the aponeurosis (Fig. 22.11).
Finally the umbilical skin, already fixed to the aponeu­
rosis, is sutured to the abdominal skin.
Baroudi’s quilting sutures are finished, the remaining
skin will be resected or not, depending on the level of
tension (Fig. 22.12).
The flap will be sutured in three anatomical levels, finish­
ing with a nonabsorbable intracutaneous tread, which stays
that will be removed as a block, preserving the safety area
(Fig. 22.7).
In the suprapubic region we use a slant incision, leaving
a small portion of level fat remaining in order to have a
better fitting for the upper flap coming downward. The
periumbilical area always has less thickness of fat.
The umbilical scar is incised in its border. The under­
mining of the central portion of superior abdomen reaches
the xiphoid, making a tunnel (Fig. 22.8).
The width of this tunnel is variable, but always detaches
only about 2 cm laterally to the medial border of rectus
abdominis muscle
This “economic” undermining preserves the perforat­ing
vessels coming from the deep superior and inferior epigas­
tric arteries. The plication will be made using absorbable
sutures in two planes; the first one, simple stitches with 2–0
nylon and the other a running suture with 3–0 nylon.
The umbilical flap will be fixed in the aponeurosis in a
triangular superior base shape (Fig. 22.9).
At this point, with the patient in a semi Fowler position,
the flap is gently moved to the pubis, checking the flap
tension. If there is some tension, the division with cannulas
will be repeated without suction.
The flap will be sutured to the inferior border with
temporary stitches and the incision for a new umbilical
FIG. 22.8  The undermined tunnel in the upper abdomen.
FIG. 22.9  The umbilical triangular superior base shape.
FIG. 22.10  Pitanguy’s demarcator.
FIG. 22.11  Quilting sutures fix the flap to the aponeurosis.
FIG. 22.7  The flap removed as a block.

224
PART | 5  Abdominal contouring procedures
The semicurved position is recommended until the 8th
day, and a light diet is used during this period.
A lymphatic drainage massage associated with ultra­
sound therapy in the manipulated area reduces the recovery
time.
The outcomes have been extremely satisfactory, achiev­
ing harmonious body contours affording patients self-
esteem and comfort.
COMPLICATIONS AND
THEIR MANAGEMENT
Epitheliolysis of the scar, granulomas in the late postopera­
tive period, scar hypertrophy, hematomas, necrosis, infec­
tions, and unsatisfactory results are possible complications.
These are rare in our practice. Two seromas were observed
in our cases in spite of the quilting sutures used.
COMMENTS AND CONCLUSION
The resection of the flap as a block permits a fast, more
precise and comfortable surgery, and nowadays is routine
in our practice. A previous precise diagnosis, based on
in place for 20 or 30 days (Fig. 22.13). The use of a vacuum
drain is routine although the liquid volume has been negli­
gible. The sutures are covered with adhesive strips, the
umbilical scar is filled with gauze and special foam is applied
under a close fitting compression garment (Fig. 22.14).
POSTOPERATIVE CARE
The patient stays in hospital about 24 hours and is mobi­
lized the next morning; the wearing of compression stock­
ings is recommended.
FIG. 22.12  Resecting the remaining skin and fat after the final posi­
tion of the flap.
FIG. 22.13  The intracutaneous suture and the final view of the
surgery.
FIG. 22.14  Postoperative garment, special foam and compression
stockings.
FIG. 22.15  Preoperative frontal view.

225
Chapter | 22  Lipoabdominoplasty with previous flap resection
FIG. 22.16  Preoperative lateral view.
FIG. 22.17  Preoperative oblique view.
FIG. 22.18  Postoperative frontal view (28th day after the surgery).
FIG. 22.19  Postoperative lateral view (28th day after the surgery).

226
PART | 5  Abdominal contouring procedures
classification suggested by distinguished authors, offers
surgeons the best surgical option to be selected.
Liposuction enhances the body contour and is a
safe procedure, to be used in the vast majority of cases.
The reduced incidence of reported complications is a conse­
quence of the drastic reduction of the undermined area,
preserving the majority of perforating vessels coming from
the deep abdominal wall. Fixing the flap to the aponeurosis
contributes to the avoidance of seroma formation.
The use of adequate postoperative garments, special
foam, and compression stockings, together with lymphatic
FIG. 22.20  Postoperative oblique view (28th day after the surgery).
drainage and ultrasound therapy, makes the recovery time
fast and comfortable. See Figs 22.15–22.20 for outcomes.
REFERENCES
1. Kelly HA. Report of gynecological cases. Johns Hopkins Hosp Bull
1899;10:197.
2. Callia WEP. Contribuição para o estudo da correção cirúrgica do
abdome pêndulo e globoso – técnica original. São Paulo: Tese de
Doutoramento apresentada à Faculdade de Medicina da USP; 1963.
3. Pitanguy I. Evaluation of body contouring surgery today: a 30 year
perspective. Plast Reconstr Surg 2000;105:1499.
4. Pontes R. Abdominoplastia. 1st ed. Revinter: Rio de Janeiro; 2004.
5. Baroudi R, Ferreira CAA. Seroma: how to avoid it and how to treat
it. Aesth Surg J 1988;18:439.
6. Avelar JM. Abdominoplasty: A new technique without undermining
and fat layer removal. Arq Catarin Med 2000;29:147–9.
7. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal
contour surgery: a national plastic surgery survey. Plast Reconstr
Surg 2006;47:1797–808.
8. Lockwood TE. Lower body lift with superficial fascial system sus­
pension. Aesth Reconstr Surg 1993;92:112.
9. Guerrero Santos J. Some problems and solutions in abdominoplasty.
Aesth Plast Surg 1980;4:227.
10. El-Mrakby HH, Milner RH. The vascular anatomy of the lower
anterior abdominal wall: A micro dissection study on the deep infe­
rior epigastric vessels and the perforator branches. Plast Reconstr
Surg 2002;109:539–47.
11. Boyd JB, Taylor GI, Corlett RJ. The vascular territories of the supe­
rior epigastric and the deep inferior epigastric systems. Plast Recon­
str Surg 1984;73:1–14.
12. Pitanguy I, Salgado F, Murakami R, et al. Abdominoplasty: classifi­
cation and surgical techniques. Rev Bras Cir 1995;85(1):23.
13. Bozola AR. Abdominoplasty: same classification and a new treat­
ment concept 20 years later. Aesth Plast Surg 2010;34(2):181–92.
14. Illouz YG. Une nouvelle technique pour les lipodystrophies locali­
sées. Rev Chir Esthét Lang Franç 1980;6:19.
15. Saldanha OR, Souza Pinto EB, Matos WM, et al. Lipoabdomino­
plasty with selective and safe undermining. Aesth Plast Surg
2003;27:322–7.
16. Hunstad JP, Repta R. Atlas of abdominoplasty. Philadelphia: Saun­
ders; 2009.
17. Klein JA. Tumescent technique for liposuction surgery. Am J Cos­
metic Surg 1987;4:263.

227
© 2013 Elsevier Inc
Chapter 23 
Key Points
●
Tensioned reverse abdominoplasty (TRA) is not
suitable for all patients, nor is it a substitute for
conventional abdominoplasty.
●
The greatest benefit of TRA is the possibility of treating
deformities of the superior abdominal wall by using a
direct approach to the region. This avoids using
conventional abdominoplasty techniques to treat
deformities located primarily at the upper abdomen.
●
TRA is a simple, fast and easy technique that can be
applied in association with other procedures, such as
mini-abdominoplasty, liposuction, reduction
mammoplasty, and augmentation mammoplasty
– either by using prostheses or by means of
retromammary insertion of dermal-fat flaps that would
be resected from the most cephalic portion of the
abdominal flap.
●
Flap fixation to the aponeurosis drastically reduces the
incidence of seroma formation. The upper traction of
the flap reshapes the upper abdomen and distributes
its supporting forces across the abdominal aponeurosis.
This principle reduces tension on the resulting scar,
favoring its quality and preventing postoperative
displacement of the new mammary sulcus.
●
TRA has a low complication rate.
Reverse abdominoplasty
Mauro F. Deos, Eduardo I. Gus and Ricardo A. Arnt
INTRODUCTION
The abdominal wall is one of the regions that most
frequently presents with a wide range of anatomical varia­
tions. This is due to several factors, which include inade­
quate diet, pregnancy, sedentary lifestyle, weight loss, and
loss of skin elasticity. These can be challenging deformities
to address.
Traditional abdominoplasty and mini-abdominoplasty
procedures with or without liposuction, usually address
most of these problems. However, skin with or without fat
excess, especially in the supraumbilical abdominal region,
still remains a challenge to most plastic surgeons.
The first description of skin and adipose tissue resection
in the upper abdomen was made by Thorek in 1942.1
However, in 1977 Rebello & Franco described and system­
atized the approach through the inframammary sulcus for
abdominal plastic surgery.2 After this period, reverse abdom­
inoplasty was practically forgotten about for many years.
This was primarily because it was said to result in poor
esthetic results with regards to the inframammary scars.3
However, TRA should be considered a therapeutic
option by plastic surgeons, as it is possible, through infra­
mammary incisions, to correct abdominal deformities in the
supraumbilical portion.
This chapter proposes a modification of the original
technique, based on the upper traction of the flap and its
strong fixation to the abdominal aponeurosis, resulting in a
tension-free inframammary scar.4 The inframammary scar
extension and the dissection amplitude are determined by
the intensity of the supraumbilical deformities.
This technique should be primarily indicated for patients
complaining of skin laxity mainly in the upper abdomen
and patients prone to have such excess after liposuction. In
these cases, it should be always considered that there is
insufficient skin excess for indicating a suprapubic abdomi­
noplasty, and that mini-abdominoplasty would render less
than optimal results.
Patients with previous inframammary scars favor this
technique, especially if the scars are extensive and are uni­
fying or almost unifying at the midline. Similarly, breasts
with wide bases, even without previous incisions, favor the
utilization of this technique, as they tend to better hide the
resulting scar. On the other hand, this technique is contra­
indicated to patients with previous history of keloids or
hypertrophic scars, especially in cases that require scar
unification at the midline.
This technique can also be indicated to patients who had
abdominoplasty procedures in the past, but show unsatis­
factory results, such as dermal-fat residues or skin excess
in the supraumbilical portion.
PREOPERATIVE PREPARATION
Preoperative marking is done preferably in the orthostatic
position, by exerting upper traction on the flap towards the
Part 5  Abdominal contouring procedures

228
PART | 5  Abdominal contouring procedures
breasts and determining the amount of skin to be resected.
At this moment, the required extension of the inframam­
mary scar and the eventual need to unify the scars at the
midline are defined. This step is extremely important, as the
patients are divided into two groups.
● Group 1: Larger amounts of skin to be resected require
incision unification at the midline. In this group, the flap
is dissected towards the umbilical scar, forming a single
U-shaped tunnel (Fig. 23.1).
● Group 2: These patients have little or moderate supra­
umbilical skin laxity and no diastasis of the abdominal
wall. The incisions will be limited to the inframammary
regions, without unification at or crossing the midline.
The flap dissection will produce two oblique tunnels
towards the umbilical scar. The width of each tunnel
will be determined by the breast width; and each tunnel
joins the contralateral portion halfway between the
inframammary sulcus and the umbilical scar (Fig. 23.2).
SURGICAL TECHNIQUE
The flap to be dissected should be infiltrated with saline
solution and epinephrine, at a concentration of 1 : 500 000.
Epinephrine (1 mg) is used for each 500 ml of saline. The
amount varies depending on the extension of the area to be
treated and the patient’s measurements. One liter is needed
for the entire abdominal surface, and about 500 ml for just
the superior half are usually used. In cases of excessive fat,
the procedure begins with a liposuction, which can be
limited to the flap region or include the entire abdominal
FIG. 23.1  Incision (dotted red line) and dissection (grey area) in
Group 1.
FIG. 23.2  Incision (dotted red line) and dissection (grey area) in
Group 2.
FIG. 23.3  Dissected flap showing traction lines and the midline
fascia plication markings in methylene blue.
wall.5 In both groups, dissection is performed with electro­
cautery at the anterior aponeurotic plane, resulting in one
or two dermal-fat flaps (Fig. 23.3).
If indicated, supraumbilical plication of the abdominal
fascia at the midline is performed, with monofilament nylon
threads in two planes. The first aponeurotic suture is done
with single interrupted sutures of 2–0 nylon monofilament
(Fig. 23.4). The second line of suture is accomplished

229
Chapter | 23  Reverse abdominoplasty
In Group 1 patients, upper traction of the flap is per­
formed with three to five lines of parallel sutures, because
the dissections are wide and the flaps are usually heavy,
requiring strong fixation.
In Group 2 patients, two smaller and lighter flaps are
produced. In these cases, two traction lines are usually
made in each tunnel. The traction sutures start right above
the umbilical scar.
Polygalactine 2–0 threads with a 4 cm needle are used
for flap fixation and traction. The surgeon or the assistant
should pull the flap towards the incision, in such a way
that each stitch determines a superior traction of the flap
as a supporting maneuver for flap cranial progression
(Fig. 23.7). The suture should include Scarpa’s fascia, but
avoid getting close to the dermis as, although the threads
are absorbable and the skin depressions will spontaneously
disappear, external notches take a long time to fade and can
be distressing to patients.
In Group 1 patients with larger dissections with a single
flap, after flap traction and fixation, the dermal-fat excess
is divided at the midline and symmetrically resected
(Fig. 23.8).
In Group 2 patients with smaller dissections with two
flaps, the fixation with superior oblique traction determines
dermal-fat excesses bilaterally, which are resected after
precise measurement.
For the sake of preserving the submammary sulcus, it is
very important to perform a deep flap fixation using polyga­
lactine 2–0 thread, a second plane of subcutaneous sutures
with polygalactine 3–0 thread and a final intradermal suture
FIG. 23.4  Midline fascia plication, first suture with separated
stitches.
FIG. 23.5  Complete midline fascia plication.
FIG. 23.6  Progressive and continuous tension sutures towards the
inframammary incision.
with a continuous suture of 3–0 nylon monofilament
(Fig. 23.5).
After performing the dissection and muscle plication
based on individual requirements, the principle of pro­
gressive and continuous tension sutures is applied towards
the inframammary incision (Fig. 23.6).6,7 The location of
traction lines is marked with methylene blue, with each
suture intended to perform superior traction on the flap.

230
PART | 5  Abdominal contouring procedures
FIG. 23.8  The dermal-fat excess is cut in two at the midline for
symmetric resection.
FIG. 23.9  Reconstruction of the submammary sulcus.
FIG. 23.10  Immediate postoperative result showing M-shaped scar.
FIG. 23.7  Upper traction of the flap for fixation to the
aponeurosis.

231
Chapter | 23  Reverse abdominoplasty
FIG. 23.11  M-shaped submammary scar: late postoperative aspect
(Group 1).
with polygalactine 4–0 thread (Fig. 23.9). In cases of inci­
sion unification at the midline, the scar is M-shaped to mini­
mize risks of hypertrophic scars and scar retractions (Figs
23.10 and 23.11). In cases with persistent skin excess in the
lower abdomen, resections can be performed with limited
dissection, as done in mini-abdominoplasty. No drain place­
ment is performed.
OPTIMIZING OUTCOMES
● We use the navel as the inferior limit of dissection in
almost all cases. Even so, due to intense upper traction
of the flap, it is possible to observe reduced skin redun­
dancy in the infraumbilical segment as well. Neverthe­
less, the inferior dissection can be carried further down,
releasing the umbilical scar and enabling midline plica­
tion along the whole extension of the abdominal fascia,
as originally proposed by Rebello and Franco.2 This
procedure is considered safe, once vascularization will
be kept by preserved lateral perforating and inferior
epigastric arteries.
● We prefer a modification of the tension suture method
– continuous and with guiding lines. Continuous sutures
make the procedure easier and faster, but we understand
that the technique can also be performed with separated
stitches, without affecting the final result.
● In Group 2, when performing resections with limited
mammary sulcus incisions, we frequently need to asso­
ciate TRA with mini-abdominoplasty to have good
esthetic results. In this way, TRA performs upper trac­
tion of the abdominal wall and mini-abdominoplasty
performs lower traction towards the pubis.
● The adequate reconstruction of the inframammary
sulcus is extremely important for the final result. The
incision is sutured in three planes, with the deeper
sutures fixed to the aponeurosis for a better definition
of the mammary sulcus position. When performed
as described above, the flap is fixed to the abdominal
wall and does not tend to displace caudally to its initial
position. This procedure minimizes the tension on the
resulting scar and prevents the inframammary sulcus or
breasts displacement. We always try to keep the infra­
mammary sulcus at its original position.
POSTOPERATIVE CARE
After the procedure, the dissected abdominal area is cush­
ioned with dressing pads (cotton wrapped in gauzes), and
compression garments should be worn for 4 weeks.
In cases of reverse abdominoplasty with larger dis­
section or cases of medical or surgical comorbidities, the
patient remains hospitalized for 24 hours. In cases of
reduced dissection, the patient is discharged from hospital
at least 8 hours after the end of the procedure. Early ambu­
lation is encouraged in the first few hours postoperatively.
The patients receive nonsteroidal anti-inflammatory
drugs combined with regular analgesics for 4 days if
required. All patients receive a dose of antibiotics at anes­
thesia induction, which is repeated if the procedure lasts for
more than 3 hours.
Results are shown in Figs 23.12 and 23.13.
COMPLICATIONS AND
THEIR MANAGEMENT
In patients requiring incision through the midline (Group
1), there is a risk of skin redundancy in this region, produc­
ing an esthetically unpleasant situation, similar to synmas­
tia. It is usually caused by insufficient skin resection at the
midline, and these patients should be subsequently treated
with excision of the skin excess under local anesthesia.
Double unilateral inframammary sulcus may be present
at the final result. This is usually due to an asymmetric
resection of the dermal-fat excess, resulting in unilateral
skin redundancy, or as asymmetric traction sutures, espe­
cially at the stitches closer to the mammary sulcus.
CONCLUSION
TRA is an efficient and safe technique, which can render
good esthetic results in cases of abdominal laxity primarily
in the supraumbilical half of the abdomen. The continuous
suture offers reduced surgery time and, when following the
pre-marked lines of suture, it is possible to determine a
better balance in the distribution of tension forces that act
on the flap.

232
PART | 5  Abdominal contouring procedures
FIG. 23.12  Group 1 patient submitted to TRA associated with liposuction. (A, C) Preoperative pictures and (B, D) late postoperative results.
A
B
C
D

233
Chapter | 23  Reverse abdominoplasty
FIG. 23.13  Group 2 patient submitted to TRA. Preoperative pictures (A, C) and late postoperative results (B, D).
A
B
C
D

234
PART | 5  Abdominal contouring procedures
This technique should be considered in cases in which
conventional abdominoplasty would result in a less than
optimal esthetic improvement, and, if carefully indicated,
is an important option among the surgical possibilities for
treating the abdominal region.
REFERENCES
1. Avelar JM. Upper abdominoplasty without panniculus undermining
and resection. São Paulo: Editora Hipócrates; 2002.
2. Rebello C, Franco T. Abdominoplasty through a submammary inci­
sion. Int Surg 1977;62(9):462–3.
3. Hakme F, Freitas RR, Souza BA. Historical evolution of abdom­
inoplasty. In: Avelar JM, editor. Abdominoplasty: Without Panni­
culus Undermining and Resection. São Paulo: Editora Hipócrates;
2002.
4. Deos MF, Arnt RA, Gus EI. Tensioned reverse abdominoplasty. Plast
Reconstr Surg 2009;124:2134.
5. Matarasso A. Liposuction as an adjunct to a full abdominoplasty
revisited. Plast Reconstr Surg 2000;106(5):1197–202.
6. Pollock H, Pollock T. Progressive tension sutures: a technique to
reduce local complications in abdominoplasty. Plast Reconstr Surg
2000;105(7):2583–6.
7. Pollock T, Pollock H. Progressive tension sutures in abdominoplasty.
Clin Plast Surg 2004;31(4):583–9.

235
© 2013 Elsevier Inc
Chapter 24 
Key Points
●
Indications
●
Diastasis of rectus abdominis muscle
●
Abdominal hernias
●
Lipodystrophy and moderate skin flaccidity.
●
Materials for video-endoscopy
●
Rigid endoscope, 4 or 10 mm
●
Micro camera
●
Halogen or xenon light source
●
Monitor
●
Retractor, attachable to the endoscope
●
Dissection materials
●
Long endoscopic tweezers and scissors with
cautery
●
Endoscopic needle holder.
●
Video imaging system
●
Video camera
●
Light source
●
Video monitors
●
Recording devices.
●
Complications
●
Skin flaccidity
●
Seroma
●
Hematoma
●
Flat navel
●
Dog-ear
●
Patient dissatisfaction.
Endoscopic plication techniques for
the treatment of abdominal contour
Ana Z.D. Badin and Lea M. Moraes
INTRODUCTION
The treatment of the abdominal contour, in general, is
managed by procedures at two extremes, liposuction and
classic abdominoplasty. Patients with excess abdominal
adiposity without flaccidity undergo liposuction, and those
with accentuated abdominal laxity have traditionally been
treated with the classic abdominoplasty, which corrects the
excess skin and fat in the abdominal wall, and is usually
performed in association with the correction of abdominal
diastasis recti. In most patients the outcome of the latter
procedure is favorable, but at the expense of extensive scar­
ring, which is not always well accepted by patients.
However, a range of intermediary cases exist which are not
a perfect match for either simple liposuction or classic
abdominoplasty.
BASIC SCIENCE
Diastasis of the rectus abdominis muscles requires
correction, regardless of whether there is enough excess
skin for classic abdominoplasty. Many cases requiring
correction of diastasis are contraindicated for classic
abdominoplasty.
In cases where the navel is high, leaving little skin
expanse above the umbilicus, or even in cases where the
supraumbilical skin has little flaccidity, a classic abdomi­
noplasty is difficult. Patients with post-pregnancy diastasis
but with plans for further pregnancies are also a relative
contraindication for the classic tummy tuck.
The correction of the diastasis can be accomplished
via a small video-assisted suprapubic incision, without
skin resection, or by a mini-abdominoplasty in a technique
described since 1971 by Callia, with a small infraumbilical
skin resection. Other authors have already described, with
variations, an infraumbilical plication only and no detach­
ment of the umbilicus.1–7 There are also descriptions of a
small incision in the umbilicus to facilitate the supraumbili­
cal detachment2 and another approach that detached the
umbilicus from the m. rectus.8,9 Since the introduction of
video-endoscopy, indications for the correction of diastasis
without skin resection can be extended to include, primar­
ily, congenital diastasis and diastasis in men.10
Indications for video-assisted mini-abdominoplasty are
limited. This option must be precisely discussed with the
patient because, on the one hand, there is the advantage of
less scarring, but on the other hand, resection of skin is
limited and there may be mild residual laxity both above
and below the umbilicus. Another factor that should be
considered in female patients is the possibility of pregnancy
Part 5  Abdominal contouring procedures

236
PART | 5  Abdominal contouring procedures
FIG. 24.1  Pre- and postoperative young patient, post weight loss,
frontal view.
A
B
after surgery. In nulliparous patients who have abdominal
flaccidity following weight loss (Figs 24.1 and 24.2), or in
patients who have post-pregnancy abdominal flaccidity
but are planning another pregnancy, this technique would
be well indicated, because it doesn’t present the same
limitations as classical abdominoplasty for postoperative
pregnancy.
FIG 24.2 APPEARS ONLINE ONLY
DIAGNOSIS/PATIENT PRESENTATION
It is essential that candidates for this procedure have a high
navel; this allows correction of the flaccidity that occurs
right above the umbilicus, by reinserting the navel a few
centimeters lower (1.5 to 2 cm), while still maintaining an
adequate distance between the umbilical scar and pubic
region.
Proper physical examination of the patient is of para­
mount importance, both in the seated position, to measure
if the supraumbilical fold is correctable with mini-
abdominoplasty, as well as lying down with effort, to assess
the degree of diastasis. In patients with thick adipose tissue,
moderate liposuction can also be performed, being sure to
maintain a sufficient thickness of the panniculus to avoid
surface irregularities and increased skin flaccidity above the
umbilicus.
PATIENT SELECTION
The selection of patients is subject to strict criteria:
● Patients with mild supra- and/or infraumbilical skin
laxity, with diastasis of the rectus abdominis.
● High navel position, more than 14 cm above the pubis.
● Firm or minimally flaccid supraumbilical skin that will
not allow the descent of the supraumbilical region to the
suprapubic region.
● The possibility of post-abdominoplasty pregnancy, pro­
vided that the flaccidity is not excessive. These patients
fall into Types III and IV of the Bozola and Psillakis
classifications,1 and Type I in the Nahas classification
system.4
● Diastasis of the rectus abdominis muscle, which can
either be acquired (post-pregnancy or following weight
loss), or congenital, which can occur in both women and
men (Figs 24.1–24.7).
FIG 24.4 APPEARS ONLINE ONLY
● Abdominal hernias (especially umbilical hernia) associ­
ated with lipodystrophy and skin flaccidity (Figs 24.8
and 24.9).
● Lipodystrophy and moderate skin flaccidity, where
liposuction would offer limited results (Figs 24.10 and
24.11). Younger patients who have undergone massive
weight loss resulting in abdominal flaccidity fall into
this category, and also those with post-pregnancy flac­
cidity but who may become pregnant in the future
(Figs 24.12 and 24.13).
FIG 24.10, 24.11 APPEARS ONLINE ONLY
SURGICAL TECHNIQUE
Materials for Video-endoscopy
Video endoscopic-assisted surgical procedures offer image
amplification and visualization, and the ability to both

236.e1
Chapter | 24  Endoscopic plication techniques for the treatment of abdominal contour
FIG. 24.2  Pre- and postoperative young patient, post weight loss, half profile view.
A
B
FIG. 24.4  Correction of congenital diastasis – male patient, half profile view.
A
B

236.e2
PART | 5  Abdominal contouring procedures
FIG. 24.10  Pre- and postoperative patient who underwent mini-
abdominoplasty with repair of diastasis associated with liposuction
scapular regions, waist and flanks, frontal view.
A
B
FIG. 24.11  Pre- and postoperative patient who underwent mini-
abdominoplasty with repair of diastasis associated with liposuction of
scapular regions, waist and flanks, half profile view.
A
B

237
Chapter | 24  Endoscopic plication techniques for the treatment of abdominal contour
FIG. 24.3  Correction of congenital diastasis – male patient, frontal view.
A
B
FIG. 24.5  Correction of congenital diastasis – male patient, profile view.
A
B
reduce scars and position them remotely, away from the
surgical field. However, they also require a greater com­
plexity in instrumentation and in organizing the surgical
suite, as well as familiarization with new technologies and
a flat learning curve.
Basic components for performing the procedures are:
● rigid endoscope, 4 or 10 mm (Figs 24.15 and 24.16)
● micro camera (Fig. 24.15)
● halogen or xenon light source (Fig. 24.15)
● monitor (Fig. 24.15)
● retractor attachable to the endoscope (Fig. 24.16)
● dissection materials (Fig. 24.14)
● long endoscopic tweezers and scissors with cautery
(Fig. 24.14)
● endoscopic needle holder.
FIG 24.15 APPEARS ONLINE ONLY
In plastic surgery we use 30° or 45° endoscopes, 4 or
10 mm at 0° for larger optical cavities in need of better
lighting, such as in surgery for the breast and torso. The
retractor compensates for the angle of the endoscope and
allows maintained visualization of the pocket being dis­
sected. The xenon light source is fundamental to the 4 mm
endoscope, to provide more illumination, because the field
with the upper abdominal muscles is a deep, dark hollow.

237.e1
Chapter | 24  Endoscopic plication techniques for the treatment of abdominal contour
FIG. 24.15  Video imaging system. Monitor, light source, micro

238
PART | 5  Abdominal contouring procedures
FIG. 24.7  Correction of diastasis of the rectus abdominis, profile view.
A
B
FIG. 24.6  Correction of diastasis of the rectus abdominis, half profile view.
A
B

239
Chapter | 24  Endoscopic plication techniques for the treatment of abdominal contour
FIG. 24.8  Abdominal hernias (especially supraumbilical hernia) associated with lipodystrophy and sagging skin, frontal view.
A
B
FIG. 24.9  Abdominal hernias (especially supraumbilical hernia) associated with lipodystrophy and sagging skin, profile view.
A
B

240
PART | 5  Abdominal contouring procedures
FIG. 24.12  Patient with post-pregnancy flaccidity and umbilical hernia who may have a future pregnancy, frontal view.
A
B
FIG. 24.13  Patient with post-pregnancy flaccidity and umbilical hernia who may have a future pregnancy, profile view.
A
B

241
Chapter | 24  Endoscopic plication techniques for the treatment of abdominal contour
The 10 mm endoscopes can be used effectively with a
250 W halogen light source.
Video Imaging System
Video-endoscopic systems include a video camera, light
source, video monitors and recording devices. These ele­
ments comprise the most costly part of the instrumentation.
They are available in most surgery centers and are com­
monly in use in all surgical specialties that employ
video-surgery.
Methods for Creating and Maintaining the
Optical Cavity
In plastic surgery, where there are no natural optical cavities
that provide visualization of the structures, they must be
created within the target tissue area.
By separating the tissues in a cranial direction, the
retractors serve a dual purpose: to expose the structures and
to facilitate the dissection, using the tension exerted by the
tissues not yet dissected. For this reason, the lens is 30° or
45°, to compensate for the rise of the optical tip, focusing
the image in the margin of the optical cavity, where most
of the dissection takes place. The 10 mm endoscopes may
have a 0° angle, because they offer the greatest amplitude
of image (Fig. 24.16).
Dissectors
In endoscopic mini-abdominoplasty, we use various instru­
ments for dissection, suction and cautery, and endoscopic
tweezers and scissors. These instruments come in several
configurations, depending on the manufacturer. They need
to be long, to accommodate the distance from the incision
to the work area. The tweezers and scissors should engage
with the cautery, to be able to cut and cauterize in a single
motion.
Video-Assisted Technique
Access to the upper abdomen without an extensive incision
is quite difficult, and fiber optic endoscopy has contributed
greatly to this approach by offering excellent access, with
reduced scarring.
The video-assisted mini-abdominoplasty consists of a
suprapubic incision, followed by detachment up to the
xiphoid process, with detachment of the umbilicus.
In patients with thick adipose tissue, liposuction using
cannulas of 3.0 to 3.5 mm is done first, above and below
the umbilicus, as well as in the waist and flank regions, if
necessary.
The detachment is performed under direct visualization
up to the umbilicus, and after this detachment, a retractor
connected to the video camera is used to complete the
detachment, for hemostasis, and for plication of the apo­
neurosis of the rectus abdominis muscles.
The plication repair is initially done with separate 2-0
nylon sutures , followed by continuous #1 Vicryl sutures up
to a point on the linea alba, about 1.5 to 2 cm from the
original position of the umbilicus before plication. Then we
continue with interrupted sutures for 1 to 1.5 cm below this
point and return to the running stitch, to complete the plica­
tion caudally.
The diastasis of the rectus abdominis muscles has a
strong impact on the body contour, especially in the upper
abdomen. A swordtail-pubic plication promotes better
abdominal contouring, with better definition of the anterior
abdominal wall and improvement of volume in the epigas­
tric region.
After completion of the plication, the navel is reinserted
through the suture that was left in the midline, and plunged
into the navel plication. This maneuver, described by
Correa,11 gives a natural depth to the navel. It is important
to fix the umbilicus in its new insertion point before resec­
tion of the skin, to achieve a precise result.
Another way of fixing the navel is to make three internal
sutures with Vicryl 3-0 in the umbilicus, two above and one
FIG. 24.14  Video-endoscopic instruments. 1 and 3 dissector; 2 hook
dissector; 4 scissors with cautery; 5 adapter; 6 normal cautery; 7 tweezers
with cautery; 8 cautery cord; 9 optic cable.
FIG. 24.16  Endoscope and retractors – the retractor is coupled to
the endoscope.

242
PART | 5  Abdominal contouring procedures
A
B
FIG. 24.17  Correction of diastasis with mini-abdominoplasty. (A) Preoperative view; (B) post mini-abdominoplasty.
below, forming an inverted triangle. Mark the new position
of the umbilicus, observing for symmetry, and fix these
sutures in the aponeurosis of the rectus abdominis. With
this method, the navel tends to be shallower.
A 4.2 mm suction drain is placed, leaving a counter
incision in the pubic region.
Then the resection of excess skin and subcutaneous
tissue that has been estimated previously is carried out. Do
not remove too much skin when doing a very minimal inci­
sion (Caesarean type). A medium-length scar (not as exten­
sive as the classic), is a better option with a good esthetic
result.
A few Baroudi stitches are made between the flap
and aponeurosis, to reduce dead space, and the suturing
of skin and subcutaneous tissue is performed in multiple
planes.
POSTOPERATIVE CARE
A pressure dressing is applied, and the drain is removed
only when the drainage volume over 24 hours is less than
30 ml. After the drain removal, the patient uses a contention
plate and abdominal compression garment for 30 to
60 days.
Smoking should be stopped at least 15 days pre-and
postoperatively.
Regarding the recovery period, we see no great differ­
ence from classical abdominoplasty, contrary to those
authors who advocate only an infraumbilical plication.7
Because of the dissection and muscle plication, the patient
remains hospitalized for 24 hours, and should relax for 10 to
14 days, which is also important for prevention of seromas.
OUTCOMES, PROGNOSIS,
AND COMPLICATIONS
Plication of the rectus abdominal with a minimal incision
involves a central swordtail-pubic detachment, and may
involve liposuction to accommodate the abdominal flap
while preserving the lateral perforations, or even the Dílson
Luz12 retractors, to release the flap from the lateral area
without compromising the perforators, and avoiding excess
skin above the navel.
As any detachment seroma and hematoma may occur,
Baroudi sutures and vacuum drainage contribute greatly to
reduce the incidence of these complications.
A flat navel, without depth, occurs particularly in thin
patients. The use of the maneuver described by Correa has
contributed to a more esthetic umbilicus. Dog-ears can be
corrected with minimal skin resection or liposuction.
Secondary Procedures
In one case, the patient experienced an epigastric hernia,
which was corrected via a new mini-abdominoplasty.
The most undesirable result is patient dissatisfaction
with the surgical result, due to unrealistic expectations.

243
Chapter | 24  Endoscopic plication techniques for the treatment of abdominal contour
Therefore, we should take enough time preoperatively,
trying to understand the expectations of the patient, to avoid
having to turn a mini-abdominoplasty into a classic abdom­
inoplasty, due to patient dissatisfaction (Figs 24.17 and
24.18). Video-endoscopy has made a major contribution to
the correction of diastasis of the rectus abdominis muscles,
umbilical and supraumbilical hernias. It enables hemostasis
and plication of the aponeurosis of the rectus abdominis
muscle, avoiding a new incision at the umbilicus. This
technical refinement facilitates surgery, reduces scarring
and results in better outcomes.
Another great advantage of this technique is the
improved vascularization of the abdominal flap, because
the detachment is more central, avoiding the costal margin,
which preserves the upper pedicles (superior epigastric and
intercostal arteries).13 This, coupled with less tension on the
scar, due to limited resection of skin, reduces complica­
tions. Beyond that, the flap procedure in combination with
abdominal liposuction does not increase risks, if performed
carefully, and allows better accommodation of the flap over
the plicated abdominal wall, especially above the navel.
The applicability of this technique is related to precise
indications and strict evaluation, to avoid patient dissatis­
faction related not to the abdominal wall fixation, which is
always satisfactory, but to skin excess, which is not toler­
ated by patients. When the indication, treatment of diastasis
without excess skin, is correct, the result will always be
pleasing for women or men.
REFERENCES
1. Bozola AR, Psillakis JM. Abdominoplasty: a new concept and clas­
sification for treatment. Plast Reconstr Surg 1988;82(6):983–93.
2. Ferraro FJ, Zavitsanos GP, VanBuskirk ER, et al. Improving the
efficiency, ease, and efficacy of endoscopic abdominoplasty. Plast
Reconstr Surg 1997;99(3):895–8.
3. Greminger RF. The mini-abdominoplasty. Plast Reconstr Surg 1987;
79(3):356–64.
4. Nahas FX. A pragmatic way to treat abdominal deformities based on
skin and subcutaneous excess. Aesth Plast Surg 2001;25:365–71.
5. Restrepo JCC, Ahmed JAM. New technique of plication for miniab­
dominoplasty. Plast Reconstr Surg 2002;109(3):1170–9.
6. Wilkinson TS. Mini-abdominoplasty. Plast Reconstr Surg 1988;
82(5):917–8.
7. Wilkinson TS, Swartz B. Individual modifications in body contour
surgery: the “limited” abdominoplasty. Plast Reconstr Surg 1986;
77(5):779–84.
8. Uebel CO. Miniabdominoplasty – a new approach for the body
contouring. Presented at the 9th Annual Congress of the International
Society of Aesthetic Surgery, New York, October 1987.
9. Uebel CO. Minilipoabdominoplastiy – its evolution. In: Saldanha
OR, editor. Lipoabdominoplasty. Rio de Janeiro: DiLivros; 2006.
p. 73–85.
10. Lockwood T. Rectus muscle diastasis in males: primary indication
for endoscopically assisted abdominoplasty. Plast Reconstr Surg
1998;101(6):1685–93.
11. Correa MAMF. Videoendoscopic abdominoplasty (subcutanoscopic)
– abdominal video plastic surgery. In: Badin AZ, Ferreira LM,
editors. Videoendoscopy in Body Contouring and Complementary
Procedures. Rio de Janeiro: Revinter; 2007. p. 202–10.
A
B
FIG. 24.18  Patient dissatisfied with mini-abdominoplasty and underwent subsequent classic abdominoplasty. (A) Preoperative view (post mini-
abdominoplasty); (B) Post classic abdominoplasty.

244
PART | 5  Abdominal contouring procedures
Mest’ák J, Mest’ák O. Miniabdominoplasty. Acta Chir Plast 2010;52(1):23–
6. PubMed PMID: 21110499.
Nahai F, Brown GH, Vasconez LO. Blood supply to the abdominal wall
as related to planning abdominal incisions. Am Surg 1976;42:691.
Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty
concept. Plast Reconstr Surg 1999;103:1021.
Uebel CO. Lipoabdominoplasty: revisiting the superior pull-down
abdominal flap and new approaches. Aesth Plast Surg 2009;33(3):
366–76.
Zukowski ML, Ash K, Spencer D, et al. Endoscopic intracorporal abdo­
minoplasty: a review of 85 cases. Plast Reconstr Surg 1998;
102:516.
12. Viterbo F. Undermining wands by Dilson Luz instruments with mul­
tiple applications. In: Luz DF, editor. Progressive Undermining –
Principles, Applications and Complementary Procedures. vol 1. Rio
de Janeiro: DiLivros; 2009. p. 63–5.
13. O’Brien J. Endoscopic balloon-assisted abdominoplasty. Plast
Reconstr Surg 1997;99(5):1462–3.
FURTHER READING
Eaves FF, III, Nahai F, Bostwick J, III. Endoscopic abdominoplasty and
endoscopically assisted mini abdominoplasty. Clin Plast Surg 1996;
23:599.
Hay-Roe V. Seroma after lipoplasty with abdominoplasty. Plast Reconstr
Surg 1991;87(5):997–8.
Iglesias M, Bravo L, Chavez-Muñoz C, et al. Endoscopic abdominoplasty:
an alternative approach. Ann Plast Surg 2006;57(5):489–94. PubMed
PMID: 17060727.
Menz, P. Pregnancy after abdominoplasty. Plast Reconstr Surg 1996;98(2):
377–8.
Fig. 24.2, Fig. 24.4, Fig. 24.10, Fig. 24.11, Fig. 24.15 can be found
online
Bonus images for this chapter can be found online at

245
© 2013 Elsevier Inc
Chapter 25 
Key Points
●
The high lateral tension abdominoplasty rejuvenates
not just the anterior abdomen, but also the inguinal
region, proximal thighs, mons, buttocks, and even
posture.
●
There is only undermining where skin will be excised
or for plication, thereby permitting simultaneous
liposuction. Tension is reduced on the mons with less
central excision, and the greatest load is carried on the
lateral limbs of the incision, thereby increasing the
frequency at which the umbilical site will not be
closed. The incision will be longer, and the lateral
portions of the incision will rise obliquely more than
with a traditional abdominoplasty.
●
Abdomens differ and since final tension can only be
felt intraoperatively, there is no diagram that can
demonstrate exactly how to mark either the initial or
the final incision. The surgeon must understand the
distinguishing principles of this approach and apply
them to each patient individually.
●
An abdominoplasty is an entirely elective, cosmetic
procedure. However, DVT, PE, and even death can
occur. Their incidence can be reduced but not
eliminated.
●
Patients’ primary objections are the location, length,
and width of the scars. This should be a major focus
during the preoperative discussion with the patient.
High lateral tension abdominoplasty
Steven Teitelbaum
INTRODUCTION
The high lateral tension abdominoplasty (HLT) accom­
plishes far more than a flatter anterior abdomen: it is a
modified lower body lifting procedure. Lockwood1 noted
that his body lifting procedure improved the abdomen more
than did an abdominoplasty. He attributed this to his obser­
vation that the greatest laxity is lateral, and therefore a
greater amount of excision should occur in those areas
(Table 25.1).
Two years later Lockwood published his HLT paper,2
which was the anterior component of his body lift. He
ascribed four key characteristics to the HLT. First, only
areas to be excised or necessary for rectus plication would
be undermined. Second, simultaneous liposuction would
therefore be safe. Third, he used permanent sutures to close
the superficial fascial system (SFS) as a means to reduce
the widening of scars and to improve skin contour far away
from the incision. Finally, he emphasized the importance
of putting the greatest tension on the lateral part of the
incision.
Though it is the basis for the name of this procedure,
the notion of placing high tension laterally remains elusive.
That is because it is not something that can be shown in a
drawing. Rather, it is a principle that must be understood
while marking the patient, and even more so when deter­
mining the extent of skin resection intraoperatively.
Instead of being called “high lateral tension” it should
have been called “higher lateral tension” because the point
is not that the lateral tension is high per se, but that it is
merely greater than the central tension.
The higher lateral tension concept also forces us to pay
more attention to the scar location. There is a natural ten­
dency to expect the final scar to correspond to the initial
incision. But the initial incision has no more to do with the
location of the final scar than does the final incision. Both
equally determine the amount to be excised, and each needs
to be planned carefully (Fig. 25.1).
PREOPERATIVE PREPARATION
Figure 25.2 shows the preoperative markings. Any abdomi­
noplasty has the potential to correct three separate anatomi­
cal structures: skin, fat, and muscle. Each is evaluated
separately in order to preoperatively plan the operation and
give the patient reasonable expectations.
Skin Excess
One of the signatures of the high lateral tension abdomino­
plasty is that it requires the greatest tension to be placed on
the lateral part of the incision. This means that the umbilical
site might not get excised, leaving a vertical scar from its
closure. While this usually heals well, and accepting that
For additional online content vist

Part 5  Abdominal contouring procedures

246
PART | 5  Abdominal contouring procedures
TABLE 25.1  Comparison of HLT to Standard
Abdominoplasty
HLT
Standard
Objective
Rejuvenation of
abdomen and trunk
Rejuvenation of
central abdomen
Anatomical
basis
Greatest laxity is
lateral
Greatest laxity is
central
Incision
Lower centrally,
raising laterally
obliquely, usually
longer
More superior and
horizontal, usually
shorter
Umbilicus
management
Better to close site
vertically than to pull
tighter to excise
Better to pull tighter
to excise than to
close vertically
Areas of
improvement
Central abdomen as
well as flanks, inguinal
region, buttocks
Mostly central
abdomen
Simultaneous
liposuction
Can be more liberal
Should be more
reserved
Location of
tension
Greatest tension on
lateral limbs of
incision along inguinal
crease; less tension
centrally on the mons
Greatest tension is
centrally over
mons; progressively
looser along
inguinal crease
Direction of
pull
In two oblique
directions,
perpendicular to the
lateral limbs of the
incision
In one superior-
inferior direction,
perpendicular to
the central incision
the presence of this scar may be considered the sine qua
non of a true HLT philosophy, this scar does not always
heal perfectly, and many patients want to avoid it. If there
is any question as to whether the site can be excised, the
patient should be warned that there are three choices: pro­
ceeding with a classic HLT (Fig. 25.3) and accepting a
vertical scar if necessary, placing the incision more superi­
orly on the abdomen so that there is a greater chance of
excising the old umbilical site (though the necessity for
elevating the lateral limbs of the flap may make the lateral
scar more likely to rise above pants), or abandoning the
HLT principles and placing as much central tension as is
necessary to remove the site.
Patients frequently ask for a “mini” tummy tuck,
wanting the horizontal extent of the incision to be as short
as possible, perhaps even as narrow as their C-section scar.
Few individuals have vertical laxity so slight and horizon­
tal laxity so centrally focused that a short scar removes
all the troubling laxity and attractively recontours the
abdomen (Fig. 25.4). The patient should always be evalu­
ated sitting straight upright or even bending forward, as
this demonstrates the amount of vertical excess as
well as the extent to which the laxity extends laterally.
Placing patients in this most unflattering of positions helps
them to see the extent of their laxity (Fig. 25.5). They can
understand that if there is laxity at the anterior axillary
line, then an incision that stops at the midclavicular line
will be inadequate to create a nice contour. It can also be
demonstrated that if there is a significant amount of verti­
cal excess to be excised, a significant length of the incision
is obligatory to avoid a dog-ear. Given that the HLT has
greater lateral tension and seeks removal of lateral skin
excess, the incision must go even more laterally. Lock­
wood’s drawings show the superior and inferior incision
joined at a 90° angle, but in his discussion he says that the
incision needs to be lengthened to eliminate a dog-ear.
(This is a reminder that the highest tension is not at the
very lateralmost extent of the incision, but is usually
located at about the midclavicular line.) An HLT incision
will invariably be at least as wide as the anterior axillary
line, and often to the posterior axillary line. The philoso­
phy of the standard tummy tuck is to excise the old umbili­
cal site at whatever tension is necessary. The length of the
scar is essentially that which is necessary to recontour the
abdomen without a dog-ear. But the HLT concept is that
the greatest laxity is more lateral, and that it is essential to
excise that to optimally tighten the thighs. Placing more
tension centrally raises and distorts the mobile mons,
oftentimes shortening the distance from the top of the
public hair to the umbilicus. Since the mons is more verti­
cally mobile than the skin along the inguinal crease, high
central tension causes the mons to rise, making the incision
more flat and horizontal, and it is the angle of the lateral
limbs that most helps flatten the epigastrium. The HLT
concept is that it is better to have a vertical scar from the
old umbilical site, with the mons/pubic hair left lower with
a greater distance between it and the umbilicus. That is
because the standard tummy tuck is essentially an exercise
in “excising the umbilicus”; the width is only that which
is necessary to remove that vertical excess without creating
a dog-ear. But the HLT considers that lateral excess the
most important area for excision. By pulling down and out
laterally, a greater degree of flattening of the epigastrium
occurs than simply pulling straight inferiorly. The greatest
laxity on the trunk of the postpartum or weight loss patient
is also laterally, so this area needs the greatest amount of
excision (Fig. 25.6).
FIG 25.5, 25.6 APPEARS ONLINE ONLY
But the incision often needs to be modified to suit
patient expectation. Patients usually want the scar low, hori­
zontal, and the umbilical site excised, despite the fact that
it creates a less attractive abdomen. The surgeon is left to
negotiate these tradeoffs with the patient. Since many

246.e1
Chapter | 25  High lateral tension abdominoplasty
FIG. 25.5  No laxity on standing. There appears to be little laxity when standing but much when bending over or sitting. This is important to notice
and document preoperatively so that the patient can recognize the extent of improvement. It also helps to define how far laterally the incision must be
carried. If this position is not examined, the incision can be kept too narrow and a patient may be displeased with inadequate lateral correction.
A
B
A
B
FIG. 25.6  Simulating HLT v standard pull vectors. (A) Standard abdominoplasty puts the most tension centrally, raising the mobile mons and
sometimes exposing the labia minora. In (B) the simulation of the high lateral tension shows less tension and distortion of the mons, but more tension
laterally, thereby creating better tightening of the anterior thighs and epigastrium.
Continued

246.e2
PART | 5  Abdominal contouring procedures
C
D
E
F
FIG. 25.6  Continued

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Chapter | 25  High lateral tension abdominoplasty
FIG. 25.1  Origins of the HLT. Before and after a high lateral tension abdominoplasty (HLT).
A
B
patients do not want a pure HLT, the reader should consider
this HLT description as a way of thinking while marking
and closing, even if it is not carried out to completion
(Table 25.2).
Despite the greatest efforts to keep the scar low, invari­
ably the scar will rise above current underwear and bikini
fashions in many patients when the patient stands (see Fig.
25.2). In reality, surgeons excise more skin than is truly
redundant in most situations lest the patients perceive too
much laxity when sitting upright. But the tension necessary
to keep a patient tight when sitting upright often leads to a
scar that will migrate superiorly when the patient stands
(Fig. 25.7).
Skin Quality and Texture
As with all excisional procedures such as facelift and breast
lift, damaged skin is what is left behind, even after a gen­
erous excision. The ultimate quality of the result and
appearance will be based upon the characteristics of the
patient’s skin. Do stretch marks still exist superior to the
likely line of resection so that many will remain, or are
they likely to be excised? Is the skin thin and/or sun-
damaged, likely to loosen again to a significant degree or
have notable lines or wrinkles? These issues must all be
addressed with the patient preoperatively in order to set
their expectations. The presence of pre-existing abdominal
scars must be assessed as they may have affected blood
supply in such a way as to necessitate modification of the
HLT design, or to limit dissection even more. There are also
sometimes transverse lines of adhesion, usually between
umbilicus and xiphoid between the midline and the anterior
axillary line that prevent transference of pull above them.
It can take substantial undermining to free these up, and
in doing so the blood supply to the flap can be compro­
mised. These issues need to be discussed with the patient
preoperatively.
Excess Fat within Flap
The HLT allows for safe suctioning within the flap. But in
most cases the significant extent of resection with an HLT