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

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Chapter | 25  High lateral tension abdominoplasty
FIG. 25.4  Positional changes. In preoperative photograph (A), note how horizontal the blue lines are. In (B), they diverge up superiorly in the lateral
part of the incision when the patient lays supine. Note also the change in position of the red line. The point is to recognize that even in a high lateral
excision, the limbs of the HLT excision are rarely higher than would be horizontal.
A
B
FIG. 25.7  Controlling scar position. (A) shows an ideally positioned scar; low, nice angle that will stay under clothing, and a long distance between
umbilicus and scar. Note the vertical scar from the old umbilical site. Had it not been moved, there would have been supraumbilical laxity. Were the
umbilicus to have been floated, it would have been too close to the pubic hair. If an attempt were made to excise it, the pubic hair would be raised. (B)
Shows a handle-bar appearing scar that is the result of the initial incision being too high, thereby requiring more excision on the flap to create lateral
tension, the result of which was to raise the ends of the scar. In planning the initial incision, it is important to place maximum vertical tension on the
inguinal area and rather than drawing just a straight line between the proposed end of the incision and the short horizontal area about the pubic hair,
make the incision slightly concave up.
A
B
creates a flat abdomen, and the tension stretches and effec­
tively thins the abdominal flap. Surgeons should be cautious
when assessing whether additional debulking of the flap
with liposuction will actually create a more attractive
contour or merely a thinner one. Abdominal liposuction
results are fraught with over-resection, uneven resection,
and contour irregularities. While simultaneous liposuction
of the abdominal flap can be safe and is sometimes desir­
able, more frequently simultaneous liposuction is better
done on adjacent areas and the abdomen left alone. The
salient question is not whether fat remains within
the abdominal fat, but whether this fat is proportional to the
patient’s overall body habitus and particularly adjacent
areas. As the flap is stretched and flatted, there is a
concomitant relative thinning of the fat flap. Consideration
should be made as to whether simultaneous liposuction
increases drain output or the likelihood of seroma
formation.
Excess Fat in Contiguous Areas
An HLT results in a significant excision of abdominal fat
along with the generous amount of skin excised. Following
this, most patients have a flat abdomen, and it is important
to assess whether that flat abdomen will look proportional
to the adjacent areas. If there appears to be a lot of fat in
the abdomen, it can be removed, and there is usually even
more in the hips or the thighs. If liposuction of the abdomen

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PART | 5  Abdominal contouring procedures
them the gap that exists between their muscles. Most
patients have an option of plicating any diastasis. While the
plication can substantially improve the outcome, so too
does it increase the severity and duration of recovery. The
umbilicus is always assessed for the presence of a fascial
defect that may need to be repaired either separately or at
the time of abdominoplasty. The patient should also be
examined in profile with her arms at her sides and above
her head, asking her to allow her abdominal musculature to
relax. During plication, it is all too tempting to tighten her
as much as possible by excessive imbrication from pubis to
xiphoid. But the goal is only to reunite the paired rectus
muscles together in the midline.
Intraabdominal Fat
Pressure from the internal organs and intraabdominal fat
puts pressure on the diastasis repair. While it is possible for
there to be relapse in any situation, patients with significant
intrabdominal fat deposits should be warned that they are
at a higher risk for some recurrence and generally do not
benefit as much from the plication. While there are no
parameters that can be measured from which exact stan­
dards can be drawn, women with a wide or loose diastasis
and less intraabdominal fat are better candidates for plica­
tion than women with a smaller or tighter diastasis.
SURGICAL TECHNIQUE
1. All patients should have photos of the entire esthetic
area from the shoulder to knee. Photos should always
be taken with the patient sitting, as this both demon­
strates the full extent of the preoperative redundancy
and critically tests the quality of the result. Photos
should also be taken in the “diver’s position.”
2. The patient wears a bikini bottom or underwear that is
typical of the style she likes to wear. Frequently,
patients are now wearing underwear that is relatively
horizontal, preventing the scar from rising laterally as
much as desirable to create an ideal result (Table 25.3
and Fig. 25.8). There are two ways to deal with this.
First, the issues in Table 25.3 can be understood by
most patients. Should the height of swimsuits rise, a
low scar would be visible in even one-piece suits.
However, a high scar that is optimal for an HLT will
always be covered by a one-piece and visible only with
a low one-piece. Another option is to make the scar
lower in the midline, which still allows the scar to
course more superiorly up to the lateral ends of the
incision. However, the lower the central incision, the
lower the likelihood that the umbilical site will be
excised. One must also be careful not to remove too
much hair-bearing skin in the pubic region; generally
is even being considered, it is important to look at those
areas and consider treating them, lest the surgeon create a
disharmonious proportion. With the abdomen flattened
from an abdominoplasty, the width that results from excess
hip fat can be very apparent. Given the substantial lateral
abdominal tightening of the HLT which abruptly stops just
beyond the incision, even the preoperatively proportional
hip can look wider postoperatively. Narrowing the waist
through suction of the posterior hip roll can dramatically
improve the appearance of the trunk. Besides recreating a
waistline that can be lost from any abdominoplasty, the hip
suctioning allows the lateralmost extents of the incision to
fall back to the lateral and even posterior parts of the trunk,
making the incision look visibly narrower from the AP
view. Similarly, excess fat in the mons area is often not
noted preoperatively in the patient with a large overhanging
pannus. With a smooth and flatter abdomen, the mons can
protrude in clothing and be disconcerting. This can be
treated with liposuction at the time of abdominoplasty.
Rectus Diastasis/Hernia
The patient should be examined standing, sitting, and laying
back flat while raising her shoulders up, as in doing a partial
sit-up. This is a good way to test for a rectus diastasis. From
this position, one can take the patient’s hands and show
TABLE 25.2  Determination of Final Line of Resection
1. Plication should be completed first because this affects the
amount that needs to be resected.
2. Sit the patient up about 30°.
3. Split the flap incrementally, stopping when closure would
distort the mons.
4. With that point held in place with a towel clamp, and
with inferior distraction of each side of the flap, use a
Lockwood marking clamp to mark the proposed resection.
The tension should be higher in the mid-clavicular area
than centrally.
5. Using the grid as a guide, mark a symmetric excision.
While it will look as if more tissue is being taken laterally,
if you look at the grid you will see that it is often a bit less
and only occasionally more than the horizontal lines of
the grid. When more tension is used in marking the
preoperative inferior incision, the final line of excision will
be more inferior than if the initial incision was more
superior.
6. After resecting the flap, align vertical lines and tack with
towel clamps. Examine the incision to assure that it has an
attractive, smooth, and gentle sweep. Oftentimes at this
stage, the inferior flap may need to be trimmed as it will
often be pulled too far superiorly (this step is avoided if
adequate tension is placed before the initial incision,
though the same result is achieved with this additional
maneuver). Rarely, the incision will be too low and the
superior flap will need to be trimmed. This final stage is
crucial to assure ideal location and contour of the scar.

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Chapter | 25  High lateral tension abdominoplasty
ANATOMY
Blood Supply
The rich blood supply and the limited undermining of the
HLT affords a large margin of safety.
The abdominal wall is densely supplied by vessels
coursing inferiorly and medially from the superior epigas­
tric artery, the subcostal artery, and lumbar branches. These
anastamose with vessels ascending superiorly from the
deep and superficial epigastric vessels.
These anastomoses are obviously disrupted with the
abdominoplasty, leaving the flap to be supplied by the supe­
rior vessels that are coursing downward. The blood supply
of the inferior cut edge is not undermined and can be closed
under great tension with no devascularization issue.
But the superior edge is dependent upon these vessels
coursing inferiorly. While the flap is robust, there is little if
any cosmetic advantage to undermining any more than is
necessary to complete the resection and expose the area
needed for plication; irregularities seen on the table will
flatten out postoperatively.
Musculofascial Layer
The abdominal wall itself is made of four major paired
muscle groups: the transversus abdominis, the external
oblique, internal oblique, and rectus abdominis muscles.
Ideally, the rectus sheath that envelopes the rectus muscles
fuses in the midline, forming a narrow and stout structure
that maintains just a few mm separation between the
muscles. However, with pregnancy, and to a lesser extent
weight loss, the linea can attenuate and stretch, allowing
the distance between the muscles to separate. This is easiest
to examine when the patient does a sit-up. Whatever gap is
noted during that maneuver is amplified when the patient
stands upright and the pressure of the viscera is applied to
the uncontracted abdominal wall. A rectus diastasis is only
a space; it is not synonymous with a hernia. A true midline
hernia is extremely rare in the absence of a previous midline
laparotomy incision. Quite common, however, is an umbili­
cal hernia. Every abdominoplasty patient should be exam­
ined to assess for the presence of one. Deep within the base
of the umbilical stalk, a fascial defect can be felt at the time
of exam. This is important as it can worsen with time. Once
noted, it should be pointed out to the patient at the time of
consultation, and if ultimately she does not wish to undergo
an abdominoplasty, she should be advised to seek consulta­
tion with a general surgeon for repair.

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Chapter | 25  High lateral tension abdominoplasty
lines parallel to the first line from the midline, going
out laterally to where the incision is expected to
end. Additional horizontal lines are drawn to create
a checkerboard on the abdomen. This helps when
marking the patient and makes for a much more
rapid and accurate determination of final resection
(Table 25.4).
4. A line is then drawn for the ideal final scar. The patient
must inspect this and any compromises be discussed
and made. This line is not where an incision will be
made! Because tension will vary along the length of
the incision, there are points at which this will be pulled
up by the final closure greater than at other areas. So
with a pen held horizontally at the level of the desired
final scar, the abdomen is pushed up superiorly with
the expected tension of the final closure at that point.
This will yield a series of dots below the desired scar
location. Check for symmetry of width, angle, height,
and orientation relative to the iliac crest. Extend the
lines for the incision beyond the planned incision to
guide lengthening of incision, if necessary.
5. The patient is given a general anesthetic. A pillow is
placed behind the knees to increase venous flow and
to take tension off the abdomen. The legs are slightly
“frog-legged” to further reduce tension on the lateral
TABLE 25.3  Rationale for Placing Scar Lower in the
Center and Higher Laterally
1. A curved scar in this region is less conspicuous than a
horizontal one.
2. A long distance between umbilicus and the top of the
mons/pubic hair is more youthful.
3. Since a scar only pulls perpendicular to it, the oblique
orientation of the lateral arms of the scar allows greater
improvement of the epigastrium.
4. The iliac bones are often too close together to allow
adequate scar length.
5. The scar can better fit within a bikini or underwear.
6. There is less of a tendency for dog-ears.
7. A higher lateral incision makes the thigh look longer, more
slender, and more youthful.
FIG. 25.8.  Placement of scars in clothes.
A
B
it should be about 6.5–7 cm from the anterior labial
commissure to the top of the pubic hair on maximum
stretch (Fig. 25.9).
FIG 25.9 APPEARS ONLINE ONLY
3. The midline is marked from xiphoid to umbilicus to
the labial commissure. Drawing a number of vertical
TABLE 25.4  Considerations and Steps in Preoperative
Marking of the Incision
1. Mark the vertical midline, from xiphoid to umbilicus, then
umbilicus to labial commissure.
2. Mark a grid across the abdomen; vertical lines of grid
should extend inferior to the proposed incision in order to
help alignment during closure.
3. Put on panties/bikini bottoms; if too low and horizontal for
optimal scar, the need for angulating lateral scar above
panties is discussed. Or can lower central incision to allow
lateral incision to rise but stay within undergarments, but
must avoid over-shortening mons height and discuss
increased likelihood umbilical site will not be excisable.
4. Mark the proposed end of the incision; greater length gives
a better contour; should end somewhere between anterior
and posterior axillary line and within her undergarments;
check distance from midline and height for symmetry.
5. Hold pen where you want the scar to be, and elevate the
mons until just before it distorts, and make a gentle curved
line at that height the width of the mons.
6. Push superiorly on the abdomen to simulate the tension of
the flap; connect the dot at the proposed end of the
incision to the central line. Check for symmetry.
7. When the patient is supine on the table, push again
superiorly to make sure that the lateral line is straight; the
central area of this line usually needs to be lowered
because it is difficult to place adequate tissue while patient
is standing without pushing her over.

251.e1
Chapter | 25  High lateral tension abdominoplasty
A
B
C
D
FIG. 25.9  Assess in three positions (A–S). Patients need to be evaluated standing, sitting, and bending over both before and after surgery in order
to assess the quality of result. Note how a portion of the scar is high in the standing postoperative view, visible above the panties. This could have
been avoided if the initial inferior incision were made lower, thereby requiring less vertical excision on the flap and avoiding the handlebar contour
of the scar.
Continued

251.e2
PART | 5  Abdominal contouring procedures
E
F
G
H
FIG. 25.9  Continued

251.e3
Chapter | 25  High lateral tension abdominoplasty
I
J
K
L
FIG. 25.9  Continued
Continued

251.e4
PART | 5  Abdominal contouring procedures
M
N
O
P
FIG. 25.9  Continued

251.e5
Chapter | 25  High lateral tension abdominoplasty
Q
R
S
FIG. 25.9  Continued

252
PART | 5  Abdominal contouring procedures
11. The excision is done with a knife in the skin and then
a cautery, pulling on the discarded part of the flap to
assure that the cut is done perpendicular to the cut
edge. Lockwood advocated back-cutting the flap in
order to create a redundancy in the skin by the closure
of the SFS; I have only had devascularization of the
skin edges when I have done this, so it should be done
with care and caution.
12. Drains are placed and a pain pump if desired. The
patient is sat back up, tacked shut, the umbilicus is
matured, and closure is done.
POSTOPERATIVE CARE
The Foley catheter is removed at the conclusion of the
operation to ensure that the patient walks on the night of
surgery. Pain pumps can be used, but their efficacy has not
been conclusively shown. One of the most common reasons
for flap loss is a tight dressing, which can worsen as swell­
ing increases. Sometimes IV fluids are continued to assure
hydration and blood flow to the flap. Compression boots
can be used as long as a patient is in a hospital or recovery
center.
OPTIMIZING OUTCOMES
Planning of the location of the incision, the distance between
umbilicus and scar, the height of the mons, and extent of
improvement in the inguinal region and thighs is very
important for the outcome. These points of finesse can lead
to the most beautiful results. Scars will fade with time.
However, all patients must be shown “bad” scars, because
part of the incision. The most critical perioperative
decision revolves around DVT prophylaxis. Compres­
sion boots are used in all cases; consideration must be
given to chemoprophylaxis. The ASPS guidelines
should be referenced, as recommendations are likely
to change.
6. Incision is made and dissection continued with an elec­
trocautery. Superficial epigastric vessels are identified
and ligated. Dissection proceeds up towards the umbi­
licus. A periumbilical incision is made and dissection
is carried widely down and around the umbilicus to its
base. If the site is likely not going to be excised, one
may consider leaving less tissue around the umbilicus
as it can result in a depression deep to the closure of
the old umbilical site.
7. If it is obvious that the umbilical site will be removed,
the flap should be split to allow for easier dissection
up towards the xiphoid. Dissection should be no wider
than necessary to complete the plication.
8. Marcaine with epinephrine is injected along the rectus
sheath. Towel clamps are used to approximate the
rectus closure. Simple interrupted #1 Nurolon sutures
soaked in Betadine are used to place the first row.
Figure-of-eight sutures can also be used. Figure-of-
eight sutures will shorten the vertical height of the
rectus muscle by the cumulative effect of the compres­
sion created between the upper and lower bites of each
of the sutures. Following the interrupted sutures, a
running 0 Prolene suture is placed, starting at the
umbilicus, and run all the way to the umbilicus; at the
umbilicus, it is run along one side of the umbilicus and
once below it, the repair again continues.
9. The flap is irrigated, debris is washed away, and hemo­
stasis is achieved. The Plasma Jet can be used for
improved hemostasis and to seal lymphatics in an
effort to reduce seroma formation.
10. The patient is sat up only about 25 or 30°; sitting up
more than that makes it too easy to over-resect cen­
trally, and it does not allow for significantly more
lateral resection, which is where resection is empha­
sized. Start by determining the amount of resection
that can be done centrally. Do not have the mons
completely draped off, as the amount of resection is
determined by mons distortion. No more than a small
of distortion should be accepted and the extent to
which the pubic hair is pulled cephalad is also noted,
as there must be an adequate distance left between
the umbilicus and the top of the pubic hair. Once this
is determined, the flap is split up to this point and
tacked into place. The Lockwood flap marker is
then used to mark the remaining flap, taking note that
there should be greater tension laterally than centrally
(Table 25.5).
TABLE 25.5  Rationale for Higher Lateral Tension and
Reduced Midline Tension
1. Mons is mobile; central tension elevates pubic hair, makes
hair pattern less dense, shortens distance between mons
and umbilicus, narrows and flattens mons, can distort
urinary stream, can expose labia minora.
2. There is greater lateral than central laxity.
3. High lateral tension creates greater rejuvenation of
inguinal region.
4. Since tension is perpendicular to the incision, with high
lateral tension on each side the epigastrium is better
flattened with oblique inferolateral pull from each lateral
incision.
5. It allows for a greater amount of skin excision.
6. The tissues caudal to the lateral arms are more robust,
immobile, and have a more developed Scarpa’s fascia than
the central portion of the incision, thereby allowing for
greater tension on the abdominal flap.
7. Greater lateral tension transmitted through Scarpa’s fascia
rejuvenates the proximal anterior thigh.

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Chapter | 25  High lateral tension abdominoplasty
there is always a possibility that any patient could develop
an unsightly scar. But so long as it is properly situated and
the overall contour is excellent, patients usually will accept
the scars.
COMPLICATIONS AND
THEIR MANAGEMENT
Venous thrombotic events (VTE) remain threats following
abdominoplasty, and they can occur despite chemoprophy­
laxis, compression boots, and early ambulation. Early rec­
ognition is critical. Leg swelling, pain, shortness of breath,
anxiousness, should be treated as serious until proven
otherwise. The entire office staff must be alert for these
complaints and understand the importance of immediate
management.
Hematomas, infections, seromas, minor flap necrosis,
constipation, and urinary retention can all occur after
abdominoplasty.
CONCLUSION
The HLT abdominoplasty is not distinct from the “stan­
dard” abdominoplasty in the same way that, for instance, a
vertical mastopexy is different from a periareolar masto­
pexy. The surgeon should be aware of the principles of the
HLT abdominoplasty and apply them as desired for each
abdominoplasty patient.
REFERENCES
1. Lockwood T. Lower body lift with superficial fascial system suspen­
sion. Plast Reconstr Surg 1993;92(6):1112–22.
Fig. 25.5, Fig. 25.6, Fig. 25.9 can be found online.
Bonus images for this chapter can be found online at

2. Lockwood T. High-lateral-tension abdominoplasty with superficial
fascial system suspension. Plast Reconstr Surg 1995;96(3):603–15.
FURTHER READING
Lockwood TE. Superficial fascial system (SFS) of the trunk and extremi­
ties: a new concept. Plast Reconstr Surg 1991;87(6):1009–18.
Lockwood T. Is the standard abdominoplasty obsolete? In: Jurkiewicz MJ,
Culbertson JH, editors: Operative Techniques in Plastic and Recon­
structive Surgery: Abdominoplasty. Vol 3 No 1. Philadelphia: WB
Saunders; 1996. p. 77–81.
Lockwood T. The role of excisional lifting in body contour surgery. Clin
Plast Surg 1996;23(4):695–712.
Lockwood TE. Lower-body lift. Aesth Surg J 2001;21(4):355–70.
Lockwood TE. Maximizing aesthetics in lateral-tension abdominoplasty
and body lifts. Clin Plast Surg 2004;31(4):523–37.
Matarasso A. Abdominolipoplasty: a system of classification and treat­
ment for combined abdominoplasty and suction-assisted lipectomy.
Aesth Plast Surg 1991;15(2):111–21.
Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast
Reconstr Surg 1995;95(5):829–36.
Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisited.
Plast Reconstr Surg 2000;106(5):1197–202.
Mustoe TA, Buck DW II, Lalonde DH. The safe management of anesthe­
sia, sedation, and pain in plastic surgery. Plast Reconstr Surg
2010;126(4):165e–76e.
Pechter EA. Instant identification of redundant tissue in abdominoplasty
with a marking grid. Aesth Surg J 2010;30(4):571–8.
Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty
concept. Plast Reconstr Surg 1999;103(3):1020–31.

© 2013 Elsevier Inc
254
Chapter 26 
Key Points
●
Fleur-de-lis abdominoplasty addresses the vertical skin
excess normally addressed with classic
abdominoplasty and also the transverse skin excess by
adding a vertical excisional component.
●
The most common area of wound healing problems is
at the junction of vertical and horizontal excisions,
thus the vertical resection should be tapered at each
end to minimize transverse tension.
●
The vertical resection provides circumferential skin
tightening, and can be modified based on existing
scars.
●
Preoperative markings must be made with the patient
standing to achieve symmetry.
●
The effects of weight gain in the mons area frequently
remain after massive weight loss and can be addressed
with liposuction or direct excision.
Fleur-de-lis abdominoplasty including
mons contouring
Joseph P. Hunstad, Bill G. Kortesis and Christopher D. Knotts
INTRODUCTION
Fleur-de-lis abdominoplasty is a full abdominoplasty
coupled with a vertical scar component to also address
transverse tissue excess. Good candidates for fleur-de-lis
abdominoplasty have excess lower abdominal skin in verti­
cal and transverse vectors. Patients with existing abdominal
scars, especially in the midline, are particularly good can­
didates as there is already a vertical scar and these patients
are often more willing to accept re-excision of this scar in
order to eliminate excess skin in the transverse dimension.
Many massive weight loss patients simply lack the dermal
elasticity for abdominal skin to shrink as the subcutaneous
fat is lost. For patients without a vertical scar, a preopera­
tive discussion must be had to make sure the patient is
willing to accept extra scarring to obtain a maximum result.
This result can be achieved predictably with good preopera­
tive surgical planning and appropriate management of
patient expectations.
PREOPERATIVE PREPARATION
For all excisional body contouring procedures, we check a
preoperative coagulation profile, complete blood count,
comprehensive metabolic profile and Factor V Leiden. Risk
factors for thromboembolism are ascertained, including
hormone or birth control use, which we ask to be discon­
tinued for at least two weeks preoperatively. We also dis­
continue aspirin and herbal medications. We ask our patients
to wear a tight abdominal binder day and night for two
weeks preoperatively to simulate the myofascial plication.
This theoretically allows the body to adapt to the higher
intra-abdominal pressure so the effect on venous return and
ventilation is minimized. Lastly, we recommend a liquid
diet for two days preoperatively to help reduce intra-luminal
volume.
Patient Evaluation
Patients with complaints of abdominal tissue excess are
evaluated for skin quality, stretch marks, subcutaneous adi­
posity, intertrigo, lymphedema and hanging skin. A careful
evaluation of the entire abdomen, flanks, back and buttocks
is carried out, noting previous surgical scars. Bimanual
palpation is used to gauge redundant tissues and demon­
strate to patients the degree of transverse skin tightening
possible with the vertical resection (Fig. 26.1). Care is taken
to diagnose hernias, particularly in patients with a history
of open bariatric procedures. Repairing these hernias at the
same time as body contouring is discussed with the patient,
as well as the possibility of needing mesh (Fig. 26.2).
Using physical exam findings and patient wishes, a sur­
gical plan is formulated. Patients found to have an excess
of abdominal tissue in the vertical and transverse dimen­
sions are offered a fleur-de-lis abdominoplasty. Often there
is associated ptosis of the flanks and buttocks, and the
patient may be best served with a circumferential body lift
and fleur-de-lis abdominoplasty. Any regions of excess adi­
posity can be addressed with concurrent liposuction. All
Part 5  Abdominal contouring procedures

255
Chapter | 26  Fleur-de-lis abdominoplasty including mons contouring
FIG. 26.2  Typical preoperative patient presenting for body contouring.
The patient is marked for fleur-de-lis abdominoplasty. Note the hernia
marked in red as a result of a prior open bariatric procedure. Frequently
the hernia can be repaired and reinforced with midline muscle plication at
the time of surgery. Postoperative results are shown in Fig. 26.10.
FIG. 26.3  The standing patient is asked to strongly lift excess abdominal
skin, and the lower incision is marked at the level of the pubis. This results
in the upper third of the hair-bearing mons being within the planned
resection.
FIG. 26.1  (A) Strong bimanual palpation is used to demonstrate the
amount of transverse tissue excess. (B) The width of the planned vertical
resection is 21 cm. A previous midline scar is marked in red. Note the
planned resection tapers toward the midline inferiorly. This is important
to take tension off the final closure.
A
B
three procedures can be performed safely during one
anesthetic.
The mons should be evaluated independently. Excess
skin, adiposity and ptosis frequently remain after massive
weight loss. If the patient perceives the region as unaccept­
ably full, treatment options include liposuction and direct
skin excision. Ptosis is corrected as part of the abdomino­
plasty closure and will be addressed later in the chapter.
Preoperative photographs are taken in five standard
views for the fleur-de-lis abdominoplasty, with an addi­
tional three views for a circumferential procedure.
Preoperative Markings
The patient is asked to strongly lift their abdominal skin
while in a standing position (Fig. 26.3). The low transverse

256
PART | 5  Abdominal contouring procedures
The medial edges of the rectus abdominus are then
identified. Most weight loss patients and parous females
exhibit some degree of diastasis recti. Myofascial plication
is performed using a number zero looped nylon in a con­
tinuous fashion starting from xiphoid to pubis. At the level
of the umbilicus, several running throws are placed into just
one rectus muscle, and then the continuous runner approxi­
mating both rectus muscles resumes below the level of the
umbilicus. By plicating the rectus edges, the undermined
region is minimized as the majority of the undermined
tissue is brought toward the midline.
Plain bupivacaine is used to block the anterior cutane­
ous intercostal nerve branches. We then proceed with
removal of the lower abdominal skin that will result in the
transverse scar. The bed is placed into semi-Fowler’s posi­
tion. A demarcator is used to confirm the preoperative
markings, and the upper portion of the horizontal incision
is made and the resected tissue passed off the field.
A 7-French closed suction drain is placed horizontally
along the inferior border of the wound. A pain pump cath­
eter is placed along the rectus plication.
If preoperatively a vertical scar was already decided
upon, then the midline incision has already been made and
temporary staple closure can proceed from laterally toward
the midline, taking care not to allow any lateral standing
cutaneous deformities. If there was any doubt regarding the
vertical scar, then staple closure can still proceed from
laterally toward the midline and if there is a significant
amount of redundant tissue left in the midline, then the
vertical incisions can be made to resect the excess tissue
from the transverse vector. With experience, the decision
for a vertical scar is almost always decided preoperatively
and the procedure is simplified.
marking is made at the level of the pubic symphisis, which
ends up removing one third of the hair-bearing mons. This
mons reduction coupled with the lift achieved during closure
is typically the extent of mons contouring required. The
low transverse incision is extended bilaterally to the level
of the anterior superior iliac crest. The incision is measured
to make sure each side is of equal length. If a body lift is
planned, the markings are continued circumferentially.
The superior portion of the abdominoplasty incision is
usually judged to be just above the umbilicus. The excess
tissue in the transverse dimension is then marked using
strong bimanual palpation (Fig. 26.1A). The planned verti­
cal resection is elliptical, tapered at the xyphoid process
superiorly and near the planned horizontal incision inferi­
orly (Fig. 26.1B). All markings should be double-checked
intraoperatively prior to incision. Adjunctive liposuction
marks are made along with existing scars and hernias.
Midline scars are simply incorporated into the planned
resection, but off-centered ones such as open cholecystec­
tomy scars may require modification of the vertical resec­
tion to incorporate the previous surgical scar and bring the
final planned closure off midline (Fig. 26.9).
SURGICAL TECHNIQUE
Dilute lidocaine and adrenaline is used to infiltrate the pro­
posed incision lines. When liposuction is anticipated,
tumescent is infiltrated liberally throughout. Liposuction of
the mons and abdomen is done prior to excisional contour­
ing in the majority of patients in our current practice. If a
circumferential procedure is planned, the prone portion is
performed first.
After any planned liposuction, the lower incision is
made into but not through the dermis. Electrocautery is
used to deepen the incision through the dermis, sealing the
subdermal plexus to minimize bleeding. The superficial
inferior epigastric and circumflex vessels are identified,
controlled and divided. Dissection is carried straight down
to the abdominal wall without beveling and then proceeds
superiorly. Perforating vessels, especially in the periumbili­
cal region, are identified and secured prior to division. Dis­
section proceeds to the umbilical stalk, at which point an
incision is made around the umbilicus in a fusiform fashion.
The stalk is sharply freed from surrounding subcutaneous
tissue, and superior dissection can then proceed uninter­
rupted to the costal margins laterally and to the xiphoid
centrally.
If there is any doubt about needing the vertical compo­
nent to achieve an aesthetic closure, the abdominal flap can
be left intact until after rectus plication. If the decision has
been made preoperatively to have a vertical scar, it is
simpler to make the entire midline incision from xiphoid
through the abdominal flap at this time (Fig. 26.4).
FIG. 26.4  The degree of undermining to the xyphoid centrally and to
the costal margins laterally can be seen. The midline incision from the
xiphoid through the abdominal flap has already been made.

257
Chapter | 26  Fleur-de-lis abdominoplasty including mons contouring
FIG. 26.5  (A, C) 50-year-old, 80 kg (176 lb) female presenting with complaints of abdominal tissue excess. A prior open cholecystectomy scar is
marked in red. The planned vertical resection marks have not yet been tapered inferiorly. (B, D) After fleur-de-lis abdominoplasty and circumferential
body lift with liposuction, a smooth tissue contour is noted. The prior cholecystectomy scar was included in the resected tissue. Total removed tissue
weight was 6.6 kg (14.5 lb).
A
B
C
D
The amount of transverse tissue to be excised is con­
firmed intraoperatively using bimanual palpation. Marks
are made and confirmed by grasping tissue with a penetrat­
ing towel clamp (Chapter 16, Fig. 6). After resection of all
tissue and temporary staple closure, the position of the
neoumbilicus is confirmed. One arm of the demarcator
device can be introduced between staples and advanced to
the umbilicus. The other arm outside the abdominal flap
points to the position of the neoumbilicus. A suture tie is
stretched from the xiphoid to the vaginal cleft to make sure
the neoumbilicus will be midline. A narrow ellipse of skin
is removed and sub-Scarpa fat excised from 3 o’clock to 9
o’clock to permit superior hooding and inferior washout of
periumbilical soft tissue.
Flap closure is carried out with number 1 polyglactin
(Vicryl) in the superficial fascial system (SFS) and 2-0
polydioxanone (PDS) for deep dermal closure. 4-0 poligle­
caprone (Monocryl) suture is used for the subcuticular skin
closure and also for the neoumbilicus.
Approximating the SFS in the region of the mons is
particularly important as this corrects the ptosis found after
massive weight loss. Occasionally the mons flap is thicker
compared with the abdominal flap. This can be addressed
via direct sub-Scarpa fat excision or liposuction. Once flap
thickness is equal, there can still occasionally be excess
skin requiring direct excision (Fig. 26.8). This is done by
beveling the incisions down to the SFS so dead space is
minimized after closure.

258
PART | 5  Abdominal contouring procedures
FIG. 26.6  (A, C) 45-year-old, 83.2 kg (183 lb) female after massive weight loss. Her planned vertical excision measured 23 cm wide. (B, D) After
fleur-de-lis abdominoplasty, body lift and liposuction, her contour is improved. Final tissue weight was 11.1 kg (24.5 lbs).
A
B
C
D
Sterile skin taping is applied and split every several
centimeters to prevent blistering. The patient is placed in a
binder with topical foam to protect against skin indentation
and transferred to the recovery room in a flexed position.
POSTOPERATIVE CARE
The patient normally stays in our facility overnight for
nurses to monitor vitals, drain output, flap viability, urine
output and administer pain medication. The patient ambu­
lates with assistance twice the evening of surgery and lower
extremity sequential compression devices (SCDs) are con­
tinued throughout the postoperative period until discharge.
At least one dose of low-molecular-weight heparin is
administered 12 hours postoperatively. Additional antico­
agulation is recommended based on preoperative Caprini
score.
COMPLICATIONS AND
THEIR MANAGEMENT
The most common complication following fleur-de-lis
abdominoplasty is local wound breakdown, particularly at
the junction of the vertical and horizontal incisions in
the midline. This is best avoided by ensuring minimal
skin tension is present in this zone. Double-checking

259
Chapter | 26  Fleur-de-lis abdominoplasty including mons contouring
FIG. 26.7  (A, C) 40-year-old, 68 kg (150 lb) female marked preoperatively for fleur-de-lis abdominoplasty. Note the tapering of the planned vertical
resection of 20 cm. (B D) After fleur-de-lis abdominoplasty with liposuction, contour is dramatically improved. Note the improved thigh contour on
oblique view. Resected tissue weight was 3.6 kg (8 lb).
A
B
C
D

260
PART | 5  Abdominal contouring procedures
FIG. 26.8  (A, C) 43-year-old, 69.5 kg (153 lb) female after open gastric bypass. (B, D) After fleur-de-lis abdominoplasty, mons excision and liposuc­
tion, the final resected tissue weight was 2.8 kg (6.2 lb).
A
B
C
D

261
Chapter | 26  Fleur-de-lis abdominoplasty including mons contouring
FIG. 26.9  (A) 48-year-old, 92.7 kg (204 lb) female with complaints of hanging abdominal tissues. Note the open cholecystectomy scar marked in red
in the right upper quadrant. The planned vertical resection has been adjusted to the patient’s right to incorporate this scar. (B) After fleur-de-lis abdomi­
noplasty with liposuction, the vertical scar is intentionally shifted off midline. Note the improvement in thigh contour. Total resection weight was 14.7 kg
(32.4 lb).
A
B
FIG. 26.10  (A, C) 44-year-old, 75 kg (165 lb) female pictured above after massive weight loss. The patient has a large ventral hernia. (B, D) After
fleur-de-lis abdominoplasty with liposuction and circumferential body lift, as well as a staged augmentation mastopexy, thigh lift and Bra Line Back
Lift, the patient has a marked change in appearance. Note the thigh and buttock contour improvement possible by adding the circumferential component.
Total resection weight was 4.9 kg (11 lb).
A
B
Continued

262
PART | 5  Abdominal contouring procedures
FIG. 26.11  (A) 53-year-old, 94 kg (207 lb) female presenting for body contouring. (B) After fleur-de-lis abdominoplasty with liposuction, the patient
is able to perform her daily activities and dress in normal clothing. Resection weight was 7.1 kg (15.6 lb).
A
B
C
D
FIG. 26.10  Continued
mea­surements before incision, placing the majority of
wound tension on the SFS closure, tapering the vertical limb
inferiorly and making sure a flexed position is maintained
post-operatively all help combat wound healing problems.
Should ischemia and impaired healing occur, conservative
debridement and traditional saline dressings are employed
until secondary intention healing or delayed primary closure
can be accomplished. The most worrisome complication
after fleur-de-lis abdominoplasty is venous thromboem­
bolism (VTE) and resulting pulmonary embolus (PE).
Preoperative risk stratification, SCDs prior to anesthetic
induction, early postoperative ambulation, attention to intra­
vascular volume status and chemoprophylaxis as indicated
are used to minimize this risk. Hematoma, seroma and
wound infection are rare and respectively managed with
drainage, aspiration and antibiotics.
CONCLUSION
Fleur-de-lis abdominoplasty has proven to be a highly
effective surgical procedure for a select group of patients
who demonstrate vertical and transverse abdominal tissue

263
Chapter | 26  Fleur-de-lis abdominoplasty including mons contouring
FIG. 26.12  (A, C) 55-year-old, 70.5 kg (155 lb) female after massive weight loss. (B, D) After fleur-de-lis abdominoplasty with circumferential body
lift, the patient’s body habitus is improved. Final resection weight was 8.2 kg (18.1 lb).
A
B
C
D
laxity (Figs 26.5–26.12). By performing a vertical resection
concurrently with an abdominoplasty, a dramatic improve­
ment in transverse skin tightening and waistline shape and
contour can be achieved. The improvement translates to
enhanced tissue contour seen extending to the posterior
midline. Caution should be exercised in determining the
transverse width of resection, being particularly mindful at
the most inferior aspect of the vertical resection. Overall,
patient satisfaction has been consistently high, and patients
are willing to accept the longer and more visible scar in
order to attain an excellent result.
FURTHER READING
Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: The University of Iowa experience. Plast Reconstr
Surg 2010;111(1):398–413.
Borud LJ, Warren AG. Modified vertical abdominoplasty in the massive
weight loss patient. Plast Reconstr Surg 2007;119(6):1911–21.
Castanares S, Goethel JA. Abdominal lipectomy: A modification of tech­
nique. Plast Reconstr Surg 1967;40(4):378–83.
Costa LF, Landecker A, Manta AM. Optimizing body contour in massive
weight loss patients: the modified vertical abdominoplasty. Plast
Reconstr Surg 2004;114(7):1917–23.

264
PART | 5  Abdominal contouring procedures
Dellon AL. Fleur-de-lis abdominoplasty. Aesth Plast Surg 1985;9(1):
27–32.
Fischl RA. Vertical abdominoplasty. Plast Reconstr Surg 1973;51(2):
139–43.
Lockwood T. High-lateral-tension abdominoplasty with superficial fascial
system suspension. Plast Reconstr Surg 1995;96(3):603–15.
Friedman T, O’Brien Coon D, Michaels J, et al. Plast Reconstr Surg
2010;125(5):1525–35.
Grazer FM. Abdominoplasty. Plast Reconstr Surg 1973;51(6):617.
Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA: Elsevier;
2009.
LeLouarn C, Pascal JF. High superior tension abdominoplasty. Aesth Plast
Surg 2000;24(5):375–81.
Regnault P. Abdominoplasty by the W technique. Plast Reconstr Surg
1973;53(3):265–74.
Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisited.
Plast Reconstr Surg 2000;106(5):1197–202.
Michaels JV, Friedman T, Coon D, et al. Mons rejuvenation in the massive
weight loss patient using superficial fascial system suspension. Plast
Reconstr Surg 2010;126(1):45e–46e.
Pannucci CJ, Dreszer G, Wachtman CF, et al. Postoperative enoxaparin
prevents symptomatic venous thromboembolism in high-risk plastic
surgery patients. Plast Reconstr Surg 2011;128(5):1093–103.
Persichetti P, Simone P, Scuderi N. Anchor-line abdominoplasty: a com­
prehensive approach to abdominal wall reconstruction and body con­
touring. Plast Reconstr Surg 2005;116(1):289–94.
Ramsey-Steward G. Radical “Fleur-de-lis” abdominoplasty after bariatric
surgery. Obes Surg 1993;3:410–4.
Strauch B, Herman C, Rohde C, Rubin JP. Mid-body contouring in the
post-bariatric surgery patient. Plast Reconstr Surg 2006;117(7):
2200–11.
Sugarbaker PH. Vertical abdominoplasty. J Surg Oncol 2001;78(3):
217–9.
van Uchelen JH, Werker PMN, Kon M. Complications of abdominoplasty
in 86 patients. Plast Reconstr Surg 2001;107(7):1869–73.
Wallach SG. Abdominal contour surgery for the massive weight loss
patient: the fleur-de-lis approach. Aesth Surg J 2005;25(5):454–65.

265
© 2013 Elsevier Inc
Chapter 27 
Key Points
●
Strict indication for patient selection according to the
Igwe Grades 4–5.
●
Panniculectomy should be considered as a combined
procedure together with the bariatric surgeon.
●
Use patient lifts for assistance.
●
Minimal undermining to prevent dead space and
seroma.
●
No muscle plication in order not to increase
intraabdominal pressure.
●
Perioperative management should comprise forced
diuresis and early ambulation.
Panniculectomy in patients with
super obesity
Dirk F. Richter, Hermann Lampe and Marianne Wolters
INTRODUCTION
In 2009 Germany has become the nation with the most
obese people in the whole of Europe. This statistic reveals
that obesity with its comorbidities has developed into a
widespread disease.
There are numerous conservative and operative strat­
egies for the treatment of obesity. Plastic surgeons are
increasingly confronted with the need for body contouring
after massive weight loss through dietetic methods or bar­
iatric surgery.1–5
A few superobese patients, however, do not respond to
the conventional treatment regimens. Then follows a
vicious circle with reduced mobility and thus reduced
calorie consumption. Reduced food intake alone is in this
case often not sufficient to achieve an appropriate weight
loss.
Patients with marked pannus usually have, in addition
to significant medical comorbidities such as metabolic syn­
drome and premature arthritis, massive problems of hygiene
in the lower abdominal fold, with recurrent furuncles,
abscesses, and fistulas. In addition, distinct functional
problems exist such as immobility, with the development
of secondary lymphedema, chronic ulceration on the
extremities, and pressure sores. Some patients with high
body mass index show severe elephantiasis in the entire
abdominal wall. Quite often there are additional problems
in micturition, especially in male patients whose genitalia
are completely obstructed6 (Fig. 27.1).
Current European guidelines recommend bariatric
surgery in those patients with a body mass index of 40
and in those with an index of 35 accompanied by sig­
nificant comorbidities. For patients with a body mass index
higher than 60, the surgical treatment is often difficult,
because the abdominal wall is very fat, and what can be
achieved with the instruments is often limited. The parallel
existing immobility is often an additional postoperative
risk.
Historically, panniculectomy was done only in selected
cases, when there was complete immobility, or patients
were not suitable for bariatric surgery. The aim of such
intervention was to interrupt the vicious circle of lack of
mobility and insufficient calorie consumption. This was
usually followed by a successful conservative weight
reduction or bariatric surgery.11–15
Today, such procedures are often performed together
with bariatric surgery.5–7 The plastic surgeon performs the
panniculectomy, thus the general surgeon gains access to
the abdominal wall and then laparoscopically places the
gastric banding or performs a gastric bypass or sleeve.
The subsequent weight loss leads to an immediate
increase in mobility. If the process of losing weight is com­
pleted and there is weight maintenance of about 1 year,
subsequent plastic-reconstructive surgical operations are
possible to complete the surgical treatment.8
PREOPERATIVE PREPARATION
Patients eligible for panniculectomy should be chosen care­
fully. Operations on such a patient population are always
risky, since metabolic syndrome and the long-lasting car­
diovascular stress tend to result in severe complications.
Part 5  Abdominal contouring procedures

266
PART | 5  Abdominal contouring procedures
FIG. 27.1  (A, B) Patient with a pannus morbidus, presenting a permanent lymphedema of the abdominal wall. Secondary lymphedema on
right leg due to compression of the inguinal region.
A
B
Besides the increased general risks, however, there exist
significantly increased surgical complication rates, with
increased blood loss, excessive seroma formation, wound
healing problems and necrosis. In the few publications
related to this issue, complication rates are more than 50%;
even serious events stated to be 2.5% seem not be substan­
tially increased. Blood loss is given in the literature as
significant (from 800 to 2500 ml with decrease of hemo­
globin and a consequent transfusion requirement in more
than 20%). Hernias were found in about 20% of patients
and were treated mostly within the same session. The infec­
tion rate given in the literature is on average about 15%,
due to poor preoperative hygiene.9–11
For these reasons, strict indications and improved oper­
ational procedures are required. We have in the past sought
for approaches to address the above-mentioned high com­
plication rates. In the following, therefore, we present our
concept, which has been derived from more than 20 years
of experience with over 100 patients. The excision weight
of our patients ranged between 10 and 65 kg.
Regarding the case history it is important to find out
how many serious attempts to diet have been undertaken
and whether there are exclusion criteria for bariatric surgery.
The normal course of the survey includes, first of all, a
classification of the pannus in the degree classification
according to Igwe:12
● Grade one: coverage of the pubic hair (Fig. 27.2)
● Grade two: coverage of the mons pubis (Fig. 27.3)
● Grade three: coverage of the upper third of the thigh
(Fig. 27.4)
● Grade four: coverage of the top half of the thigh
(Fig. 27.5)
● Grade five: coverage of the knee and below
(Fig. 27.6).
In addition to this classification the presence of a per­
manent lymphedema of the abdominal wall (elephantiasis)
needs to be documented. In this case it is called a pannus
morbidus and recurrence after abdominal amputation in
later courses of surgery is almost certain (Fig. 27.7).
Furthermore, we look for secondary lymphedema in
the extremities; carefully inspecting the abdominal fold,
the umbilical region, and the external genitalia, especially
for intertriginous inflammation, boils, or abscesses. The
abdomen is carefully examined in the supine and standing
positions for clinical hernia. In particular, the umbilical

267
Chapter | 27  Panniculectomy in patients with super obesity
FIG. 27.2  Igwe grade 1 deformity: coverage of the pubic hair.
FIG. 27.3  Igwe grade 2 deformity: coverage of the mons pubis.
region is a predilection site. An exploratory ultrasound of
the abdomen should be mandatory, because the clinical
examination is often difficult. In most cases, we also request
a CT scan of the entire abdomen for safe exclusion of a
hernia, and a Doppler ultrasound of the deep venous system
for the safe exclusion of thrombosis.13
Besides the usual laboratory tests, we look in particular
at protein balance and wound healing parameters, such as
zinc, vitamin C, and other trace elements.
Early involvement of anesthesiologists is advisable
to optimize the preoperative situation in order to accom­
plish any therapeutic recommendations early enough.
Breathing exercises should be initiated 1 month before the
operation.
A preliminary cardiological examination should follow
to check the resilience of the cardiovascular system. The
substantial electrolyte and fluid shifts due to the large
volume of excision are to be taken into account. If there
is a lymphedema of the abdominal wall, the patient should
be hospitalized for a few days before the operation to
elevate the abdominal wall, to perform lymph drainage
and forced diuresis, balancing the electrolytes in control of
the renal parameters. On the preoperative day the patient
should take only a liquid diet and reduce drug support. The
abdominal fold should be treated at least a week before
surgery with antiseptic soaps and the umbilical region
with antiseptic ointment. Two hours before surgery the
patient is preheated with prewarmed infusions and surgical
table covers are provided. Antithrombosis stockings are
applied.
A urinary catheter is applied, as well as a central venous
catheter for measurement of the central venous pressure
and an arterial cannula for continuous blood pressure
measurement.
With initiation of anesthesia, an intravenous antibiotic
treatment is given and the patient is well padded and sup­
ported with a Bear-Hugger blanket.
SURGICAL TECHNIQUE
Immediately after the initiation of anesthesia the pannus is
to be lifted (Fig. 27.8). To facilitate this procedure two to

268
PART | 5  Abdominal contouring procedures
FIG. 27.5  Igwe grade 4 deformity: coverage of the top half of the
thigh.
FIG. 27.4  Igwe grade 3 deformity: coverage of the upper third of
the thigh.
three conventional meat hooks are placed after stitch inci­
sions at the apex of the abdominal wall (Fig. 27.9). Then,
a patient lift, such as that found on most intensive care
units, is pushed through the abdominal wall and iron chains
suspended from the meat hooks. Slowly, and with continu­
ous monitoring of the central venous pressure, the pannus
is now lifted. This maneuver is carried out slowly, as there
may be a significant relevant effect on the circulation due
to interstitial and intravascular fluids. It follows an improve­
ment in breathing resistance and a return blood flow in the
sense of an autotransfusion (Fig. 27.10).11,14,15
When the maximum height is reached the base of the
area to be excised is infiltrated with tumescent solution to
allow the most anemic preparation. Now the abdominal
fold is meticulously disinfected and the bladder catheter is
placed. Then the lifting crane is slightly released, so that
the resection marks can be checked once more for tension-
free closure. Afterwards the abdomen is scrubbed and
sterile draped. The resection usually starts with two
surgeons working in parallel. By using a Colorado needle
for the incision it should be ensured that the lower incision
is made strictly at 90° to the abdominal wall, so that no high
tension on the skin occurs later. This follows the prepara­
tion to the upper resection marks, preserving Scarpa’s
fascia in order to avoid seroma (Fig. 27.11). To prevent heat
development and seroma we use an ultrasound cutting
device, which shows significantly less fluid collection post­
operatively.16 We avoid further preparation to prevent any
unnecessary cavitation. In general, the umbilicus is resected,
as an umbilical transposition would require further prepara­
tion that in turn would increase the likelihood of further
cavitation. The voluminous periumbilical veins are either
clipped or ligated.
In this region the surgeon has to watch out for hernias
as they can occultly occur around the navel (Fig. 27.12).
Then the pannus is cut off and weighed. In the upper
section of the incision line a 90° angle is essential in order
to achieve good adaptation to the lower cut line (Fig. 27.13).

269
Chapter | 27  Panniculectomy in patients with super obesity
FIG. 27.6  Igwe grade 5 deformity: coverage of the knee and below.
FIG. 27.7  Pannus morbidus. (A) Preoperative (B) Postoperative
A
B
Continued

270
PART | 5  Abdominal contouring procedures
(C, D) Postoperative
C
D
FIG. 27.7  Continued Pannus morbidus.
If a bariatric surgery is planned in the same session, the
general surgeon is now involved and usually performs the
intervention laparoscopically. Because of the removal of fat
it is now easier to use the instruments. In case of high
intraabdominal pressure it is possible to switch to an open
procedure.
Finally, the entire wound is again checked for bleeding
and rinsed carefully and thoroughly with sodium chloride.
The wound is closed in multiple layers, and multiple
Baroudi sutures are applied to reduce the cavities. In par­
ticular, Scarpa’s fascia is adapted exactly to minimize the
tension of the skin. We insert multiple drains and plug them
in a vacuum pump with continuous pressure. The closure
of the skin is done atraumatically intracutaneously, with
additional application of PRINEO-topical skin adhesive to
prevent local wound infections (Fig. 27.14).
Case studies are shown in Figs 27.15–27.22.
OPTIMIZING OUTCOMES
The surgical concept is developed to avoid major complica­
tions such as blood loss, seroma, and wound healing
problems.
To prevent blood loss, we start the operation directly
with the autotransfusion, use the tumescent infiltration solu­
tion, and finally incise the skin with the Colorado needle to
avoid microbleeding. In this way the transfusion rate can
be reduced to 11%.
Most complications can be attributed to wound fluid
retention. Therefore, the prevention of fluid loss has highest
priority. We showed in an evidence-based study level I that
the use of an ultrasonic scalpel results in less blood loss and
lower seroma rates.16 Furthermore, a preparation preserving
Scarpa’s fascia has also the advantage of not damaging the
underlying lymphatic network. Thus less seroma occurs.
The insertion of drains in abdominoplasty is also evidence
based. In this case we insert multiple drains and connect
them to a continuous vacuum system. The significant
advantage is that not only are the liquids aspirated, but a
continuous negative pressure causes the wound surfaces to
stick together more effectively. The use of Baroudi sutures
is also evidence based and leads to a reduction of the cavi­
ties, as well as progressive tension sutures, which reduce
the tension of the wound surface.
Studies have not yet shown a significant reduction of
seroma using fibrin glue.

271
Chapter | 27  Panniculectomy in patients with super obesity
FIG. 27.8  Preparing the patient in a beach chair position.
FIG. 27.9  Elevating the pannus with hooks and hains using a patient
lift.
FIG. 27.10  During prep and drape the pannus is elevated in terms
of autotransfusion. After 20 min. the base of the pannus is infiltrated
with tumescent fluid.
FIG. 27.11  (A) Starting the resection from both sides using clips for
hemostasis of the large vessels. (B) Care must be taken not to run into
hernia especially around the area of the umbilicus. (C) The patient
lifter enables you to manage the huge weight of the pannus.
A
B
C

272
PART | 5  Abdominal contouring procedures
FIG. 27.12  The resected pannus is weighed with a lot of edema is
inside.
FIG. 27.13  Primary closure can easily be achieved without under­
mining to prevent seroma. Baroudi stitches may be helpful to close
the existing dead space.
FIG. 27.14  Wound closure in multiple layers using several drains
and a permanent vacuum pump.
FIG. 27.15  Patient after Roux-en-Y bypass and weight loss of
180 kg. He presents with a double pannus grade 5 and a hernia of the
umbilicus.

273
Chapter | 27  Panniculectomy in patients with super obesity
rare cases postoperative ventilation is useful; however,
a stay in the intensive care unit is recommended.
Because of the potential electrolyte and fluid imbalance in
particular, this approach has been established in our
department.
Directly after surgery, we start with the injection of
weight-adjusted low molecular weight heparin and a calf
muscle pump. The breathing exercises begin 2 weeks prior
and right after surgery.
In general, patients are carefully mobilized on the
first postoperative day to prevent thrombosis. An abdo­
minal compression garment, specially made for this
patient, is applied. The perioperative administration of a
single-shot antibiotic treatment is evidence based in
abdominoplasty.
We do not deliver continuous antibiotics and regularly
monitor the inflammatory markers. On the fifth postope­
rative day, we replace the vacuum pump by suction
bottles and remove the drains if less than 30 ml per day is
produced.
Wound healing in this patient population occurs very
often and is not an exception. First, most patients have
significant endocrinological comorbidities as well as nutri­
tional deficiency.
Important factors such as zinc and vitamin C may be
evaluated preoperatively and if necessary supplemented. A
protein deficiency can also be easily compensated before
surgery. Intensified hygiene with antiseptic soaps may also
lead to an improvement of the local wound healing. The
topical skin glue PRINEO also effectively prevents any
secondary bacterial infection.
The operation time plays an important role in respect of
the complication rate. Usually two surgeons operate simul­
taneously, so that the operation time does not exceed 90
minutes (Fig. 27.23).
POSTOPERATIVE TREATMENT
In the early recovery phase the patient lies in the beach-
chair position covered with Bear-Hugger blankets. In
FIG. 27.16  Elevating the abdominal pannus shows the elephantiasis
of the mons pubis.
FIG. 27.17  Functional problems.

274
PART | 5  Abdominal contouring procedures
wound-healing problems are treated with vacuum-assisted
closure therapy. Hemoglobin decline is tolerated to a clini­
cal relevance and a transfusion is provided if hemoglobin
declines to less than 8 mg/dl.
In case of bariatric surgery at the same time blood
glucose should be checked. Amazingly, the blood glucose
returns to a normal level after bypass surgery within a very
short time, so that insulin-dependent diabetic patients can
easily become hypoglycemic.
In general, patients continue to receive reduced-calorie
soft food, to keep the intraabdominal pressure as low as
possible. Flatulent food should be avoided and drugs should
be applied for prevention of meteorism.
To improve the microcirculation for the first 4 days the
patients receive 2500 ml Ringer’s solution given intrave­
nously. They are additionally encouraged to drink at least
3 liters per day. The preoperative drink containing protein,
vitamins, and minerals is continued until wound healing is
completed.
The wounds are disinfected twice daily and the dressing
is done under aseptic conditions. Patients are showered
with drains in place to reduce any local bacterial
infection.
COMPLICATIONS AND
THEIR TREATMENT
With the concept presented here we managed to reduce the
complication rate to an acceptable range for this patient
group. Nevertheless, minor complications often occur and
require special attention.
Early complications include hematoma, which should
be aspirated early, sucked, or surgically removed because
they encourage bacterial growth. Other complications
include local inflammation and dehiscent wounds. Wound
healing problems are treated by keeping the wound
moist and closing early by secondary sutures. Larger
FIG. 27.18  Frontal view demonstrating the mons pubis.
FIG. 27.19  Elevating the abdominal pannus and the mons pubis,
demonstrating the hidden penis and scrotum.

275
Chapter | 27  Panniculectomy in patients with super obesity
can be pursued. Clinical experience shows that this particu­
lar group of patients can rarely be managed without bariat­
ric surgery. The simultaneous combination of surgical
intervention and panniculectomy has been established as a
useful concept.
The planning of the operation requires strict indications
and extensive preparation to make the postoperative com­
plications as few as possible. Special emphasis should be
given to the specific metabolic situation.
The operation is preferably done by two surgeons simul­
taneously to ensure rapid progress. Criteria for the preven­
tion of seroma and bleeding need to be taken into account.
The postoperative course is characterized by early mobili­
zation and prevention and treatment of wound healing
problems.
In case of a positive clinical course, great weight loss
and weight maintenance patients will be prepared for
further plastic reconstructive interventions.
Seromas occurring after removing the drains are to be
aspirated under sterile conditions. If necessary they can be
drained and antibiotic injections can be used. Formation of
a pseudo bursa needs to be excised.
CONCLUSION
Surgery in super obese patients with a high body mass
index is always a precarious treatment. Due to the meta­
bolic comorbidities and restricted blood flow and healing
of the fat tissue, operations in these patients are carried out
unwillingly. For the treatment of obesity physical exercise
is part of the therapy. Mobility is restricted and often fol­
lowed by a complete immobility due to the mechanical
problems caused by the excess pannus.
The panniculectomy, once considered a last resort, can
interrupt the existing vicious circle. By regaining mobility,
the calorie consumption is increased and dietary approaches
FIG. 27.20  After complete resection of the abdominal pannus and
mons pubis, hernia repair and umbilicus transection and excavating
the penis, lateral view.
FIG. 27.21  After complete resection of the abdominal pannus and
mons pubis, hernia repair and umbilicus transection and excavating
the penis, frontal view.

276
PART | 5  Abdominal contouring procedures
10. Vastine VL, Morgan RF, Williams GS, et al. Wound complications
of abdominoplasty in obese patients. Ann Plast Surg 1999;42:34.
11. Venturi ML, Attinger CE, Mesbahi AN, et al. Mechanisms and clini­
cal applications of the vacuum-assisted closure (VAC) device: A
review. Am J Clin Dermatol 2005;6:185.
12. Igwe D, Stanczyk M, Lee H, et al. Panniculectomy adjuvant to
obesity surgery. Obes Surg 2000;10:530.
13. Hughes KC, Weider L, Fischer J, et al. Ventral hernia repair with
simultaneous panniculectomy. Am Surg 1996;62:678.
14. Richard EF. A mechanical aid for abdominal panniculectomy. Br J
Plast Surg 1965;18:336.
15. Jensen PL, Sanger JR, Matloub HS, et al. Use of a portable floor
crane as an aid to resection of the massive panniculus. Ann Plast
Surg 1990;25:234.
16. Stoff A, Reichenberger MA, Richter DF. Comparing the ultrasoni­
cally activated scalpel (harmonic) with high-frequency electrocau­
tery for postoperative serous drainage in massive weight loss surgery.
Plast Reconstr Surg 2007;120(4):1092–3.
FURTHER READING
Belin RP, Stone NH, Fischer RP, et al. Improved technique of panniculec­
tomy. Surgery 1966;59:222.
REFERENCES
1. Petty P, Manson PN, Black R, et al. Panniculus morbidus. Ann Plast
Surg 1992;28:442.
2. Hanna D, Cloutier R, Lapointe R, et al. Abdominal elephantiasis:
A case report. J Cutan Med Surg 2004;8:229.
3. Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in
the United States, 2000. JAMA 2004;291:1238.
4. Hopkins MP, Shriner AM, Parker MG, et al. Panniculectomy at the
time of gynecologic surgery in morbidly obese patients. Am J Obstet
Gynecol 2000;182:1502.
5. Igwe D Jr, Stanczyk M, Lee H, et al. Panniculectomy adjuvant to
obesity surgery. Obes Surg 2000;10:530.
6. Haritopoulos KN, Labruzzo C, Papalois VE, et al. Abdominoplasty
in a patient with severe obesity. Int Surg 2002;87:15.
7. Acarturk TO, Wachtman G, Heil B, et al. Panniculectomy as an
adjuvant to bariatric surgery. Ann Plast Surg 2004;53:360.
8. Kenkel J. Body contouring surgery after massive weight loss. Plast
Reconstr Surg 2006;117:1S.
9. Friedrich JB, Petrov RV, Askay SA, et al. Resection of panniculus
morbidus: a salvage procedure with a steep learning curve. Plast
Reconstr Surg 2008;121:108.
FIG. 27.22  Same patient wearing his old clothes.
FIG. 27.23  (A, B) Clamps may be helpful to get a better overview
during preparation.
A
B

277
Chapter | 27  Panniculectomy in patients with super obesity
Larkin CL. Lipectomy for abdominal fat. Conn Med J 1950;14:706.
Matory WE Jr, O’Sullivan J, Fudem G, et al. Abdominal surgery
in patients with severe morbid obesity. Plast Reconstr Surg 1994;
94:976.
Meyerowitz BR, Gruber RP, Laub DR. Massive abdominal panniculec­
tomy. JAMA 1973;225:408.
Smith L. Excision of panniculus adiposus. J Med Assoc Ga 1939;
28:193.
Jackson JA, Steeper JR. Operative incision of giant panniculus adiposus.
J Int Coll Surg 1951;15:85.
Jones LJ, Boines GJ. Rehabilitation in the obese by lipectomy. Del Med
J 1946;18:161.
Kelly HA. Excision of the fat of the abdominal wall-lipectomy. Surg
Gynecol Obstet 1910;10:229.
Kelly HA. Report of gynecological cases. Johns Hopkins Med J 1899;
10:197.

278
© 2013 Elsevier Inc
Chapter 28 
Key Points
●
Lipoabdominoplasty was developed and patterned as
a safe and functional option with which to perform
liposuction and abdominoplasty during the same
surgical procedure, promoting the benefits of both
techniques.
●
This technique is not simply using liposuction while we
are performing abdominoplasty. It has a much wider
concept, respecting the complete abdominal anatomy
by performing a selective undermining and preserving
the Scarpa fascia. This will be studied in this chapter.
●
A technique that greatly reduces the complications of
abdominoplasty by the preservation of the blood
supply and drainage (perforating vessels), nerves, and
lymphatic branches.
Lipoabdominoplasty
A.  LIPOABDOMINOPLASTY
Osvaldo R. Saldanha, Luis Humberto Uribe Morelli,
Sergio Fernando Dantas de Azevedo,
Osvaldo R. Saldanha Filho and
Cristianna Bonetto Saldanha
INTRODUCTION
1. Traditional and wide undermining used in abdominal
plastic surgery has a high rate of morbidity.1–4
2. Plastic surgeons were not satisfied with the esthetic
results and complication rates from traditional abdomi­
nal plastic surgery.
3. Surgeons have always been motivated to offer the best
results with a lower complication rate. In the 1990s,
many papers were published relating to the decrease
in undermining and the avoidance of performing full
liposuction in abdominoplasty because of increasing
complications. Patient safety was our major objective
when developing lipoabdominoplasty. This technique
patterned the limits of abdominal flap undermining,
making it safe and generating a better esthetic result. It
can be learned quickly because surgeons are used to
performing each procedure, liposuction and abdomino­
plasty, separately.
Observations
According to published evidence, the perforator vessels
represent 80% of the blood supply of the abdominal wall.5,6
Consequently, the vascularity of the remaining flap is sup­
plied by the intercostal, subcostal, and lumbar perforating
branches, which are situated in the back and flank regions.7
The occurrence of ischemic processes with tissue necrosis
and dehiscence of the suture has been described when
abdominoplasty is associated with liposuction (this is
without a selective undermining).8
PREOPERATIVE PREPARATION
1. Indications: same indications as traditional abdomino­
plasty (skin flaccidity, fat accumulation, plus diastasis
of the rectus muscle).
2. Surgeons who wish to adopt this technique should
perform the lipoabdominoplasty first in patients with
excessive skin flaccidity and in those who are over­
weight; surgeons can then develop more confidence with
this procedure, which has a short learning curve.
3. Assessment of the entire abdomen must be performed,
especially looking for hernias. Ventral, lumbar, and
femoral hernias should be ruled out. In the authors’ prac­
tice, preoperative ultrasonography of the abdominal wall
looking for hernias is routinely performed on all patients.
Warning
1. Fibrous tissue from previous abdominal liposuction
could make mobility of the abdominal flap difficult.
2. Previous scarring or previous endoscopic procedures
could permit the cannula to cross through the abdominal
muscle aponeurosis.
3. Never perform this procedure in patients with a hernia.
Observations
Begin with a high suprapubic incision in patients where the
descent of the abdominal flap is not clear.
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Part 5  Abdominal contouring procedures

278.e1
Chapter | 28  Lipoabdominoplasty
HISTORY
1899 to 1990s
1. 1899 to 1957, progressive undermining of the abdomi­
nal wall was performed.
2. 1957, Veron standardized the extensive undermining to
facilitate umbilical transposition.9
3. 1980, Illouz developed liposuction, and from this date
the combination of both techniques has always been a
hot topic in the main literature, national and interna­
tional meetings.10
4. 1985, Hakme and Shestak presented a new approach for
abdominal lipectomies, the “Mini-abdomiplasty tech­
nique” of liposuction of the abdomen and flanks, associ­
ated with an elliptical resection of the suprapubic skin
and the plication of the supra and infraumbilical muscles,
without relocating the umbilicus.11,12
1990s
1. 1991 and 1995, Matarasso focused on the complications
of combined liposuction and abdominoplasty, present­
ing two articles recommending the safe areas of liposuc­
tion. In those articles he considered the back and the
flanks safe areas, did not regard the lateral region of the
abdomen as a safe area, and considered the central
region of the abdomen prohibited for liposuction.8
2. 1995, Lockwood reported “high lateral tension abdomi­
noplasty” in which he used Scarpa fascia to decrease the
tension of the skin closure.13
Since the 1990s, the undermining has decreased in
extent because of the large number of complications
(seroma, hematoma, and most of all, necrosis),14 reach­
ing zero in 1992 with the publication of “abdomino­
plasty mesh undermining” by Illouz.10
4. The trend of abdominolipoplasty with or without small
undermining continued up to 1999, when Shestak pre­
sented the partial abdominolipoplasty method, with no
undermining, associated with liposuction.12
2000 to Present
Lipoabdominoplasty was developed by Saldanha in 2000
and first published in 2001as a safe option to correct esthetic
and functional abdominal deformity while achieving better
esthetic results with technical simplicity for surgeons.15
In that publication, a selective undermining between the
medial borders of the rectus abdominal muscles was pre­
sented and use of the term “Lipoabdominoplasty” was
standardized for the first time. Lipoabdominoplasty com­
bines two traditional techniques, abdominoplasty and lipo­
suction. The new and conservative concept is based on the
preservation of the abdominal perforating vessels (subcuta­
neous pedicle), which are branches of the deep epigastric
vessels.5–7 This technique conserves about 80% of the blood
supply of the abdominal flap compared with traditional
undermining. The lymphatic branches and nerves are pre­
served, maintaining the cutaneous sensitivity of the flap to
superficial pain and superficial touch caused by tempera­
ture, vibration, and pressure, which is an improvement over
traditional abdominoplasty.15–19

279
Chapter | 28  Lipoabdominoplasty
Anatomy
Preservation of Scarpa’s fascia and the deep fat layer
partially in the lower abdomen (between the umbilicus
and the pubis) allows a complete reconstruction of the
abdominal wall in the lower abdomen to be performed
(Fig. 28.1).
Tunnel undermining is performed exactly between the
medial borders of the rectus muscles, corresponding to the
diastases area, preserving at least 80% of the perforating
vessels, and also preserving lymphatics and nerves. Graf
et al,20 using echo Doppler, showed the flow of the perium­
bilical perforating vessel 15 days after the procedure, and
Munhoz and colleagues,21 through a Doppler ultrasound
study, found that about 80% of the perforating vessels
mapped in the preoperative period were maintained. This
validates the hypothesis of lesser complication rates due to
flap ischemia when performing lipoabdominoplasty.
Sensitive nerves of the abdominal wall run along the
abdominal perforating vessels. For this reason performing
a reduced undermining will result in better sensitivity in the
postoperative period.
SURGICAL TECHNIQUE
We base the technique on three main principles:
1. Superficial and deep liposuction:
The deep and mainly superficial liposuction increases
the mobility of the abdominal flap, and it can descend
easily to the suprapubic region.22
2. Anatomic study of the abdominal blood supply:
The study of the exact localization of the perforating
abdominal vessels led us to perform a selective under­
mining (tunnel undermining), preserving at least 80%
of the blood supply of the abdominal wall, also reduc­
ing nerve trauma and maintaining lymphatic drainage.
This produces fewer complications when compared
to traditional abdominoplasty, even in post-bariatric
surgery.
3. Scarpa’s fascia preservation:
Although the lipoabdominoplasty may be performed
removing Scarpa’s fascia, its maintenance is one of the
most important steps of the technique.
Marking
1. Mark the initial incision line (Fig. 28.2 and 28.4).
2. Mark the areas to be liposuctioned (Fig. 28.5).
3. Mark the diastasis of the rectus muscles (Fig. 28.5).
Perforating vessels
Scarpa’s fascia and
deep fat layer
Abdominal rectus muscles
AA
FIG. 28.1  (A–C) Preservation of Scarpa fascia and partial deep fat
layer in the lower abdomen to accommodate the abdominal flap.
Perforating vessels
Abdominal rectus muscle
Deep fat layer
Scarpa’s fascia
BB
Perforating vessels
Abdominal rectus muscle
Deep fat layer
Scarpa’s fascia
CC
FIG. 28.2  Horizontal marking.

280
PART | 5  Abdominal contouring procedures
Observations on this Step
Point A: 7 cm from the vulva commissure (Fig. 28.3).
Points B and C: 14 cm horizontal parallel line divided
by point A. Point B: right side of the patient, Point C:
left side of the patient.
Point D: 7 cm from point B in the direction of the
patient’s right iliac crest.
Point E: 7 cm from point C in the direction of the
patient’s left iliac crest.
In summary, the distance between the points:
A/B: 7 cm
B/D: 7 cm
C/E: 7 cm
Total length at the initial marking: 28 cm.
Infiltration
1. Tumescent technique (Fig. 28.6).
2. 1 : 500 000 saline solution with epinephrine (adrenaline)
in the abdominal region (average of 1 to 1.5 l)
(Fig. 28.6).
3. No lidocaine is used.
FIG. 28.3  Oblique marking.
FIG. 28.4  Previous demarcation of diastasis.
FIG. 28.5  Initial distance from the pubis.
FIG. 28.6  Infiltration.

281
Chapter | 28  Lipoabdominoplasty
Upper Abdominal Liposuction
1. The patient is placed in a hyperextended position on the
surgical table (safer position).
2. Liposuction of the deep and superficial layers of the
upper abdomen using 3 and 4 mm cannulas is carried
out.
3. Extend liposuction to the flanks as the lateral limits and
up to the submammary fold as the upper limit (Fig. 28.7).
Observations on this Step
About 2.5 cm of fat thickness is maintained to avoid vas­
cular impairment and contour deformities.
Performing liposuction in the upper abdomen not only
removes fat, producing a better body contour, but also
undermines the abdominal flap (cannula undermining) to
facilitate flap descent. This stage of the surgery is manda­
tory and is one of the keys to successful outcomes.
Lower Abdominal Liposuction
1. Entire liposuction of the superficial fat layer in the lower
abdomen is carried out with a 6 mm cannula (Fig. 28.8).
2. Partial liposuction of the deep fat layer in the lower
abdomen is done with a 4 mm cannula.
3. Assessment of the descent and mobility of the abdomi­
nal flap (Fig. 28.9). (If safe, the next step can be per­
formed – “incision”.)
Observations on this Step
Many surgeons think that liposuction of the lower abdomen
is not necessary and a waste of time when the lower
abdomen is going to be excised. However, doing liposuc­
tion of the entire superficial layer of the lower abdomen
provides a better visualization of Scarpa’s fascia (this is
important and one of the main principles of the surgery)
and doing a partial liposuction of the deep layer of the lower
abdomen reduces the fat thickness, to give a better contour.
Incision and Undermining in the
Lower Abdomen
1. The incision is made in the previously marked area.
2. The flap is undermined above Scarpa’s fascia.
3. The umbilicus is isolated.
Observations on this Step
If necessary, complementary open liposuction is performed
to remove fat above and below Scarpa’s fascia and to create
a homogeneous surface to accommodate the superior flap,
which becomes thinner in its descent (Fig. 28.10).
Scarpa’s Fascia Preservation
The preservation of Scarpa’s fascia is important for many
reasons (Fig. 28.11A).
1. There is less bleeding and less seroma because of the
preservation of the inferior perforating vessels and the
FIG. 28.7  Superior abdominal liposuction.
FIG. 28.8  Lower abdominal liposuction.
FIG. 28.9  The flap descent evaluation.

282
PART | 5  Abdominal contouring procedures
preservation of the lymphatic branches. This leads to
less morbidity.
2. It creates a homogeneous support and better adherence
between the upper flap and the deep layers.
3. It causes the contention of the scars laterally (Fig.
28.11B).
Selective Undermining
(Tunnel Undermining)
1. Undermining is performed in the midline of the upper
abdomen, between the internal edges of the rectus
abdominal muscles (Figs 28.12 and 28.13). Neglecting
to limit the dissection in this manner may result in
damage to perforating vessels, which increases morbid­
ity and the risk of abdominal flap necrosis.
2. Tunnel undermining may reach the xiphoid, depending
on the need for rectus muscle plication.
3. The tunnel width may vary with the distance of diastasis
because the perforating vessels follow the muscle
separation.
FIG. 28.10  Open liposuction.
FIG. 28.11  (A) Scarpa fascia preservation. (B) Contention of scars
laterally.
A
B
FIG. 28.12  (A, B) Selective undermining of the tunnel.
A
B

283
Chapter | 28  Lipoabdominoplasty
In this part of the surgery we recommend using a retrac­
tor developed by the senior author, which brings the fol­
lowing benefits:
● Better visualization of the tunnel and the anatomic
structures.
● Easier plication of the rectus muscle.
● Prevents trauma to the edges of the flap (Fig. 28.14).
Observations on this Surgical Step
Discontinuous undermining using the liposuction cannula
without suction in the upper abdomen can be performed to
facilitate the descent of the flap.
After the surgeon is completely sure that the flap easily
transposes the pubic symphysis, the excess of skin in the
lower abdomen must be removed (Fig. 28.15).
OPTIMIZING OUTCOMES
Combining liposuction and abdominoplasty improves the
authors’ results, is safe, leads to a greater reduction in
FIG. 28.13  Perforating vessels.
FIG. 28.14  The Saldanha retractor.
FIG. 28.15  Resection of the infraumbilical skin.
FIG. 28.16  Resection of the infraumbilical fuse.
FIG. 28.17  Plication.

283.e1
Chapter | 28  Lipoabdominoplasty
Removing the Infraumbilical Excess
1. We remove a vertical ellipse of tissue that contains
Scarpa’s fascia and deep adipose tissue in the mid-
infraumbilical line to visualize the edges of the rectus
muscle (Fig. 28.16).
2. After removing the vertical ellipse, the plication of the
medial edges of the rectus muscle in the lower abdomen
is performed. This way we complete the plication of the
entire abdomen (upper and lower) (Fig. 28.17).
3. Finally, we replace the Scarpa’s fascia.
Umbilicoplasty/Omphaloplasty
1. The “Star-shaped omphaloplasty technique” is marked
and incised on the skin of the abdominal wall.
2. A diamond shape is marked on the umbilical pedicle.
3. The cardinal points of the umbilical pedicle are sutured,
accommodating themselves on the cruciform incision of
the abdominal wall skin.
Observations on this Surgical Step
The scar results in continuous Z plasty that offers a little
possibility of retraction (Fig. 28.18).
Closure of the Abdominal Wound
1. 3-0 Monocryl sutures for the deep layer.
2. 4-0 Monocryl for the subdermis.
3. The skin is sutured with 5-0 mononylon interrupted
stitches.
4. The scar can be lowered in the final step of the surgery
by resecting a cutaneous ellipse (1–3 cm) from the
pubic skin, without the risk of harming the flap or
having too much tension at the suture line, to obtain a
lower scar (Fig. 28.19).
5. A closed suction drain is placed for 1 to 2 days
(Fig. 28.20).
6. The wound is covered with micropore surgical tape, and
a surgical garment is placed on the patient while still on
the surgical table.

284
PART | 5  Abdominal contouring procedures
abdominal measurements, and leads to better body contour
(Figs 28.21 and 28.22).
FIG 28.21 28.22 APPEARS ONLINE ONLY
There has been less demand for surgical revision since
adopting this technique.
Patient satisfaction with this technique has led to an
increase in requests for lipoabdominoplasty in the authors’
practice. In the first 9 years of technique implementation,
there was an increase of 100% in the abdominal interven­
tions made by the author (O.R.S.) (before 2000, an average
of 35 patients per year, and in 2008, an average of 75
patients per year).
The incidence of complications in traditional abdomi­
noplasty was compared with that of lipoabdominoplasty.
From 1979 to 2000, the author performed 494 traditional
abdominoplasty surgeries. In 2000, the author began to
develop lipoabdominoplasty, and in 2001 it was standard­
ized, which corresponds to 688 procedures from 2000 to
2010. In 2007, only one traditional abdominoplasty was
performed because it was a specific case of skin excess in
a post-bariatric surgery patient. There was a 50% reduction
of surgical revisions in the same period.
A decrease in the final scar length was observed when
compared with the initial marking in 30% of patients. The
initial markings always measured 28 cm in length, 14 cm
horizontally and 7 cm obliquely on each side. Of the 520
patients who underwent lipoabdominoplasty, 156 had a
final scar between 25 and 27 cm, with an average reduction
of 2 cm compared with the initial markings. This is because
of the traction of Scarpa’s fascia on the skin.
The graceful shape of the umbilicus scar has been evalu­
ated by the team and the patients as good or excellent
(Figs 28.21 and 28.22).
POSTOPERATIVE CARE
1. The dressing is changed on the third and eighth days
after surgery, when the stitches are removed, except for
FIG. 28.18  (A) Marking the star-shaped omphaloplasty technique. (B) Incision for omphaloplasty. (C) Final aspect of umbilicus.
A
B
C
FIG. 28.19  Suture of the layers and lowering of the scar.
FIG. 28.20  Drain.

284.e1
Chapter | 28  Lipoabdominoplasty
A
B
D
E
C
F
FIG. 28.21  Case 2: pre (A–C) and postoperative (D–F) views of the patient.

284.e2
PART | 5  Abdominal contouring procedures
FIG. 28.22  Case 3: pre (A–C) and postoperative (D–F) viewsof the patient.
A
B
C
D
E
F

285
Chapter | 28  Lipoabdominoplasty
those on the umbilicus, which are removed on the 12th
postoperative day.
2. As previously mentioned, the drain is removed 1 to 2
days after surgery.
3. Patients who undergo lipoabdominoplasty have an
intermediary recovery between those of abdominoplasty
and liposuction because this procedure is less invasive,
causes little neurovascular trauma, and leads to less
discrete dead space. These factors result in lower mor­
bidity and enable the patient to return early to his or her
social and professional activities.
COMPLICATIONS AND
THEIR MANAGEMENT
By following the surgical steps carefully as they are pro­
posed, lipoabdominoplasty considerably reduces complica­
tions, especially those that are difficult to treat and can
jeopardize the doctor–patient relationship.
Figure 28.23 shows the 11-year statistics of lipoabdomi­
noplasty performance with selective undermining, compar­
ing the percentage of complications with that of traditional
abdominoplasty.
Reduced incidence of the following complications has
statistical significance:
● Seroma (from 60% to 0.4%, p < 0.00001)
● Epitheliolysis (from 3.8% to 0.2%, p < 5 0.00007)
● Dehiscence (from 5.1% to 0.4%, p 5 0.00001)
● Necrosis (from 4% to 0.2%, p 5 0.00004).
Although the reduced incidence of hematoma (from
0.6% to 0.2%) and the incidence of deep venous thrombo­
sis/pulmonary embolism remained the same (0.2%), it
cannot be considered statistically significant because of the
small number of cases.
FIG. 28.23  Complications of lipoabdominoplasty compared with
those of traditional abdominoplasty. DVT/PE, deep venous thrombosis/
pulmonary embolism.
(%)
60
50
30
10
40
20
0
Dehiscence
Epitheliolysis
Seroma
60.0%
0.4%
0.2%
0.4%
0.2%
4.0%
5.1%
0.2%
0.6%
0.2%
0.2%
3.8%
DVT/PE
Hematoma
Necrosis
Traditional abdominoplasty
Lipoabdominoplasty
Surgical revisions decreased from 20% to 10% only
when lipoabdominoplasty was adopted, remaining so for 11
years. Table 28.1 shows the percentage of surgical revisions
in lipoabdominoplasty. The cases of surgical revision
because of complementary liposuction and postoperative
skin flaccidity (3.2%) corresponded to patients who had
previously undergone bariatric surgery and presented a
great amount of flaccidity. Surgical revision of scars was
needed in 6%, which represents 63% of surgical revisions.
Because of this, since 2001, the authors have been perform­
ing only lipoabdominoplasty (Table 28.2).
CONCLUSION
Significant reduction in complications, such as seroma,
hematoma, and flap necrosis has been proven. This tech­
nique avoids two-stage procedures (abdominoplasty and
isolated liposuction) in most patients deemed reasonable
candidates for abdominoplasty. Using a conservative
TABLE 28.1  Surgical Revision in Lipoabdominoplasty
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total primary cases
15
45
55
64
62
65
68
71
75
82
86
Scars
3
6
4
3
4
3
3
4
2
1
2
Insufficient liposuction
–
–
1
2
2
1
1
1
1
1
1
Excessive liposuction
–
–
–
–
–
–
–
–
–
–
–
Skin flaccidity
–
–
1
2
1
1
12
–
–
–
Infection
–
–
–
–
–
–
–
–
–
–
–
Other causes
–
–
–
–
1
–
–
–
–
–
–
Total
3
5
6
7
8
5
5
7
3
2
3
Percentage
20%
11%
11%
11%
13%
8%
7%
10%
4%
3%
3%

286
PART | 5  Abdominal contouring procedures
approach, liposuction can be safely performed in the
abdominal and costal regions to obtain a harmonious body
contour, with low morbidity.
Lipoabdominoplasty results in a greater reduction of the
abdominal dimensions and a better body contour, not only
because of the traditional removal of skin but also because
of a decrease in the fat layer located in the abdomen and
flanks using liposuction.
The 100% increase in demand for abdominal surgery,
not encountered in other procedures in the authors’
practice, shows patients’ acceptance of the technique and
how they have recognized the improvement that it has
brought.
The decrease in the need for surgical revisions is another
fact that motivates other surgeons to perform this
technique.
The use of vacuum closed suction drainage is important
to drain the liquid injected to perform liposuction.
In addition, the technique results in the preservation of
suprapubic sensitivity, quicker healing, faster postoperative
recovery, lower morbidity, and a better-looking shape of the
umbilicus scar.
Lipoabdominoplasty also proves to be a special indica­
tion for high-risk patients (smokers and patients with previ­
ous abdominal scars) because of the preservation of the
perforating abdominal vessels.23
The publication of articles and chapters in the most
relevant journals and books related to lipoabdominoplasty
has increased greatly in the last 10 years.24–27
REFERENCES
1. Callia WEP. Dermolipectomia Abdominal. Sao Paulo, Brazil: Carlo
Erb; 1963.
2. Castro CC, Salema R, Atias P, et al. The abdominoplasty to remove
multiple scars from the abdomen. Ann Plast Surg 1984;12:369.
3. Dillerud E. Abdominoplasty combined with suction lipoplasty: a
study of complication, revisions, and risk factors in 487 cases. Ann
Plast Surg 1990;25(5):333–8.
4. Pitanguy I. Abdominoplasty: classification and surgical techniques.
Rev Bras Cir 1995;85:23–44.
5. El-Mrakby HH, Milner RH. The vascular anatomy of the lower
anterior abdominal wall: a microdissection study on the deep inferior
epigastric vessels and the perforators branches. Plast Reconstr Surg
2002;109(1):539–47.
6. Taylor GI, Watterson PA, Zest RG. The vascular anatomy of the
anterior abdominal wall: the basis for flap design. Perspect Plast Surg
1991;5:1–28.
7. Huger Jr WE. The anatomic rationale for abdominal lipectomy. Am
Surg 1979;45:612.
8. Matarasso A. Liposuction as an adjunct to full abdominoplasty. Plast
Reconstr Surg 1995;95:829–36.
9. Vernon S. Umbilical transplantation upward and abdominal contour­
ing in lipectomy. Am J Surg 1957;94:490–2.
10. Illouz YG. A new safe and aesthetic approach to suction abdomino­
plasty. Aesth Plast Surg 1992;16:237–45.
11. Hakme F. Technical details in the lipoaspiration associated with
liposuction. Rev Bras Cir 1985;75(5):331–7.
12. Shestak KC. Marriage abdominoplasty expands the miniabdomino­
plasty concept. Plast Reconstr Surg 1999;103:1020–31.
13. Lockwood T. Fegli-lateral-tension abdominoplasty with superficial
fascial system suspension. Plast Reconstr Surg 1995;9:603–8.
14. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat
it. Aesth Surg J 1988;18:439.
15. Saldanha OR, Souza Pinto EB, Matos Jr WN, et al. Lipoab­
dominoplasty without undermining. Aesth Surg J 2001;21:518–26.
16. Saldanha OR. Lipoabdominoplasty with selective and safe under­
mining. Aesth Plast Surg 2003;22(4):322–7.
17. Saldanha OR. Lipoabdominoplastia. Rio de Janeiro, Brazil:
Di-Livros; 2004.
18. Saldanha OR. Lipoabdominoplasty. Rio de Janeiro, Brazil:
Di-Livros; 2006.
19. Saldanha OR. Lipoabdominoplasty: the Saldanha technique. Clin
Plastic Surg 2010;37:469–81. doi:10.1016/j.cps.2010.03.002.
20. Graf R, Reis de Araujo LR, Rippel R, et al. Lipoabdominoplasty:
liposuction with reduced undermining and traditional abdominal
skin flap resection. Aesth Plast Surg 2006;30:1–8.
21. Munhoz AM, Kamamoto F, Saito FL, et al. Anatomical mapping of
the perforant abdominal vessels and clinical application in the treat­
ment of aesthetic deformities of the abdominal wall through lipoab­
dominoplasty. In: Saldanha O, editor. Lipoabdominoplasty. Rio de
Janeiro, Brazil: Di-Livros; 2006.
22. De Souza Pinto EB, Erazo PJ, Prado Filho F. Superficial liposuction.
Aesth Plast Surg 1996;20:111–22.
23. Samra S, Sawh-Martinez R, Barry O, Persing JA. Complication rates
of lipoabdominoplasty versus traditional abdominoplasty in high-
risk patients. Plast Reconstr Surg 2010;125(2):683–90.
24. Costa-Ferreira A, Rebelo M, Vasconez LO, Amarante J. Scarpa
fascia preservation during abdominoplasty: a prospective study. Plast
Reconstr Surg 2010;125(4):1232–9.
25. Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation in a
more superficial plane: decreasing the need for drains. Plast Reconstr
Surg 2010;125(2):677–82.
TABLE 28.2  Personal Statistics of Abdominal Surgery
1979–1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total
Abdominoplasty
469
25
–
–
–
–
–
–
1
–
–
–
459
Lipoabdominoplasty
–
15
45
55
64
62
65
68
71
75
82
86
688

286.e1
Chapter | 28  Lipoabdominoplasty
SUMMARY OF ADVANTAGES
1. Preservation of the abdominal wall anatomy.
2. Decrease in final scar length when compared with the
initial markings in 30% of patients.
3. A better body contour is achieved because liposuction
decreases abdominal dimensions and the thickness of
the abdominal flap.
4. Morbidity is decreased because of the preservation of
the perforating vessels and the absence of a dead space.
5. Percentage of complications is low.
6. Rejuvenated abdomen with a more natural profile.
7. Preservation of the suprapubic sensitivity.
8. Rapid postoperative recovery and shorter scar.
9. Safe for patients who are smokers or for those who
had previously undergone bariatric surgery or reversal
abdominoplasty.
SUMMARY OF DISADVANTAGES
1. Initially, more than 30 minutes is needed to perform the
surgery.
2. The procedure should not be performed on patients with
a large hernia or eventration.
3. A learning curve is required to assimilate the new
procedure.
SUMMARY OF STEPS
1. Marking
2. Infiltration
3. Upper abdomen liposuction
4. Lower abdomen liposuction
5. Incision and undermining in the lower abdomen
6. Scarpa fascia preservation
7. Selective undermining and muscle plication
8. Removing the infraumbilical excess and complemen­
tary muscle plication
9. Umbilicoplasty/omphaloplasty
10. Closure of the abdominal wall
11. Refinements
12. Postoperative care.