Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

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SECTION II
CHAPTER 22.2 • Correction of liposuction deformities with the SAFE liposuction technique
These patients frequently benefit from prolonged compres­
sion to assist in resolution of swelling and discomfort, as well
as prevention of contour deformities. Half-inch or 1-inch
Reston foam (3M Inc., St. Paul, MN) is used for uniform
compression of smooth, treated areas. One-inch foam with
cutouts is used for differential foam compression for large
depressions where formal fat grafting has been performed.
The foam is held in place by a compression garment that is
snug, but less compressive or constricting than typical gar­
ments used in liposuction.
Simple instructions with pictures on how to use the foam
will prevent mishaps and irritations: foam is lined on all edges
with gauze to prevent blisters; the foam is unstuck the morning
after surgery and at 2–3 days postoperatively. Simply unstick­
ing the foam and reapplying it immediately prevents traction
blisters from forming and keeps patients more comfortable.
The same foam can be used for 2 weeks around the clock, then
for 2 weeks during the day only, with nothing on at night.
Wearing nothing at night allows the body to get used to
handling the edematous areas and also prevents any compres­
sion lines. Baby powder can be used under the foam for
greater comfort or, if needed, a spandex compression shirt or
tight cotton shirt can be worn under the foam if sensitivity
develops. With repeated washing, the foam will become softer
and more comfortable. Beware of applying new foam postop­
eratively as it is stiff and sticky and can cut into the patient’s
skin causing blisters or ulcerations.
Beyond foam and the accompanying compression garment,
patients are instructed to avoid skin creases and flexion in
susceptible areas (mostly the abdomen). Tight constricting
clothes should be avoided for at least 4 months.
Results and outcomes
SAFELipo for repeat liposuction improves on traditional,
thermal, and other forms of liposuction in several ways. Fat
is reduced and redistributed, and areas are augmented to the
Ancillary procedures
The Cellfina cellulite device is useful and effective in releasing
tethered areas, or dimples, in a precise and standardized
fashion in repeat liposuction. The precise, vacuum-assisted
release of tethered spots at a controlled depth minimizes
bleeding, disruption of the supporting stromal network, and
ultimately ensures less disruption of fat that may have
been grafted into these areas. Prior to the procedure, areas
designated for treatment with Cellfina are photographed and
marked. The device is utilized only during the final step of
the SAFELipo process, when residual defects are addressed.
The Cellfina device obviates the need for traction sutures and
large, imprecise cutting cannulas or wires.
To optimize results, repeat liposuction may be combined
with additional body contouring procedures, including
abdominoplasty or breast enhancement procedures. Fat har­
vesting from repeat liposuction areas for transfer to other
body areas is also feasible, although the quality of fat grafts
may not be as optimal as in a primary procedure. In this
regard, there are few differences between primary and
secondary.
Postoperative care
Postoperative healing is more complex following repeat
liposuction. These patients are prone to prolonged swelling
and the development of unevenness, seromas, and contour
deformities. Patients are counseled that it will take at least 1
year, and sometimes up to 2 years or longer, for all swelling
to resolve and for the skin to soften and resume more normal
pliability and elasticity. Furthermore, they are more prone to
paresthesias and dysesthesias. Early postoperative recogni­
tion and management with Lyrica, desensitization therapy,
and massage treatments beginning 2 weeks postoperatively
can mitigate this.
Fig. 22.2.6  Liposuction of protuberant areas, avoiding areas of
depression, while fat grafting the depressed areas – the “spot
approach”.
Fascia
Muscle
Fibrotic area
Adipose tissue
Fat grafting to areas of depression
Ideal plane

575
Problems and complications
desired thickness and equalized throughout entire anatomic
units, allowing for thorough and aggressive liposuction
without increasing the risk of contour deformities.
There is some evidence that the fat separation and equal­
ization in SAFELipo promotes angiogenesis and improved
oxygen tension in ischemic adipose tissue by activating resi­
dent adipose stromal cells. It is likely that this promotes
healthy adipose tissue repair and reconstruction.
Problems and complications
It must be understood that revision and secondary liposuction
procedures are associated with less ideal outcomes than other
revisionary cosmetic procedures. Patients undergoing exten­
sive repeat liposuction will almost always have some degree
of residual deformity from existing contour irregularities, skin
imperfections, or scarring that compromises the overall result.
Furthermore, some residual areas of deformity will not be
amenable to repair, particularly if the previous procedure
involved thermal or avulsive methods. The amount of fibrosis
and scarring from these liposuction methods generally
Bonus images for this chapter can be found online at

Fig. 22.2.7 A 30-year-old female with history of multiple rounds of liposuction,
including suction-assisted liposuction and ultrasound-assisted liposuction, was
treated with SAFELipo of superficial abdomen, release processes, 60 cc fat
grafting; she is seen at 1 year postoperatively.
Fig. 22.2.8 (A–C) Stage 1: SAFELipo of circumferential trunk and chest
– 4.5 L. (C–E) Stage 2: superficial SAFELipo of abdomen and flanks – 1.3 L.
Fig. 22.2.9 A 48-year-old female with history of prior suction-assisted
liposuction of circumferential trunk, thighs, and knees elsewhere was treated
with SAFELipo of circumferential trunk, circumferential thighs, knees, calves,
lower face, jowls, and neck – 6.8 L.
Fig. 22.2.10 A 52-year-old female with history of suction-assisted liposuction
of circumferential trunk and thighs ×3, with residual lipodystrophy of the
circumferential trunk, was treated with SAFELipo of circumferential trunk with
mini-abdominoplasty – 3.3 L.
reduces the feasibility of successfully treating all residual
deformities. (For more examples, see the online-only Figs.
22.2.7–22.2.10
).
Figs. 22.2.7–22.2.10 appear online only.

575.e1
Problems and complications
Fig. 22.2.7  A 30-year-old female with history of multiple rounds of liposuction, including suction-assisted liposuction and ultrasound-assisted liposuction, was treated
with SAFELipo of superficial abdomen, release processes, 60 cc fat grafting; she is seen at 1 year postoperatively. (© 2017 Simeon Wall Jr., MD, FACS.)
A
B
C
D
E
F

575.e2
SECTION II
CHAPTER 22.2 • Correction of liposuction deformities with the SAFE liposuction technique
Fig. 22.2.8  (A–C) Stage 1: SAFELipo of circumferential trunk and chest – 4.5 L. (C–E) Stage 2: superficial SAFELipo of abdomen and flanks – 1.3 L. (© 2017 Simeon
Wall Jr., MD, FACS.)
A
B
C
D
E
F

575.e3
Problems and complications
A
B
C
D
E
F
Fig. 22.2.9  A 48-year-old female with history of prior suction-assisted liposuction of circumferential trunk, thighs, and knees elsewhere was treated with SAFELipo of
circumferential trunk, circumferential thighs, knees, calves, lower face, jowls, and neck – 6.8 L. (A,C,E,G,I) Before SAFELipo; (B,D,F,H,J) after SAFELipo. (© 2017 Simeon
Wall Jr., MD, FACS.)

575.e4
SECTION II
CHAPTER 22.2 • Correction of liposuction deformities with the SAFE liposuction technique
G
H
I
J
Fig. 22.2.9, cont’d

575.e5
Problems and complications
Fig. 22.2.10  A 52-year-old female with history of
suction-assisted liposuction of circumferential trunk
and thighs ×3, with residual lipodystrophy of the
circumferential trunk, was treated with SAFELipo of
circumferential trunk with mini-abdominoplasty – 3.3 L.
(A,C) Before SAFELipo; (B,D) after SAFELipo.
(© 2017 Simeon Wall Jr., MD, FACS.)
A
B
C
D

SECTION II • General Aesthetic Surgery
23 
Abdominoplasty procedures
Dirk F. Richter and Nina Schwaiger
SYNOPSIS
■ The abdominal area is the one of the most common areas treated in
plastic surgery procedures. Mostly after pregnancies or weight
changes, patients desire improvement of the abdominal wall, including
the repair of additional ventral hernias.
■ Assessment of the abdominal region includes a detailed medical and
physical history, including pregnancies, prior surgeries, especially in
the lower truncal area, and weight changes. Preoperative identification
of any existing ventral hernia including diastasis recti is imperative.
■ Essential issues of abdominal findings are the existence and
localization of vertical and horizontal tissue excess, the relation of fatty
and skin excess, and the examination of the umbilical stalk with
exclusion of umbilical hernia. Further perioperative issues are
preoperative bowel evacuation for reduction of intra-abdominal
pressure, careful intraoperative handling, maintenance of an adequate
body temperature, sufficient medical thromboembolism prophylaxis,
precise intraoperative preparation with respect to anatomical key
points, postoperative compression treatment, and early management of
postoperative complications such as seromas.
■ The “fleur-de-lis” abdominoplasty allows an improvement of the entire
abdominal area with simultaneous tightening of the waist
circumference. It is essential to initially assess and temporarily close
the vertical line prior to resection of the lower abdominal redundant
tissue. Care should be taken to avoid extending the vertical incision
line cranially between the breasts.
■ In patients with massive weight loss, aesthetic outcome will improve by
high lateral tension and fleur-de-lis abdominoplasty, and in most cases,
circumferential truncal procedures are necessary for superior results.
■ The preparation epifascial to the Scarpa’s fascia allows a preservation
of subfascial lymphatic vessels for prevention of seroma formation and
enables an additional tightening of Scarpa’s fascia for improvement of
the inner thigh region.
■ It is mandatory to analyze any suspected skin tumor in the area of
excised tissue.
Access the Historical Perspective section online at

Introduction
Abdominoplasty is one of the most commonly performed
aesthetic procedures, which encompasses not only aesthetic
features but also structural reconstruction of the abdominal
wall. Aesthetic enhancements include improvement in
abdominal wall contour, reconstruction of a natural-appearing
umbilicus, and optimal placement of the resulting abdominal
scar. The reconstructive component includes recreation of the
original fascial and muscular anatomy as well as the restora­
tion of any other anatomical deformations that may be present.
The primary goals in abdominoplasty procedures are to
achieve an optimal resection of abdominal skin and subcuta­
neous tissue in a three-dimensional manner, with a resulting
wound tension that is distant from the area of tissue resection;
the purpose of keeping wound tension distant from the resec­
tion is to prevent an impairment of perfusion. In addition, the
abdominal musculoaponeurotic layer should be restored to
prevent abdominal hernias, diastasis, and consequent muscu­
lar imbalance of the trunk, while at the same time improving
the abdominal wall contour.
Due to the number of variations and modifications of
abdominoplasties, it is key to select the appropriate technique
in every individual case, determining the best procedure by
minimizing morbidity and postoperative disability for desir­
able and predictable results.1
Anatomy
Knowledge of the anatomy of the abdominal wall is essential
for aesthetic and reconstructive abdominal procedures. The
abdominal wall is embryonically derived in a segmental
manner, reflected in blood supply and innervation. The
formation of the abdominal wall is initiated by the transition
of the embryo from a trilaminar disk to a three-dimensional
structure on the 22nd day of gestation. The further intra­
uterine development of the abdominal wall has multiple
  Access video and video lecture content for this chapter online at expertconsult.com

576.e1
Historical perspective
Historical perspective
One of the first publications in abdominal wall surgery dates
back to 1899. Kelly attempted to correct excess abdominal skin
and fat using a large horizontal midabdominal incision,2,3
resecting a panniculus weighing over 7000 g. In 1916, Babcock
presented a vertical midline incision.4 Since that time, numer­
ous variations have been suggested. Thorek (1924) was the
first to devise an abdominal procedure including the nowa­
days preferred lower transverse incision that preserved the
umbilicus.5,6
In 1957, Vernon published a modern version of abdomino­
plasty, including an umbilical transposition and plication
of the musculoaponeurotic layer.7 Pitanguy reported in 1967
on 300 abdominal lipectomies;8 Regnault published the
W-technique for abdominoplasty in 1972.9 In 1973, Grazer
described the so-called “bikini line incision”.10 The St. Tropez
bikini, fashioned in the 1960s with a very low waistline,
favored the abdominoplasty with a nearly horizontal incision.
In the mid-1980s, the French-line bikini (cut high at the lateral
aspect and low centrally) became popular, favoring the
abdominoplasty incision to be converted from a nearly hori­
zontal line to an incision line that accompanied the inguinal
fold.9,10 Nowadays, bikinis with very low waistlines have
gained higher popularity again. Therefore, proper adjust­
ments in every single technique are necessary to achieve a
tailor-made abdominoplasty.
In 1977, Grazer and Goldwyn reported the first complica­
tions using new abdominoplasty techniques.11 They had noted
the ability to reduce the anterior projection of the abdominal
wall by aponeurotic suturing without decreasing the diameter
of the waist. Psillakis published, in 1978, the external belt for
extensive waist diameter reduction by suture plication of the
external oblique muscle after raising it in a belt-like fashion.12
The addition of liposuction to body contouring surgery in
the 1980s allowed a further evolution of abdominoplasty
procedures. In 1985, Dellon published the new approach to a
combined vertical and transverse resection of the abdominal
wall resulting in a fleur-de-lis pattern.13 In 1988, Matarasso
expanded the use of abdominal contour surgery to a classifi­
cation based on variations in patients’ anatomy, from liposuc­
tion alone to limited and full abdominoplastic surgery.14
Ted Lockwood described the high lateral tension abdomi­
noplasty in 1997, differing from conventional abdominoplasty
by limited direct undermining, increased lateral skin resection
with high-tension wound closure along the lateral flanks with
reconstruction of the superficial fascial system (SFS).15
In 2001, Saldanha published a new technique combining
lipoplasty with traditional abdominoplasty without under­
mining of the abdominal flap, followed by modifications of
this technique by extended undermining.16
According to the American Society for Aesthetic Plastic
Surgery’s 2016 Cosmetic Surgery National Data Bank Statis­
tics, the number of abdominoplasty procedures performed
has increased approximately 434% since 1997.17

577
Anatomy
Lymphatic system
The lymph vessels collect the subdermal accumulated lymph
fluid and drain into the deeper fat layer, passing into larger
vessels (Fig. 23.3). The abdominal lymphatic system is divided
into supraumbilical drainage into the ipsilateral axillary and
lateral thoracic lymph nodes and infraumbilical drainage into
the superficial or lateral inguinal lymph nodes. The lymph
vessels in the infraumbilical area pass through the sub-Scarpa
l plane, explaining the importance of Scarpa’s fascia preserva­
tion in abdominal wall surgery.18
Blood supply
The blood supply to the abdominal wall comes from numer­
ous major arteries of the thorax and pelvic region, which
communicate through many anastomotic interconnections.
Taylor and Palmer introduced the concept of angiosomes, or
vascular territories of the body.20 They describe two types of
cutaneous blood supply: (1) direct vessels that directly supply
the skin and (2) indirect vessels that “emerge from the deep
fascia as terminal spent branches of arteries whose main
purpose is to supply the muscles and other deep tissues”. In
a subsequent study in 1988, Moon and Taylor were able to
demonstrate connections between the deep superior and deep
inferior epigastric systems and their relationship to the cuta­
neous circulation.21–23
A detailed knowledge of the arterial supply of the abdomi­
nal wall is important for abdominal wall surgery, especially
crucial stages, problems with any of which can lead to con­
genital defects of the abdominal wall. After separation of
the umbilical cord, the abdominal wall becomes a definitive
structure.
Abdominal skin and fat tend to be distributed in the lower
abdomen with aging and pregnancy. Especially as a result of
multiple pregnancies, striae become common, resulting in a
rupture and separation of dermal collagen with consequent
skin thinning.18 At this time, the therapy of striae is exclusively
by surgical excision (Fig. 23.1
).
Fig. 23.1 appears online only.
The umbilicus
As one of the most visible and aesthetically recognized land­
marks of the abdominal wall, the umbilicus is situated in the
midline, approximately 9–12 cm above the top of the mons
pubis. The periumbilical area is characterized by a round or
ellipsoid shape with a slight depression of 4–6 cm in diameter.
The fascia surrounding the umbilicus can be unstable with an
increased incidence for hernias, resulting in a risk of bowel
injury during umbilical dissection. The blood supply to the
periumbilical area is supplied by branches from the subder­
mal plexus, from both deep inferior epigastric arteries as well
as a blood supply from the median umbilical ligament.
Skin, muscle, and fascia
The skin of the abdomen has areas of increased adherence to
the underlying fascia (“zones of adherence”), such as the
anterior superior iliac crest and the linea alba. The abdominal
subcutaneous tissue is divided by two layers of fascia, the
superficial Camper’s fascia and the deep Scarpa’s fascia, a
strong fibrous layer of connective tissue that is continuous
with the fascia lata of the thigh.19
The superficial fat layer has a more compact character, with
smaller lobules and a rich vascularization, while the deeper
fat layer contains larger lobules with a more scattered pattern.
Since patients presenting for abdominal wall surgery often
have musculoaponeurotic laxity, the knowledge of these
anatomical structures is crucial. The abdominal musculature
includes four paired muscles, which are the rectus abdominis,
connected in the median linea alba, the external oblique,
internal oblique, and the transversus abdominis muscle,
which incorporate into the anterior and posterior rectus
sheath at the linea semilunaris. The rectus abdominis muscles
are enclosed by an anterior and posterior sheath, originating
at the infracostal margin and attaching at the symphysis
pubis. Above the arcuate line (or semicircular line of Douglas,
situated approximately midway between umbilicus and pubic
symphysis), the anterior rectus sheath is formed by the exter­
nal oblique and internal oblique aponeurosis, while the pos­
terior rectus sheath is formed by the internal oblique and
transversus aponeurosis. Below the arcuate line, the posterior
rectus sheath is absent, except for the transversus fascia and
the peritoneum, which are found posteriorly. At the inferior
aspect of the rectus muscles, the pyramidalis muscles are
present in 80–90% of patients (Fig. 23.2
).
Fig. 23.2 appears online only.
The correction of frequently accompanying rectus diastasis
with consequent muscular imbalance is an important step in
abdominal wall surgery in order to avoid back complaints.
Fig. 23.3  The abdominal lymphatic system is divided into supraumbilical drainage
into the ipsilateral axillary and lateral thoracic lymph nodes and infraumbilical
drainage into the superficial or lateral inguinal lymph nodes. The lymph vessels in
the infraumbilical area pass through the sub-Scarpa plane, explaining the
importance of Scarpa’s fascia preservation in abdominal wall surgery.
Axillary
lymph nodes
Superficial
inguinal
lymph nodes

577.e1
Anatomy
D
R
W
H
E
C
A
B
Fig. 23.1  Anatomical landmarks. Normal abdominal anatomic proportions. The
approximate measurements for an average female abdomen are listed. These vary
according to individual height and bone structure. The umbilicus is located in line
with the most superior point of the iliac crest in 99% of patients. A, Distance
between top of mons and anterior valvar commissure. Average height is 5–7 cm. B,
Distance between umbilicus and top of mons. Average height is 11–13 cm. C = A
+ B, Distance between umbilicus and top of anterior and vulvar commissure (C =
D). E, Distance between the costal marginal and the iliac crest. The proportion of
this distance to the width of the base of the rib cage (R) determines whether the
patient is long waisted or short waisted. The normal proportion (E : R) is roughly
1 : 3 (long-waisted approaches 1 : 2; short-waisted approaches 1 : 3). The rib cage
tapers inferiorly. A narrower lower rib cage relative to the width under the armpits
helps to emphasize the waist by creating a subtle “V”, H, Hip width. A wider pelvis
than rib cage emphasizes the waist; the waist is more defined when R < H. W,
Natural waist – the narrowest point of the torso. (Note that the umbilicus usually
sits below the natural waist by about 1–4 cm.) Relative to the hips, this waist-to-hip
(W : H) ratio in healthy women is roughly 0.72 : 1; in healthy men, it is roughly
0.83 : 1. Note that the natural contour of the healthy abdomen reveals a subtle
epigastric sagittal depression transitioning to a mild infraumbilical convexity. A
subtle vertical sulcus at “eh” lateral rectus border, which is more distinct in a
muscular person, may also be seen.

577.e2
SECTION II
CHAPTER 23 • Abdominoplasty procedures
Fig. 23.2  (A) Anatomy of the musculature of the
abdominal wall with arterial supply. (B) Arcuate line and
linea semilunaris.
A
Superficial
circumflex
iliac artery
Deep
circumflex
iliac artery
Subcostal
artery
Pectoralis major
Rectus abdominis
External oblique
Internal oblique
Transversus
abdominis
Superficial inferior
epigastric artery
Deep inferior epigastric artery
Superior
epigastric artery
Superficial external pudendal artery
Anterior rectus
sheath
(reflected)
B
Semilunaris line
Arcuate line

578
SECTION II
CHAPTER 23 • Abdominoplasty procedures
Nerves
Cutaneous sensation of the abdominal wall is derived from
the anterior and lateral cutaneous branches of the intercostal
nerves VIII–XII, which pass between the internal oblique and
transversus abdominis muscles, entering the rectus abdomi­
nis muscle and reaching the overlying fascia and skin. The
lateral cutaneous branches penetrate the intercostal muscles
in the midaxillary line, ending in the subcutaneous layer. Both
branches are responsible for the overlapping of the sensory
dermatomes T5–L1. The motor branches of the oblique and
transversus abdominis muscle derive from lower thoracic
and lumbar dorsal nerves, while the rectus abdominis
muscle is innervated from branches of the intercostal nerves
V–XII, which pass behind the rectus muscles and enter the
muscles at the junction of the lateral one-third and medial
two-thirds.23
As peripheral nerves with either motor or sensory innerva­
tions to the abdominal wall, the iliohypogastric and ilioingui­
nal nerves have to be mentioned, since their course can be
disrupted in lateral transverse lower abdominal incisions,
resulting in consistent loss of sensation in the area of the groin
and medioventral thigh (Fig. 23.5).
in cases of prior abdominal or chest wall surgeries. Huger
described different zones of the abdominal blood supply,
which should guide the surgeon in planning and performing
a safe operation (Fig. 23.4).22 Huger defined zone I of the
abdominal wall as the area that is fed anteriorly by the verti­
cally oriented deep epigastric arcade. Zone III was defined as
the lateral aspect of the abdominal wall (flanks) that are fed
by the six lateral intercostal and four lumbar arteries. The
lower abdominal circulation is provided by the superficial
epigastric, superficial external pudendal, and superficial cir­
cumflex iliac systems (zone II). A rich plexus between these
systems allows collateral flow.
In standard abdominoplasty procedures, after mobiliza­
tion of the abdominal flap in the lower abdominal area and
midline region up to the xiphoid, the cutaneous blood supply
to zone I and a main part of zone II is disrupted, resulting
in an abdominal flap perfusion mainly supplied by zone III.
Since the mobilized abdominal flap is dependent on the lateral
perforating branches from the lateral intercostals and lumbar
arteries, it is imperative to preserve these vessels. Therefore,
it is crucial to study any preoperative existing scar, such as
subcostal cholecystectomy incisions. In certain circumstances,
even a vertical midline incision can jeopardize flap perfusion.
Fig. 23.4  Zones of blood supply.22
Superficial epigastric artery
Ascending branch of deep
circumflex iliac artery
Intercostal artery
Subcostal artery
Lumbar branches
Zone I
Zone II
Zone III
Zone III
Inferior epigastric artery
Superior epigastric artery

579
Pathology
Fat accumulation occurs in a distribution pattern that
varies according to the gender. With weight gain, women tend
to add local adiposity in the lower trunk and hip region, while
men see an increase in abdominal girth. In women, fat accu­
mulation commonly in the posterior thigh region can result
in cellulite, induced by fibrous septa within the subcutaneous
tissue.24
Diastasis recti results from a hyperextension of the rectus
sheath with a widening of the aponeurosis at the linea alba,
presenting as a supra- and/or infraumbilical protrusion.
This abdominal wall weakness can occur in conjunction
with ventral hernias, including postoperative incisional,
congenital epigastric, and umbilical hernias. Preoperative
diagnosis of hernias is crucial to avoid intraoperative bowel
injury.
Infections in the abdominal wall have to be treated meticu­
lously since they can escalate to a bacterial gangrene and
necrotizing fasciitis with life-threatening conditions. Benign
Pathology
Pregnancy is the commonest cause of abdominal wall defor­
mities because the skin and musculoaponeurotic structures
are stretched beyond their biomechanical capability to retract.
Consequently, there is thinning and loss of elasticity of the
skin with possible striae and diastasis of the rectus muscles.
Postpartum weight loss contributes to the process of abdomi­
nal wall deformities because of limited skin retraction (Fig.
23.6). Massive weight loss after dieting or bariatric surgery
results in similar pathophysiologic changes to the abdominal
wall, including excess skin and subcutaneous tissue and a
laxity of the abdominal wall musculature. Increasing demand
of these specific patients for abdominal wall restoration has
extended the abdominal surgery to lower circumferential
procedures. These problems are reviewed in Chapters 25.2
and 28.
Fig. 23.5  Abdominal nerves.
Latissimus dorsi
Lateral cutaneous branches
of intercostal nerve
Lateral cutaneous branches
Anterior lamina of rectus sheath
Transversus abdominis
Anterior cutaneous branch
Rectus abdominis (cut)
Arcuate line
Transversalis fascia
Serratus anterior
Intercostal nerve
Tenth intercostal nerve
Eleventh intercostal nerve
Subcostal nerve
Iliohypogastric nerve
Ilioinguinal nerve
External oblique (cut)
External oblique
Internal oblique (cut)
Inguinal ligament
Round ligament of uterus

580
SECTION II
CHAPTER 23 • Abdominoplasty procedures
closure or staged silo repair. A discussion of abdominal wall
reconstruction appears in Volume IV, Chapter 12.
Classification of problems
In 1988, Bozola and colleagues published a classification
including five different groups of aesthetic deformities of the
abdomen with assigned operative procedures.26,27 Group I
comprised younger nulliparous women with normal elastic
skin and good muscle tone but excess adipose tissue in the
subcutaneous layer in the abdominal area. Group II patients
usually had at least one pregnancy, mild lower abdominal
skin laxity, diastasis recti, and excess adipose tissue most often
present inferior to the umbilicus. Group III included patients
with significant infraumbilical skin, excess adiposity, and
abdominal muscle laxity with diastasis of the rectus and
oblique muscles. In addition, patients often had striae after
multiple pregnancies. Patients in group IV and V had severe
skin and fat excess superior and inferior to the umbilicus,
accompanied by mild to severe diastasis of the rectus and
oblique muscles. Group V patients presented with an umbili­
cus that is below the ideal height.
To attempt the correlation of appearance and physical
examination findings to appropriate surgical interventions
in patients after massive weight loss, Song et al. designed
the “Pittsburgh Rating Scale”, a classification system that
addresses the full range of post-weight loss deformities found
in this unique population (Fig. 23.7A–D).28
Patient selection and indication
The preoperative evaluation of intra-abdominal content and
the resulting pressure is important to avoid a postoperative
pressure increase or abdominal compartment syndrome. In
cases of elevated intra-abdominal pressure, in the supine
position, the abdominal wall elevates above the costal margin
and the level of the iliac crest (Fig. 23.8
). Abdominoplasty
procedures, with or without rectus plication, have to be per­
formed cautiously in such cases.
Fig. 23.8 appears online only.
and malignant tumors in the abdominal area are quite
uncommon. Possible wide resections can lead to larger sub­
stantial defects with the requirement of microsurgical tissue
transfer.
Congenital abdominal wall defects distant to the umbilicus
are relatively uncommon and based on structural defects of
the abdominal wall. Omphalocele, a defect in the group of
persistent fetal ducts, resolve spontaneously in 80% of chil­
dren within the first 12 months.25 Gastroschisis, one of the
more common congenital abdominal wall defects, results in
herniation of fetal abdominal viscera into the amniotic cavity,
which has to be surgically corrected in most cases by primary
Fig. 23.6  Massive weight loss after dieting or bariatric surgery as well as
pregnancies results in similar pathophysiologic changing of the abdominal wall,
including excess skin and subcutaneous tissue and a laxity of the abdominal wall
musculature.
Preop
Diastasis recti
Linea alba
Fig. 23.7  The Pittsburgh Rating Scale 0–3 showing the different deformities for a better surgical planning.
A
B
C
D

580.e1
Patient selection and indication
Fig. 23.8  Assessment of intra-abdominal pressure in the
supine position. The non-scaphoid abdomen will be prone
to pressure increase after abdominoplasty.
Scaphoid
Non-scaphoid

581
Patient selection and indication
skin and fat tissue is done by pinching and measurement of
the subcutaneous layer thickness. Skin quality and the pres­
ence of striae are assessed, noting that supraumbilical striae
commonly are not resected in abdominoplasties. Studies on
skin quality in post-bariatric patients have demonstrated
damage to collagen structures.29,30
The lower and occasionally upper abdominal pannus have
to be evaluated and measured, with the fold areas examined
for eczema and consequent hyperpigmentation. The skin
excess in the areas below the lower abdominal fold, in the area
of the lateral and upper abdomen, the waist, hips, and thighs,
as well as the lower chest have to be included into the preop­
erative assessment, during upright standing, supine as well
as sitting positions.
Any scar in the abdominal area can impair the blood
supply, especially subcostal and midline scars. Horizontal
upper abdominal scars will limit the choice of procedure,
perhaps leaving reverse abdominoplasty as the only viable
option. Vertical midline scars can be included into the fleur-
de-lis technique.
The knowledge of abdominal zones of adherences in the
supraumbilical midline and the inguinal area is crucial for the
surgical planning. Upper abdominal rolls arise from a zone of
adherence at the waist level.
Lastly, the abdominal wall has to be critically examined for
bulging due to a rectus diastasis or due to incisional, epigas­
tric, or umbilical hernias. In cases of diagnostic uncertainty, a
computed tomography (CT) or magnetic resonance imaging
(MRI) scan can be helpful. Small trocar hernia may be difficult
to detect. The following documentation is recommended:
■ Quality of skin
■ Thickness of adipose tissue
■ Number and location of folds
■ Location of abdominal wall defects
■ Patient’s favored clothing
■ Pre-existing scars
■ Status of abdominal musculature.
The following measurements are recommended:
■ Distance from umbilicus to top of mons
■ Distance from umbilicus to sternal notch
■ Distance from anterior vulva commissure to top of mons
■ Waist and hip measurement, waist-to-hip ratio
■ Thickness of abdominal adipose tissue by pinching.
Due to an increased risk of thromboembolism and seroma
formation, indication for abdominal surgery should be made
critical in cases of a BMI higher than 30 or an estimated weight
of resection above 1500 g. Further, a higher preoperative BMI
restricts the postoperative aesthetic results.
Photographic documentation
It is important to ensure complete photographic documen­
tation pre- and postoperatively, consisting of at least five
and if possible eight views, including anterior, oblique ante­
rior, side, oblique posterior, and posterior views. Additional
photographic documentation should include the patient in
a forward bending position from side and front views as
well as the patient in sitting position. Commonly accepted
postoperative time points for photography are at 3, 9, and
12 months.
History and physical examination
During the first consultation, a review of the patient’s medical
history and a physical examination are done. The evaluation
of medical history should include the weight history with the
current body mass index (BMI), the BMI drop, weight fluctua­
tions and constancy, possible bariatric procedures, nutritional
disorders, medications, the number of pregnancies and chil­
dren, history of cesarean section, abdominal surgeries and
abdominal hernias, the frequency of exercise, gastrointestinal,
cardiac and pulmonary history, and a smoking history. It is
important to know which possible bariatric procedure has
been used. Look for the port if a gastric banding was per­
formed that may be in your area of undermining or liposuc­
tion. Traction on your flap may result in a dislocation of the
band causing strangulation of the stomach. Some anesthesi­
ologists prefer to have the band deflated. Watch out for a
proper supplement of vitamin B12 in patients after bypass and
sleeve resection.
The routine blood tests after bariatric surgery are hemoglo­
bin, hematocrit, electrolytes, vitamin B1, B12, folic acid, iron/
ferritin, vitamin D3, glucose, transaminases and albumin.
Total protein, total cholesterol, parathyroid hormone (PTH),
A1C (the latter only if the patient was diabetic before surgery).
The recommended annual lab work for post-bariatric
patients:
■ Vitamin A
■ Vitamin B6
■ Vitamin B12
■ Vitamin E
■ Vitamin D (25-hydroxyvitamin D)
■ Copper
■ Calcium
■ Magnesium
■ Phosphorous
■ Zinc
■ Folate
■ Prealbumin/total protein/albumin
■ Iron/total iron-binding capacity (TIBC), ferritin,
transferrin
■ Complete blood count (CBC), hemoglobin and hematocrit
■ Chem. 7 (comprehensive metabolic panel)
■ Liver panel: serum glutamic-oxaloacetic transaminase
(SGOT)/serum glutamic-pyruvic transaminase (SGPT),
alkaline phosphatase, T/D bilirubin
■ Cholesterol/triglyceride levels
■ Hemoglobin A1C level (only if patient was diabetic
before surgery)
■ Dehydroepiandrosterone (DHEA)
■ Thyroid-stimulating hormone, T4 (required if patient has
thyroid disease)
■ PTH
Previous liposuction in the abdominal area has to be docu­
mented. Women wishing to become pregnant should be
advised to postpone abdominal contouring, however. Long-
term future pregnancy is not a contraindication.
The physical examination covers the entire abdominal wall,
including the skin and fat layer, the musculoaponeurotic
layer, and the intra-abdominal volume. Examination of the

582
SECTION II
CHAPTER 23 • Abdominoplasty procedures
The area to be photographed should extend from the sub­
mammary fold down to the symphysis pubis; adjoining areas
can be included in additional photographs. Also helpful are
views with abdominal muscles contracted and relaxed. One
photo-set is made in the upright position with the patient’s
arms down and another with raised arms. Furthermore,
patients can be photographed in the sitting position to dem­
onstrate redundant upper abdominal laxity and tissue excess.
Supplementary images can be obtained with patients grasp­
ing and holding up excess abdominal tissue in the central and
waist region, as well as pinching of excess tissue in the central
abdominal area with front and side views in a bent forward
position.
Informed consent
Patient education and consultation on the operative proce­
dure, possible alternative techniques, as well as the risks and
benefits are a crucial part of preoperative management.
Besides regularly available standard consent forms, which
have to be reviewed with the patient, an audiovisual demon­
stration is useful for improved understanding and recollection
later. As with any cosmetic procedure, patients have to be
informed comprehensively about any imaginable complica­
tion; this can include seeing photographs of major wound
complications such as flap necrosis with subsequent skin
grafting. Additionally, standard and individual consent forms
have to be explained and documented. Ideally, the informed
consent should be signed by the patient and the consulting
surgeon at the earliest opportunity, followed by a second
consent shortly before surgery. Patients have to be informed
about their postoperative care, including their expected level
of activity. Patients must clearly understand the limitations of
the surgical result in cases of existing variables of bone struc­
ture, intra-abdominal fat, and existing scars. Lastly, patients
must be aware that, like any aesthetic or reconstructive pro­
cedure, their abdominoplasty may require an operative revi­
sion at a later date.
Patients’ preoperative instructions
Patients are required to stabilize weight for at least 12 months
preoperatively; any desired weight loss should be imple­
mented prior to the surgery. Patients are strongly advised to
stop smoking 6 weeks prior to the surgery and, at a minimum,
at latest 2 weeks prior and for at least 2 weeks postoperatively.
Patients should take antiseptic showers in the evening and
morning prior to the surgery, the abdominal folds and the
umbilicus should be cleaned thoroughly with cotton sticks
and antiseptic solutions.
If perioperative blood transfusion is a possibility, patients
are informed preoperatively, as this will require blood typing
and an informed consent.
Anticoagulant drugs must be avoided 10 days prior to
surgery. The patient should also avoid perioperative use of
various homeopathic drugs and nutritional supplements,
which can induce bleeding.
Due to an expected increase of intra-abdominal pressure,
surgery is generally performed with bowel purgation the
night before surgery. In severe cases, patients can be restricted
to a fluid diet for 24 h prior to surgery.
Patients should be well informed about the intraoperative
procedures, including any adjunct activities such as position­
ing, antithrombotic arrangements, Foley catheter, drain and
garment placement, and patient-controlled analgesia.
Patients must be instructed about the postoperative course,
regarding thromboembolism prevention, respiratory exer­
cises, early mobilization, avoidance of high abdominal pres­
sure, the schedule for drain and suture removal, and the
minimum time required off work and away from exercise.
Preoperative markings
The expected markings should be demonstrated and discussed
with the patient during the initial consultation to allow
enough time for patients to be concerned with the future scar
course. Preoperative markings should be carried out as close
as possible to the time of surgery. We recommend the photo­
graphic documentation of operative markings for reference
later in cases of the patient’s discontent. Reviewing the pre­
operative markings after the surgery will also aid the surgeon
in a personal program of quality improvement.
The scar course in male patients should generally run
flatter and lower than in female patients with respect to a
reduced waist tightening.
We find it helpful to tack the midline and tattoo the draw­
ings with methylene blue.
Aesthetic procedures
Markings and scar position – measurements
We commence the marking with a partially dressed patient in
the upright position in order to mark the borders of the
underwear. The future scars should then be evaluated and
discussed with the patient. In this context, it is important to
inform the patient that traction forces and tissue excess may
cause asymmetric results and aberrant scar positions. We
mark the future scar line with a different colored felt pen. This
procedure has proved to be of great value, since the patient
gets involved in the preoperative planning and thus feels
jointly responsible for the future scar course (Fig. 23.9
).
Fig. 23.9 appears online only.
The expected resection is then evaluated by careful pinch­
ing of the tissue (Fig. 23.10
). According to the physical
equilibrium of forces, we mark the lower incision line about
one to two finger-breadths below the expected scar line. The
patient is asked to evaluate the redundant tissue for precise
positioning.
Fig. 23.10 appears online only.
The lower incision line will run parallel to the scar line
and is normally 1–2 cm below the abdominal fold. It is
essential to respect a minimum distance of 6–7 cm superior
to the anterior vulva commissure. In cases of mons pubis
hypertrophy or ptosis, the lower incision line must be adapted
(Fig. 23.11).
Subsequently, we estimate the upper incision line, which
will be checked intraoperatively prior to the abdominal flap
resection to ensure wound closure. Finally, we evaluate the
abdominal wall for local fat depots; these are marked for
adjunctive liposuction. The markings end with measurement
for symmetry and a marking of the midline.

582.e1
Aesthetic procedures
Fig. 23.10  Pinching of the abdominal tissue in upright and supine position.
Fig. 23.9  Markings are to be performed with respect to the anterior vulva
commissure and the umbilicus.

583
Aesthetic procedures
hyperlordosis cases), shoulders, and head. A change of intra­
operative positioning to the “beach-chair” position should be
previewed at the start of the procedure because it will be used
for reduction of wound tension at the time of wound closure.
Before the patient awakes from anesthesia, a compression
girdle should be fitted in order to avoid rupture of fascial
sutures on awakening. Coughing and increased abdominal
pressure should be avoided during extubation, a process that
should be handled gently and with great care. Postoperative
patients are immediately transferred into a preheated bed.
Core temperature should be measured in the recovery room,
and active warming should be started when patients are
hypothermic or if they feel cold. Adequate hydration is an
essential condition for good wound healing and for support
of the circulatory system.
Gender differences – surgical considerations
for male patients
We have to differentiate between male and female desires not
only in terms of scar position but also in terms of shape of the
abdomen and flanks (Box 23.1). The beautiful normal in the
female is a more curved silhouette with an inward belly
button and central midline groove with no muscular appear­
ance. In the male, a more straight contour course is desired
with no central groove nor belly retraction. The careful
Pre-, intra-, and postoperative management
and general considerations
All important steps in pre-, intra-, and postoperative manage­
ment should be documented in standard checklists.
Special preoperative care is recommended in patients with
dry skin with stretch marks, using lipid-balancing cream,
massage of the abdominal tissue, and avoiding ultraviolet
exposure at least 14 days prior to the operation. Two days
prior to surgery, patients are advised to use antiseptic lotions
for body wash, with special focus on regions of surplus skin.
Preoperatively, patients should always be pre-warmed by
using convective warming devices immediately prior to
surgery, and active warming should be used in surgeries
longer than 1 h. Numerous studies have shown a significant
reduction of postoperative complaints and complications due
to systemic warming.31
Perioperative thromboprophylaxis with sequential com­
pression devices or stockings should be implemented in all
patients having abdominal wall surgery. In many cases, the
intraoperative and postoperative use of heparin may also be
indicated. Antibiotic prophylaxis is recommended as a single
shot, especially in patients with prolonged umbilical stalk or
impaired body hygiene with distinct abdominal fold.
Patient positioning in the operating room should involve
adequate padding of feet, knees, buttocks, back (especially for
A
B
Fig. 23.11  Horizontal and vertical monsplasty.

584
SECTION II
CHAPTER 23 • Abdominoplasty procedures
Fig. 23.12  (A) The ideal male body shape showing
an enhanced muscular appearance and six-packs.
(B) A male patient showing the typical neutral
waistline with moderate abdominal fat. (C) The
typical male deformity with increased intra-abdominal
content, positive waistline, and love handles.
A
B
C
analysis and the evaluation of the patient’s expectation may
prevent feminization of a male patient (Fig. 23.12A–C).
To identify too much intra-abdominal content and pres­
sure, we lay the patient flat down and see if the abdomen still
stays above the costal margin. This is not a good indication
for surgery as it will end up with a bad aesthetic result and
the patient will still feel obese. Increasing pressure can also be
dangerous in terms of deep vein thrombosis (DVT) and
abdominal compartment syndrome.
Usually we will find thin subcutaneous tissue with no folds
and good skin quality. We do not find cellulite in men. In most
of the male patients with a history of weight loss, we find a
drum-like appearance with a combined diastasis of the rectus
and oblique muscles, which gives them a positive waistline.
It is important to look for love handles as it may change
the surgical plan completely. If big love handles are present,
a circumferential abdominoplasty or a bodylift procedure in
combination with liposuction must be considered and dis­
cussed with the patient.
Male patients like a more muscular appearance and the
look of six-packs (Box 23.2). This can be achieved by aggres­
sive superficial liposuction of the rectus intersections and the
midline. No open excision of the midline is recommended as
it will feminize the physiognomy.
The flat abdomen with a straight contour and a neutral
waistline can be achieved by a mild rectus plication within an
additional oblique muscle plication. An external belt proce­
dure should not be implemented in males.
The beauty normal belly button is at skin level with no
hooding, so no deep fixation of the umbilicus stalk down to
the fascia is required. If the stalk is too long, it may be
shortened.
Important for the final appearance is also a flat and straight
scar in the low position. Male underwear can sit low and may
not be able to cover a high-riding scar. The scar design needs
to be adapted and a relatively longer upper incision line is
necessary to end up with a straight scar.
Love handles are typical for male patients and are not easy
to liposuction due to the fibrosis tissue and thick skin with a
poor ability for retraction. Excisional procedures may be
necessary with the problem of a higher scar position at the
back.
Wound closure
■ For optimal wound closure, the patient has to be
intraoperatively flexed at the level of the hips. As
mentioned previously, this maneuver should be checked
prior to preparation and draping.
Male
• Increased intra-abdominal
content
• Thin subcutaneous tissue
• Oblique muscle diastasis
• Love handles
• Good skin
• Positive waistline
Female
• Low intra-abdominal
content
• Thick subcutaneous tissue
• Multiple folds
• Wrinkled skin
• Cellulite
• No love handles
• Rectus diastasis
• No definition of waistline
after pregnancy (neutral
waistline)
BOX 23.1  Anatomical findings
Male
• Enhanced muscular
appearance and six-packs
• Straight contour
• Flat abdomen, no central
groove
• No emphasis on waistline
• Thin subcutaneous tissue
• Flat curved scar in deep
position
• Liposuction or excision of
love handles
• Belly button at skin level
Female
• No muscular appearance
• Enhancement of rectus
shade
• Emphasis on waistline
little above the belly
button
• Flat or drawn in abdomen
with central groove
• Belly button fixed at fascial
level with little hooding
• Sub-Scarpa fat resection
and or liposuction of the
whole abdomen and
flanks
BOX 23.2  Surgery goals

585
Surgical techniques and results
weakness and hernias, including their repair and reconstruc­
tion. The management of the umbilicus should be carefully
documented, as should the use of absorbable and non-
absorbable sutures and any other reconstructive material.
Furthermore, it is essential to document the weight of the
resected abdominal tissue and ideally to photo-document
the specimen. Any skin or tissue abnormalities should be
recorded, and the cutaneous perfusion of the wound edges
should be documented. If liposuction has been done, the type
of technique should be recorded (vibration-, ultrasonic-, or
laser-assisted, or manual), along with the amount of and type
of fluid infiltrate and the type and diameter of the cannula
used. The areas of liposuction should be documented,
along with the amount of fluid and fat after the aspirate has
settled.
Surgical techniques and results
Surgical techniques and results are shown in Table 23.1.
Mini-abdominoplasty
Introduction
The mini- or short scar abdominoplasty is characterized by a
transverse incision that is shorter than the incision used in full
abdominoplasty procedures. Originally, the results of the
short scar technique were limited, but with the development
of liposuction and endoscopy, the mini-abdominoplasty has
experienced a renaissance (Fig. 23.15).
Indication and patient selection
The mini- or short scar abdominoplasty is indicated in patients
with mild to moderate skin laxity and tissue excess of the
lower (infraumbilical) abdomen, together with a sufficient or
longer distance between the symphysis and the umbilicus. It
is common for young women with a pre-existing Pfannenstiel
incision to benefit from this technique. Liposuction of the
upper abdomen and flanks has a supportive effect by improv­
ing abdominal contour. In addition, by utilizing endoscopy,
or a long, lighted retractor, a co-existing diastasis recti or an
epigastric hernia can be treated. The exact position of the
incision is quite flexible, depending in large part upon
the patient’s personal preference. With respect to vascular
anatomy, the mini-abdominoplasty is a safe procedure because
only Huger zone II is compromised.
Markings
As mentioned above, the patient most suited for a mini-
abdominoplasty will have a moderate problem confined to
the lower abdomen.
Markings are made with the patient in the upright position.
The borders of the patient’s underwear are initially marked.
The patient is asked to pull up the abdominal tissue symmetri­
cally to evaluate the lower incision line in relation to the
future scar position. A critical measure is the width of skin
preserved between the umbilicus and the upper skin incision
after skin excision: a distance of at least 9 cm between the
upper resection line and the umbilicus should be strictly
respected to avoid an unaesthetic appearance. If, after skin
■ Larger wound cavities superior and inferior to the
umbilicus may be reduced using progressive tension
sutures, utilizing slow-absorbable suture material. This is
done to help prevent seroma formation and to take away
tension from the skin closure (Fig. 23.13).
■ Wound closure is performed by reapproximation of each
layer. It is recommended to insert drains before starting
with the progressive sutures and deep closure. We
usually prefer to insert one drain on each side. For the
past few years we have started to avoid drains in selected
cases when using progressive tension sutures.
■ Continuity of the Scarpa’s fascia is achieved with slow-
absorbable sutures in a single knot or running technique.
A new-generation barbed suture may be used (in a
running manner) for a shortened closure time and less
tissue damage. The subdermal layer is closed using
slow-absorbable sutures in single-knot or running
technique or, alternatively, using barbed sutures in a
running technique. We facilitate a minimum of tension at
the dermal layer by everting both wound edges; this
helps to ensure optimal coaptation of the wound in order
to avoid using intracuticular sutures. Nevertheless, for
reasons of wound security, an intracuticular absorbable
barbed suture can be used (Fig. 23.14). Alternatively, a
two-component wound closure device consisting of an
adhesive mesh tape and new-generation cyanoacrylate
(PRINEO, Ethicon Inc., Somerville, NJ) has been shown
to be equally safe but faster than intradermal sutures in a
multicenter study.32 We currently favor this closure
system, since it reduces operating time, it acts as a germ
barrier, and it is easily removable.
Documentation
In addition to standard information, operative records
should document the presence and extent of abdominal wall
Fig. 23.13  Progressive tension sutures should be placed generously to reduce
dead space and reduce tension on the abdominal flap.
Sutures for
rectis plication
Progressive
tension sutures

586
SECTION II
CHAPTER 23 • Abdominoplasty procedures
resection, the distance is expected to be <9 cm, an inverse
T-scar with umbilical transposition should be preferred.
How long a scar should be planned? In this context, the fat
distribution in the region of the iliac crest should be evaluated
and a compromise reached between lateral elongation of the
scar and the potential of a dog-ear deformity. The cosmetic
outcome should always be optimized, despite the final scar
length.
Anesthesia
This procedure may be performed under local anesthetic,
with or without sedation, in slim patients. If surgery includes
Fig. 23.14  (A) Schematic and (B) postoperative (3 weeks
and 3 months) view of an everted skin closure for optimal
scarring. Patients have to be forewarned about the initially
unpleasing appearance. SFS, superficial fascial system.
A
Dermis
Subcutis
SFS suture
Subcutaneous suture
Intracutaneous running suture
B
Table 23.1  Indication for different abdominoplasty techniques
Mini
Modern
Short-T
Standard
HLT
Anchor
Circular
Reverse
Lower abdomen
+
++
++
+++
+++
+++
+++
0
Periumbilical
(+)
+
+
++
++
+++
++
+
Upper abdomen
0
(+)
+
++
++
+++
++
+++
Diastasis/hernia
(+)
+
++
++
++
+++
++
+
Flanks/hips/thighs
0
0
0
(+)
+
++
+++
0
HLT, high lateral tension.
a reconstruction of the anterior rectus sheath, local anesthesia
may be inadequate, since adequate anesthesia of this layer is
difficult to obtain. In this situation, we recommend general
anesthesia or spinal anesthesia.
Preoperative care
Preoperative considerations have been discussed above. Since
the extent of preparation and resection as well as the resulting
wound size are limited, perioperative risks are less frequent.
General principles should be followed, including preparation
for intraoperative beach-chair positioning, bowel purgation,
and thrombosis prophylaxis.

587
Surgical techniques and results
the umbilical stalk. If a supraumbilical rectus diastasis is
diagnosed preoperatively, we recommend detaching the
umbilical stalk from the abdominal wall fascia and continuing
the dissection to the xiphoid and costal margins. The umbili­
cal base should be marked for refixation.
The plication of the anterior rectus sheath from the xiphoid
to the symphysis is accomplished using non-absorbable
suture material in a single-knot technique. In this regard, a
second layer of fascial suturing may be applied (Pitanguy
technique). The same suture material can be used for the
refixation of the umbilicus. Markings should be done on
tensed skin and adhere to a distance of minimum 9 cm
between the umbilicus and the upper incision line.
The first incision is performed in the midline with placing a
bullet forceps subdermally. This enables the surgeon to evalu­
ate the lateral vectors of tension and amount of resection. The
marked superior line of skin and tissue excess is checked and,
if appropriate, is adjusted to the level of the inferior incision
line. A Pitanguy-type flap demarcator can be utilized. The
resection of skin and tissue excess is performed oblique to the
wound edge in a 45° angle to enable a precise adaptation of
different layer thicknesses for optimal wound closure.
Further, patients are bent into beach-chair position, and
after a few Baroudi stitches to close the dead space, temporary
wound closure is performed with bullet forceps starting later­
ally to medial. In order to avoid dog-ears, the longer superior
wound edge is shifted slightly medially to adapt to the shorter
inferior. Forceps are removed consecutively from lateral to
medial and an immediate closure of Scarpa’s fascia and
subcutaneous tissue is performed using absorbable suture
material. Final approximation of wound edges can be ensured
during subcutaneous closure. Wound closure ends with an
intracuticular suture or application of PRINEO (Ethicon,
Somerville, NJ).
Drains
can
then
be
inserted,
although
in
mini-
abdominoplasty procedures without fascial reconstruction
and without liposuction, they may be dispensable. After
dressings are placed and a compression garment is fitted, the
patient is transferred into the beach-chair position.
Postoperative care
The operation can be performed as outpatient or inpatient
surgery. Early ambulation is mandatory. Drains are left in
place until discharge is <30 mL in 24 h. The patient should
rest in a relaxed position with a flexion of approximately 30°
at the hip joint. This position should be retained for 2–3 weeks
postoperatively in order to assure a tension-free healing of the
scar. Showering is generally permitted after drain removal.
Postoperative clinical examination should investigate the
possibility of seromas. Patients should be asked about bowel
function; abdominal auscultation and percussion is advisable,
especially when a reconstruction of the fascial system or a
herniotomy has been performed.
Decreased bowel sounds, a postoperative fever, or other
signs of illness should lead to investigation for the possibility
of intra-abdominal incidents. An ultrasound scan may be
helpful.
Suture material or PRINEO should be removed after 3
weeks postoperatively. After suture removal, we recommend
the use of silicon patches for at least 3 months, which may
improve scar quality and maturation.
Operative technique
Preoperative infiltration of lactated Ringer’s solution with
epinephrine can be performed before preparation and draping
to allow ample time for the epinephrine to achieve proper
vasoconstriction. Any supportive liposuction of the abdomi­
nal wall should be performed prior to the abdominoplasty in
order to sufficiently thin out the different layers, including the
epifascial layer. Techniques such as ultrasonic- or vibration-
assisted liposuction may generate shrinking of the skin for
additional skin-tightening effect. Thus, in young patients with
an elastic skin tone and a long distance between symphysis
and umbilicus, an umbilical transposition may be omitted.
The procedure is initiated by making the inferior transverse
incision. The dermis can be divided utilizing a cold blade or
electrocautery, preferably with a Colorado microdissection
needle for optimal dermal hemostasis. It is mandatory to
move the Colorado needle in a precise and rapid manner to
avoid burn injuries and consequent wound healing disorders,
which are usually very rare. Dissection continues downwards
to Scarpa’s fascia. The surgical assistant has to ensure a careful
upward pull of the abdominal flap in order to facilitate a clear
layer definition of Scarpa’s fascia, which in general is strongly
developed and simple to identify. Appropriate preservation
of Scarpa’s fascia requires a learning curve. Dissection pro­
ceeds cranially on the epifascial surface of Scarpa’s fascia to a
point that is two or three finger-breadths inferior to the umbi­
licus. At that point, Scarpa’s fascia is incised and dissection is
carried down to the anterior rectus sheath. Preservation of
major lymphatic vessels in the inferior abdomen and a conse­
quent reduction of postoperative seromas is fostered through
this approach.21,33
Even if rectus fascial reconstruction is unnecessary, the
abdominal flap is raised cranially up to the level of
Fig. 23.15  A distance of at least 9 cm between the upper resection line and the
umbilicus should be strictly respected to avoid an unaesthetic appearance. If, after
skin resection, the distance is expected to be <9 cm, an inverse T-scar with
umbilical transposition should be preferred.

588
SECTION II
CHAPTER 23 • Abdominoplasty procedures
sufficient distance of at least 14–18 cm between the symphysis
and the umbilicus as well as a good elastic skin tone with
limited stretch marks is essential for superior results, since the
amount of resectable skin is limited and comparable with
mini-abdominoplasty procedures. By transposing the umbili­
cus caudally, a tightening of the periumbilical skin is created
without a scar of the umbilicus itself. Additionally, this
approach enables excellent visualization for rectus diastasis
or hernia repair.
Therefore, this technique represents a good alternative
between mini-abdominoplasty and standard abdomino­
plasty procedures. In addition to patients with periumbilical
Sporting activities should be omitted for 6 weeks postop­
eratively and, in cases of fascial reconstruction, for 8 weeks.
Patients should be advised to avoid saunas and tanning beds.
A compression garment should be worn for the same period
of time.
Outcomes and results
As mentioned earlier, patients with mild to moderate skin and
tissue excess of the lower abdomen are good candidates for a
short scar mini-abdominoplasty. Patients with a pre-existing
cesarean scar can have this scar excised or revised in conjunc­
tion with a mini-abdominoplasty.
Patients with a pot belly due to diastasis recti and mild skin
excess are also appropriate candidates for this technique, with
considerable improvements after concurrent plication of the
anterior rectus sheath (Fig. 23.16).
The primary limitation of this procedure is the presence of
upper abdominal skin folds and rolls; these patients will
require one of the more extensive procedures described sub­
sequently in this chapter.
“Modern” abdominoplasty with
umbilical transection
Introduction
Abdominoplasty with a pre-fascial release and transposition
of the umbilicus without circumferential release from the
abdominal flap presents another effective procedure that can
accomplish astounding results, especially in combination
with liposuction and fascial plication. This enables mainte­
nance of umbilical appearance without a periumbilical scar
(Fig. 23.17).
Indication and patient selection
This abdominoplasty represents an extension of mini-
abdominoplasty procedures for patients who suffer from
surplus skin in the area of the lower abdomen, as well as a
modest amount of looseness in the periumbilical area. A
Fig. 23.16  A 31-year-old patient after two pregnancies with two cesarean sections. (A,B) Pre- and (C,D) postoperative oblique and front views of a short scar
abdominoplasty without umbilical transection. Note the low placement of the previous scar and the high-riding umbilicus as well as the infraumbilical diastasis recti.
A
B
C
D
Fig. 23.17  Abdominoplasty with a pre-fascial release and transposition of the
umbilicus without circumferential release from the abdominal flap presents another
effective procedure that can accomplish astounding results, especially in
combination with liposuction and fascial plication.
Minimum 9cm

589
Surgical techniques and results
order to ensure a tension-free wound closure. Wound healing
disorders and wound edge necrosis were often misinterpreted
as a result of too much wound tension. Multiple studies
have since demonstrated that circulatory disturbance of the
abdominal skin flap is the result of extensive undermining and
destruction of the lateral perforators of the Huger zone II.
Modern abdominoplasty techniques respect these circula­
tory principles. The main principle is to operate with the most
minimally invasive technique that will yield the best achiev­
able aesthetical result. Undermining is mainly performed in
the midline area anterior to the linea alba and both rectus
muscles, including the median zones of adhesion first
described by Lockwood and specified by Aly.34,35 The lateral
abdominal regions may be released indirectly using additional
liposuction or the Lockwood dissector for discontinuous
undermining, preserving the lateral perforators and the lateral
attachment to the rectus abdominis muscles. This is important
for the overall aesthetic outcome in cases of a pre-existing
diastasis. In this context, the contour of the rectus muscle may
be restored by midline plication of the rectus fascia. Ideally,
the superficial fascial system should remain connected to the
rectus muscle aponeurosis. If divided, the upper abdomen
will appear tent shaped, with an elevated risk of seroma.
The disadvantage of midline rectus fascial plication may be
a midline gathering of soft tissues. This tissue excess can be
easily and safely reduced through the open excision or with
additional liposuction without the risk of circulatory distur­
bance. Occasionally, extended lateral undermining may be
necessary.
Indication and patient selection
This operation is indicated in patients presenting skin and
soft-tissue excess of the upper and lower abdomen with
acceptance of a circular periumbilical scar.
Suitable patients typically demonstrate a localized and
diet-resistant adiposity of the abdominal wall in combination
with co-existing slack and atonic skin. Such patients have
often been through multiple pregnancies. A pot belly defor­
mity of the upper abdomen may be misinterpreted as tissue
redundancy rather than a fascial diastasis. In such cases,
liposuction can be dangerous if there is an epigastric hernia.
Due to the relatively long incision in the lower abdominal
fold, excellent access is available for diastasis or hernia repair.
Also, with this incision, a considerable amount of excess
tissue may be removed. Smokers have an elevated risk for
wound healing disorders.36,37 Diabetics are predisposed to
suffer from postoperative wound infection. Apart from that,
diabetics represent a group of patients who may benefit from
this procedure by preventing chronic and potentially life-
threatening infections within the abdominal fold.
Markings
As described earlier, the border of the patient’s underwear is
first marked. Then we mark the expected and desired scar
position.
In the upright position, we precisely mark the midline. The
patient is asked to elevate the redundant abdominal tissue for
identification of the abdominal fold. A vertical distance of
7 cm is measured from the labial commissure to the lower
incision, followed by marking of the lower incision line
looseness, this abdominoplasty is well suited for patients who
will not accept umbilical scars or who would be at risk of
developing hypertrophic or keloid scars. Lastly, this technique
is helpful in the candidate for a mini-abdominoplasty in
whom a tension-free closure cannot be ensured or where there
is concern about vascularity due to smoking.
Markings
In contrast to mini-abdominoplasty procedures, this technique
is suited for patients with longer distances of 14–18 cm
between the umbilicus and symphysis; this will be seen in
patients who have an unnatural high umbilical position. The
principles of the scar line assessment and positioning are
similar to mini-abdominoplasty and demonstrated earlier. In
general, the scar line is slightly longer, since more tissue can
be resected compared with the mini-abdominoplasty.
Certain aesthetic principles should be understood and fol­
lowed. The aesthetic relations of 60% upper to 40% lower
abdomen as well as a distance of at least 9 cm between the
umbilicus and the symphysis have to be respected.
Preoperative care
This is covered under “Patient selection and indication”,
above.
Operative technique
The operative technique is, in general aspects, identical with
the mini-abdominoplasty described above. Common features
include the infiltration of lactated Ringer’s solution with
epinephrine, adjunctive liposuction, and flap dissection with
preservation of Scarpa’s fascia in the lower abdomen.
However, the base of the umbilical stalk is detached from the
anterior rectus sheath. As the flap is migrated caudally, the
umbilical stalk is then reattached at an inferior position.
The umbilicus should not be moved inferiorly any closer
than 9 cm from the pubic symphysis (Fig. 23.18).
Postoperative care
This has been discussed earlier.
Outcomes and results
Abdominoplasty with umbilical transection represents a good
alternative between mini-abdominoplasty and standard
abdominoplasty. This technique is suitable for patients with
mainly periumbilical skin wrinkles without the degree of
tissue surplus necessitating a full abdominoplasty procedure
(Fig. 23.19).
Standard abdominoplasty
Introduction
The standard abdominoplasty is one of the most common
plastic surgery procedures performed worldwide. Prime
advantages are the simultaneous treatment of the upper
abdomen, periumbilical area, and lower abdomen, with con­
cealable scars.
Traditional abdominoplasty involved widely mobilizing
the abdominal wall up to the costal arch or even higher in

590
SECTION II
CHAPTER 23 • Abdominoplasty procedures
A
B
C
D
E
F
Fig. 23.18  Intraoperative view of abdominoplasty with umbilical transection. (A) Markings in the supine position; (B,C) preservation of Scarpa’s fascia; (D,E) preparation
of the umbilical stalk; (F) closure of the umbilical base with non-resorbable suture material; (G,H) assessment of the distance between upper resection line and the
umbilicus with resection of the redundant tissue; (I) refixation of the umbilical stalk to the anterior rectus sheath; and (J) the intraoperative result.

591
Surgical techniques and results
Preoperative care
Preoperative considerations have been discussed above. In
patients who are candidates for a standard abdominoplasty,
the wound size and operating time are greater, and patients
may have a surplus of weight as well as other co-morbid
factors. For all these reasons, as compared with minimal
procedures, the full abdominoplasty patient will be at a higher
risk for complications.
Prophylaxis for pulmonary embolism and DVT is an
essential consideration, especially in patients taking birth
control medications or hormone replacement therapy, since
they have an increased risk. The patient should be coun­
seled about this preoperatively; risks will be decreased if
hormonal replacement is discontinued 3–4 weeks prior to
surgery.38
In cases of an extended diastasis or hernia, the reconstruc­
tion of the fascia results in an increased intra-abdominal
pressure, which may be a source of respiratory difficulties.
Preoperative breathing exercises (utilizing an incentive spi­
rometer) beginning 1–2 weeks prior to and continuing for 2
weeks after the operation are advisable for the patient. A cold,
dry cough, or any kind of respiratory infection should lead to
postponement of surgery, since fits of coughing may provoke
a rupture of the fascial sutures with consequent secondary
bleeding.
parallel to the abdominal fold, considering any ptosis of the
mons pubis. Then in the supine position, the expected amount
of resection is assessed and marked. Particular attention is
paid to the midline area to assess for the potential necessity
of an inferior inverse “T” incision, including an umbilical
circumcision. This upper incision is drawn as a preoperative
estimate. Normally, the upper incision is not made until the
end of the procedure after intraoperative assessment of the
correct tissue resection.
Evaluation of possible pre-existing hernias and diastasis
should be repetitively performed in the supine position,
marking the extent of the diastasis recti. We measure and
document the length of the scar line bilaterally, starting from
the midline to ensure symmetry.
Choosing an appropriate incision line, we need to be aware
that a longer inferior incision will lead to a gently curved,
upward course of the scar (Baroudi), and a longer superior
incision will cause a straighter or downward course of the scar
(Pitanguy).
Respecting this simple principle, the scar course may
individually be matched to the age and fashion style of the
patient. An exceptional scar course should be discussed criti­
cally with the patient, since fashion changes occur at short
intervals. For example, a high-cut bikini approach may later
cause problems for the fashion-conscious patient wearing
hipsters or a bare midriff T-shirt.
G
H
I
J
Fig. 23.18, cont’d

592
SECTION II
CHAPTER 23 • Abdominoplasty procedures
order to sufficiently thin out the different layers, including the
epifascial layer. We commence the operation with a final check
of the measurements and markings. Points of reference may
be tattooed using methylene blue, especially the midline
inferior and superior to the estimated resection area.
■ The lower incision line may be additionally infiltrated
with local anesthetics to reduce postoperative pain and
the consequential risk of blood pressure increase. The
lower incision line is cut, utilizing the Colorado needle
with careful superficial coagulation. During downward
dissection, the frequently large superficial epigastric
vessels should be ligated.
■ The surgical assistant has to ensure a careful upward pull
of the abdominal flap using bullet forceps in order to
facilitate a clear layer definition to preserve Scarpa’s
fascia. By staying above Scarpa’s fascia, the subjacent
lymphatic vessels are preserved. In previously operated
patients, identification of the appropriate dissection layer
may be difficult. Dissection superficial to Scarpa’s fascia
continues cranially up to a level two to three finger-
breadths inferior to the umbilicus. At that point, Scarpa’s
It can be helpful to recommend placing the patient into a
tight compression girdle for 2 weeks day and night preopera­
tively to accommodate to the increased intra-abdominal
pressure postoperatively.
Smoking cessation for 6 weeks preoperatively is suggested
to patients. In case of failure, cessation or at least a drastic
reduction of smoking for at least 2 weeks prior to the opera­
tion is recommended. Diabetes may be a relative contraindica­
tion to this procedure, especially in poorly controlled patients.
Furthermore, it is important to exclude any skin irritation or
inflammation in the area of the abdominal folds and umbili­
cus. An inspection of these areas immediately prior to the
operation is strongly advised. Diabetics should receive a
single-shot antibiotic immediately prior to surgery.
Operative technique (Video 23.1 )
Preoperative infiltration of lactated Ringer’s solution with
epinephrine can be performed before preparation and draping
to allow ample time for the epinephrine to achieve proper
vasoconstriction. Any adjunctive liposuction of the abdominal
wall should be performed prior to the abdominoplasty, in
Fig. 23.19  Schematic of a 40-year old patient after multiple
intra-abdominal surgeries. (A,B) Pre- and (C,D) postoperative
front and oblique view of an abdominoplasty with umbilical
transection.
A
B
C
D

593
Surgical techniques and results
Postoperative care
General postoperative care has been discussed with mini-
abdominoplasty. For the standard abdominoplasty, we prefer
to perform the operation on an inpatient basis with a 2- to
3-night hospital stay.
Patients with pre-existing umbilical scars from previous
surgery such as herniotomy or laparoscopy should be
observed for possible disturbances of blood supply. A slight
postoperative discoloration of the umbilicus is usually not
precarious. A complete necrosis of the umbilical stalk is very
uncommon and may be treated conservatively, with satisfying
results.
Outcomes and results
Patient satisfaction after standard abdominoplasty is consis­
tently high, since it enables treatment of the entire abdomen.
The legacy of a long scar with limited treatment effects to the
hips and the back region is an unfortunate aspect of this
procedure.
Patients often ask how the operative benefits may be
affected by future pregnancies. If they are able to control
weight, continue to exercise, and treat their abdominal skin
with topical agents, the benefits of the abdominoplasty pro­
cedure may persist after pregnancies (Figs. 23.22 & 23.23).
High lateral tension (HLT) abdominoplasty
Introduction
This extended modification of abdominoplasty procedures
not only treats the abdomen but also the hips and the lateral
thighs. A modified incision pattern is used (Fig. 23.24).
In the 1990s, Lockwood recognized that many patients,
particularly those after massive weight loss who received a
standard abdominoplasty, showed good results in the central
abdominal region, but the flanks showed no improvement or
were made worse due to a gathering of excess tissue in the
flank region. This led to the concept of shifting tension from
the central abdomen to increased tension laterally. Lockwood
established several surgical principles that were in many
ways diametrically opposed to the ones of a standard abdomi­
noplasty, namely, an extensive discontinuous undermining
and a more conservative resection centrally with wider exci­
sion of the lateral skin.
Indication and patient selection
The HLT abdominoplasty is suitable for patients who expect
more than an abdominal tightening and is often applicable for
patients after massive weight loss. Women usually suffer from
an additional skin laxity in the lateral thigh region, whereas
men often complain about the typical love handles. The
experienced surgeon may be confronted with abdominoplasty
procedures that result with lateral dog-ears, despite the extent
of lateral tissue excision and scar elongation. Additional
liposuction may be supportive, although often insufficient
due to a surplus of skin.
Even though this procedure may address only a minority
of patients, this technique represents a good solution for
patients for whom an abdominoplasty is insufficient and a
lower bodylift is beyond their needs.
fascia is incised and dissection continues along the
anterior rectus sheath.
■ The umbilical stalk is then circularly transected from the
abdominal flap and may be temporarily sutured closed
for asepsis. Surrounding perforators may be ligated with
maximal awareness, since they tend to retract after
dissection beneath the anterior rectus sheath. Dissection
continues superior to the umbilicus along the rectus
fascia up to the xiphoid. The linea alba can easily be
identified, as it is distinctively connected to Scarpa’s
fascia. The lateral perforators should be preserved
(Fig. 23.20
).
Fig. 23.20 appears online only.
■ Plication of the anterior rectus sheath from the xiphoid to
the symphysis is accomplished using non-absorbable
suture material in the technique described by Pitanguy
(see above). In the case of a diastasis of the lower
abdomen located beneath Scarpa’s fascia, the tissue may
be bluntly mobilized to allow for midline fascial plication.
In some patients, there may be a pronounced fat layer
beneath Scarpa’s fascia, something which can be thinned
using liposuction. Since lateral dissection is avoided up to
the costal arch for preservation of the lateral perforators,
medial rectus plication may cause soft-tissue bulging in
the midline. This may be treated by one of three ways:
discontinuous separation of lateral adhesions using the
Lockwood underminer; performing an open excision of
fatty tissue; or doing liposuction after wound closure.
■ The abdominal flap is then pulled down and several
progressive tension sutures are placed, followed by an
incision of the flap in the midline. Utilizing a bullet
forceps or Pitanguy tissue demarcator, the upper
resection line can be estimated for a tension-free wound
closure. Further evaluation of resection volume may be
facilitated by additional vertical incisions and temporary
wound closure using bullet forceps. The upper incision
line is then marked and the resection of skin and tissue
excess is performed oblique to the wound edge in a 45°
angle to enable a precise adaptation of different layer
thicknesses for optimal wound closure. After meticulous
coagulation, the wound is closed temporarily. The new
umbilical position is estimated and marked. Several
umbilical incision patterns have been described (we
prefer the inverted “V” incision). The umbilical section of
the abdominal flap is then circumferentially defatted to
achieve a surrounding depression around the umbilical
stalk. The supraumbilical midline may also be
accentuated by midline liposuction or open excision.
■ Paramedian plication of the anterior rectus sheath may
facilitate a correction of an asymmetrically located
umbilical stalk or for accentuation of an hourglass figure
with further waist tightening.
■ As an option, the upper side of the umbilical incision
may be fixed to the cranial base of the umbilical stalk and
the anterior rectus sheath, using a non-absorbable suture
in order to create a periumbilical depression and for
reduction of tension within the umbilicus (Fig. 23.21
).
Fig. 23.21 appears online only.
■ Wound closure, drains, and compression garment
application have been described earlier (see “Wound
closure”, above).

593.e1
Surgical techniques and results
Fig. 23.20  Excision pattern of the umbilical stalk from the previous abdominal wall
(red line A–F) and the incision pattern at the new umbilical insertion (blue line
A′–F′).
F
FI
EI
AI
CI
BI
DI
E
A
C
D
B
Fig. 23.21  Fixation of the umbilical stalk to the anterior
rectus sheath after midline plication. The blue line indicates
the umbilical stalk incision pattern, the red area has to be
provided from the abdominal flap in terms of an inverted
V-flap.
A
B

594
SECTION II
CHAPTER 23 • Abdominoplasty procedures
Fig. 23.22  A 42-year-old woman with a remarkable amount of striae distensae in the periumbilical region after a single pregnancy. (A,B) Pre- and (C,D) postoperative
oblique and front images of a standard abdominoplasty procedure with incomplete elimination of striae.
A
B
C
D
Fig. 23.23  A 42-year old patient after two pregnancies and a 15 kg weight loss. (A,C) Pre- and (B,D) postoperative oblique and frontal view of a standard abdominoplasty
with rectus plication.
A
B
C
D
Markings
Markings are made with the patient in an upright position.
As described earlier, the borders of the underwear are ini­
tially marked. Like a standard abdominoplasty, the patient
is asked to elevate the redundant abdominal tissue for
identification of the abdominal fold. A vertical distance of
7 cm is measured from the vulva commissure, followed by
marking of the lower incision line parallel to the abdominal
fold. The inferior incision line is drawn laterally towards the
anterior axillary line and continues upwards to the midaxil­
lary line following an angle of 45°. In a next step, a second
line is drawn starting at the highest point of the umbilicus
running parallel to the lower incision line. When this marking
reaches the anterior axillary line, it turns downwards in an
angle of 45° meeting the lower line in the midaxillary line
forming an angle of 90° at the end of the resulting scar (see
Fig. 23.24). This extended modification of abdominoplasty
procedures not only treats the abdomen but also the hips and
the lateral thighs by using a modified incision pattern. The
concept is shifting the tension from the central abdomen more
laterally.
Preoperative care
This is discussed in detail above. In addition, for this proce­
dure, it is helpful to position patients on additional soft
cushion pillows in the gluteal area for elevation of the flanks
and the lateral thighs. This will facilitate access for the more
lateral extension involved in this procedure. Alternatively, a
change to the lateral position can be done.
Operative technique
The operative technique is similar to a standard abdomino­
plasty, although flap mobilization in the midline area is per­
formed as far lateral as necessary for rectus plication. Further
flap advancement can be achieved through vertical discon­
tinuous undermining utilizing the Lockwood dissector.
However, the skin resection pattern with a significant lateral
resection farther laterally is performed with high-tension

595
Surgical techniques and results
Fig. 23.25  A 54-year-old patient with a massive skin and soft-tissue redundancy at the abdominal and flank region. (A,B) Pre- and (C,D) 3 months’ postoperative oblique
and front images of a high lateral tension abdominoplasty procedure with fascial tightening without any additional liposuction.
A
B
C
D
Fig. 23.24  This extended modification of abdominoplasty procedures not only
treats the abdomen, but also the hips and the lateral thighs by using a modified
incision pattern. The concept is shifting the tension from the central abdomen more
laterally.
wound closure. In the lateral area of the right angle incision,
it is recommended to reduce subdermal fat and lengthening
of the abdominoplasty incision in order to avoid dog-ears.
Postoperative care
Postoperative care has been discussed previously.
Outcomes and results
The HLT abdominoplasty presents a treatment concept with
additional focus on hips and thighs. A laterally elongated scar
has to be tolerated for a convincing result, which is mostly
well accepted by the patient. Since the lateral abdominal
perforators are generally not injured, a safe and constant
perfusion can be ensured and thus an extensive liposuction of
the entire abdominal wall may be securely performed (Fig.
23.25). In some cases, limited benefit may be noted at the
lateral aspect of the thighs.
Fleur-de-lis abdominoplasty
Introduction
The fleur-de-lis or anchor abdominoplasty was first popular­
ized in 1985 and is derived from techniques previously
described by Regnault9 (classic “W” technique) or Kelly (1910)
and Babcock (1916).1–4 The principles and the power of this
procedure is the ability to eliminate horizontal and vertical
redundant tissue of the lower and upper abdomen, with a
maximum improvement of body shape and reduction of waist
circumference. It is also possible to combine this technique
with a high lateral tension abdominoplasty, thus accomplish­
ing impressive changes. General principles such as preserva­
tion of the lateral perforators, and discontinuous undermining
with elimination of dead spaces, are mandatory. The primary
disadvantage of this procedure is the increased scar length
(Fig. 23.26).
Indication and patient selection
This technique is suitable for patients suffering from a tissue
surplus of the lower and particularly of the upper abdomen,
often after massive weight loss. One unique indication is the
patient who presents with a pre-existing abdominal midline
scar.
Another special case is the patient who presents having
already undergone an abdominoplasty, but who is still con­
cerned about tissue excess, often in the upper abdomen. This
can be demonstrated with the patient in a sitting position or
bending over slightly in the upright position.
Bariatric surgery is discussed in Chapter 28. When consid­
ering a vertical midline scar, it is important to ask about the

596
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CHAPTER 23 • Abdominoplasty procedures
Operative technique
The general operative technique is as for standard
abdominoplasty.
■ Abdominal flap mobilization is done as for standard
abdominoplasty. Principles include staying above Scarpa’s
fascia inferiorly, dissecting superiorly on the anterior
rectus fascia and laterally to the lateral rectus margin
(linea semilunaris), and preserving lateral perforators.
■ For lateral flap mobilization, we prefer the Lockwood
underminer for careful discontinuous lateral undermining.
Before final tissue resection may be accomplished, the
entire estimated vertical and transverse resection area has
to be temporarily closed utilizing bullet forceps.
■ Precise closure of each wound layer is the key for
adequate wound healing and discreet scarring. In this
technique, the umbilicus must be integrated into the
vertical scar. At the appropriate umbilical height, a
transverse incision is made on both abdominal flaps with
the circular fat excision in the periumbilical region. The
umbilical stalk is then adapted to the abdominal flaps,
allowing skin excisions for optimal incorporation. A
secondary aesthetically unpleasing trumpet-like widening
of the umbilicus may result from extensive skin removal.
To control this, a step-by-step excision is done, observing
the effects of transverse tensile forces.
■ Wound closure at the cranial end of the vertical scar may
be difficult because of the frequent problem of a dog-ear
in this region. To avoid this complication, an open
excision of the subdermal fat tissue or even additional
“Burow triangles” on the level of the inframammary fold
may be indicated. A primary correction by superficial
liposuction may be attempted.
■ After finalizing wound closure, an adjusting liposuction
may be performed.
■ We regularly insert three to four drains.
■ Before the patient wakes from anesthesia, the
compression garment has to be applied. Patients are
transferred into the beach-chair position.
presence of a gastric band, as transverse tissue resection may
reposition a gastric band access port.
Markings
The key in planning this procedure is to independently assess
the horizontal and vertical surplus of skin and fat tissue. The
estimate of tissue surplus is accomplished through accurate
pinching of the skin while the patient is in the upright and
relaxed supine position.
We usually commence in the upright position with the
marking for a standard abdominoplasty or more frequent
HLT abdominoplasty incision pattern. Then the horizontal
tissue surplus of the upper abdomen is estimated and the
marking may be performed in a single- or double-ellipse
technique as previously described by Aly35 to avoid an over-
resection (Fig. 23.27). Markings usually result in an omega-like
figure.
It is important to clarify to the patient the height of the
vertical scar, since it may extend up between the breasts after
final closure. In order to prevent this, we recommend a precise
marking below the xiphoid and treatment of any possible
dog-ear primarily by local superficial liposuction, rather than
a more superior excision.
Symmetry is controlled during the entire examination and
marking. Finally the upper and lower incision line as well as
the vertical incision lines may be measured and compared.
Markings should be checked in the upright, supine, and
sitting positions.
Preoperative care
Preoperative care is as discussed previously. If a simultaneous
high lateral tension abdominoplasty is planned, the additional
padding discussed for that procedure is used.
Fig. 23.26  The typical fleur-de-lis pattern to eliminate horizontal and vertical
redundant tissue of the lower and upper abdomen, with a maximum improvement of
body shape and reduction of waist circumference.
Fig. 23.27  (A,B) The fleur-de-lis pattern can be combined with a high lateral
tension abdominoplasty to achieve maximal contouring and reduction of excess
tissue.
A
B

597
Surgical techniques and results
Abdominoplasty with Scarpa lift
Introduction
During abdominoplasty, the accurate dissection and preserva­
tion of Scarpa’s fascia enables an adjunctive intraoperative
maneuver utilizing fascial tightening, without impairment of
the lymphatic drainage. Because Scarpa’s fascia continues
caudally into Colles’ fascia, traction placed on Scarpa’s fascia
can result in a transition of traction into the medioventral
thigh region. This, in turn, can facilitate a limited indirect
subcutaneous lifting effect on the medial thigh.39
Indication
Patients after mild to moderate weight loss may suffer from
minor skin laxity at the inner thigh region that does not
require an additional direct tightening procedure. As an
intraoperative adjunctive procedure to the vertical skin tight­
ening during an abdominoplasty, the subdermal tightening of
Scarpa’s fascia might additionally help the inner thigh region.
It has to be emphasized that only a limited group of patients
can be addressed by this maneuver. Patients with a massive
surplus of skin generally have to undergo traditional horizon­
tal and vertical procedures.
Operative technique
After preparation and preservation of Scarpa’s fascia to the
level of the arcuate line, it can be vertically tightened to the
anterior rectus sheath utilizing non-absorbable sutures in
single-knot or running technique. Effects to the inner thigh
region may be checked and demonstrated intraoperatively.
Outcomes
The main advantage in terms of providing a simultaneous
indirect lift of the medial thigh region by fascio–fascial
transition from Scarpa’s to the medial thigh inguino-cruralis
fascia has gained our attention. Since patients after a mild to
Postoperative care
Postoperative care has been discussed previously. The hospi­
talization period is usually slightly prolonged, since patients
frequently demonstrate a prolonged drainage from the upper
abdominal area. Special attention should be given to breath­
ing exercises.
Single-shot antibiotic prophylaxis should be mandatory in
this procedure. Optionally, a broad-spectrum 5-day regimen
may be used.
Outcomes and results
If basic principles such as maximal preservation of perfora­
tors and minimal undermining with minimal dead space
are followed, wound healing should be unproblematic and
rapid. The aesthetic effects to the hip and waist are dra­
matic and not comparable with any other technique. The
midline incision most often heals without excess scarring.
Additionally, a significant improvement is achievable to
the back and flank folds due to an extreme recruitment of
lateral skin.
Patients with massive tissue surplus in the upper abdomen
are good candidates for this procedure, providing they can
accept the visible scar (Fig. 23.28).
Abdominoplasty in massive
weight loss patients
The number of patients after massive weight loss (MWL)
has increased dramatically within recent years, mainly due
to a changed health consciousness, as well as modern and
popularized techniques in bariatric surgery. Both men and
women often suffer from massive deformations of the abdom­
inal wall, which cause significant hygienic and functional
discomfort.
Because of remarkable perioperative problems in this
patient group, the MWL patient and bariatric surgery are
reviewed in Chapter 28.
Fig. 23.28  A 44-year-old patient after 125 kg weight loss after sleeve gastrectomy. (A,C) Pre- and (B,D) postoperative oblique and front images after fleur-de-lis
abdominoplasty.
A
B
C
D

598
SECTION II
CHAPTER 23 • Abdominoplasty procedures
moderate weight loss are often impatient with their medial
thigh skin laxity and decline an additional medial thigh
procedure with additive medial thigh and groin scars and
their consequent potential complications, this additional
intraoperative maneuver enables an extension of surgical
offerings to our patients in this rapidly growing field of plastic
surgery (Figs. 23.29 & 23.30
).
Fig. 23.30 appears online only.
Circumferential abdominoplasty
The original idea of circumferential abdominoplasty was to
deal with lateral dog-ears extending around to the back from
an abdominoplasty. Since the early 1990s, however, the cir­
cumferential abdominoplasty has been adapted to an increas­
ing demand for circular lower trunk dermatolipectomies
involving an extended preparation and resection of the entire
lower trunk.33,40,41 This topic is reviewed in Chapter 25.2.
Reverse abdominoplasty
Introduction
The majority of patients presenting with excessive truncal
tissue suffer from redundant skin and soft tissue of the lower
abdomen. These patients can normally be treated with one
of the procedures described in this chapter. In certain indi­
viduals, however, tightening of skin in the upper abdomen
alone may be indicated.
Indication
The indication for this procedure is not as common as other
abdominoplasty procedures and is rarely performed solely. It
may be performed either during a reduction mammaplasty or
in combination with a standard abdominoplasty. The most
common indication in our practice is the MWL patient who
has undergone a conventional abdominoplasty and may
suffer from persistent skin and soft tissue excess of the upper
abdomen.
Patient awareness and acceptance of the resulting scar line
is mandatory for the performance of this procedure. Since the
majority of patients are female, a positioning of the scar in the
inframammary fold is achievable, although patients must be
aware of a visible scar between the breasts. The indication for
male patients is limited, because the scar in this region cannot
be concealed.
In selective cases, the excess tissue of the reverse abdomi­
noplasty may be utilized for autologous augmentation of
A
B
Fig. 23.29  (A) Intraoperative preservation of Scarpa’s fascia and (B) fascial tightening to the anterior rectus sheath.

598.e1
Surgical techniques and results
Fig. 23.30  A 41-year-old female patient
after 22 kg weight loss and two
pregnancies. (A) Preoperatively and (B) 3
months postoperatively after a standard
abdominoplasty, including a bilateral
Scarpa lift. The inner thigh region could be
improved, preventing the patient from an
additional inner thigh scar. (Printed with
kind permission from Springer; Richter DF,
Stoff A. The Scarpa lift – a novel technique
for minimal invasive medial thigh lifts. Obes
Surg. 2011;21:1975–1980.)
A
B
Fig. 23.31  A 52-year-old patient after an atypical open laparotomy procedure with a transverse scar. (A,B) Pre- and (C,D) postoperative front view following an
abdominoplasty procedure with a pre-existing scar.
A
B
C
D

598.e2
SECTION II
CHAPTER 23 • Abdominoplasty procedures
A
Fig. 23.32  Multiple umbilicoplasty techniques.

598.e3
Surgical techniques and results
B
6 o’clock
9 o’clock
3 o’clock
12 o’clock
Fig. 23.32, cont’d

599
Surgical techniques and results
subcutaneous tacking sutures. It is also crucial to grasp stable
tissue of the umbilical stalk at an appropriate height for fixa­
tion at the anterior rectus sheath to avoid any herniation and
improve the hollow appearance.
When the new umbilical location is determined, a circu­
lar area of 4–6 cm diameter is defatted and the abdominal
flap thickness subsequently reduced in the supraumbilical
midline cranially to the level of the xiphoid. This can be
performed either through liposuction or direct excision of
a 1–2 cm subcutaneous wedge for creation of a midline
groove.
A main aspect of umbilical accentuation, in our experience,
is emphasizing the supraumbilical abdominal flap depres­
sion. This is accomplished through fixation of the abdominal
flap dermis to the anterior rectus fascia slightly above the
umbilical stalk origin.
Attention has to be taken regarding a sufficient size of
abdominal flap incision for reinsertion of the umbilical stalk.
If the incision is performed too small, a contracting scar with
small appearance of the umbilicus results. In contrast, an
overly large incision can result in a huge, unfavorable umbi­
licus. In this regard, it is recommended that the incision is
performed while the abdominal flap is closed temporarily to
take into account the conditional umbilical enlargement from
increased tension.
Externus belt
In cases of severe abdominal muscular wall laxity, a simple
anterior rectus sheath plication can be insufficient for waist
accentuation. In these instances, a supraumbilical externus
belt can be applied for enhancement of the waist contour.
After midline plication of the anterior rectus sheath, two
fascial reins of external oblique aponeurosis about 2–3 finger-
breadths wide are incised, overlapped across the midline, and
sutured. To aid with dissection of the fascia, hydrodissection
with saline solution can be helpful. Under maximal tension,
the fascial reins are fixated to the below external oblique fascia
using non-resorbable sutures.
If this procedure results in secondary relaxation of the
median plication of the anterior rectus sheath, the central
plication can be retightened with a second layer of sutures
(Figs. 23.33 & 23.34
).
Fig. 23.33 appears online only.
Techniques with previous scars
In the era of minimally invasive surgery with multiple short
scars, we frequently observe patients with atypical scars,
which restrict the choice of abdominoplasty technique. Of
note, horizontal scars near the costal margin can complicate
operative planning, since they cannot be included into the
preferred lower abdominal approach.
As a rough guide to avoid complications from impaired
perfusion, if a scar will not be removed in the resected speci­
men, surgeons should at most indirectly undermine or if
possible, completely avoid, any undermining in the scar area.
Ideally, the pre-existing scar should be integrated into the
proposed incision course, regardless of a possible impaired
aesthetic appearance. Impaired perfusion of the abdominal
flap may result in necrosis of the dermal and fat layer with
consequent wound dehiscence.
the breast as part of a mastopexy procedure. The abdominal
flap of the upper abdomen is de-epithelialized and rotated
cranially for tissue augmentation. A secure fixation to the
periosteum of the ribs is performed with permanent sutures.
Markings
The marking is performed with the patient in the upright
position. The patient is asked to slightly bend forward for
demonstration of tissue excess. This enables an optimal
assessment of the vertical and horizontal tissue excess. The
inframammary fold is then marked extending laterally to the
anterior axillary line. The patient in the supine position facili­
tates the examination of the inframammary fold mobility,
which can be considerable in patients after massive weight
loss. The surplus of tissue and the consequent lower incision
line is assessed by accurate pinching. It is recommended to
include a V-shaped scar course at the midline to avoid an
apparent décolleté scar. Vertical markings for orientation may
be helpful to ensure a symmetric wound closure. The width
of resection is generally <15 cm (Fig. 23.31
).
Fig. 23.31 appears online only.
Vertical abdominoplasty
The vertical abdominoplasty refers to a purely vertical inci­
sion with lateral mobilization of abdominal soft tissue. This
procedure is primarily indicated in patients with a pre-existing
scar in the abdominal midline who seek an improvement of
the abdominal contour without additional transverse scars.
Especially in patients with a request for vertical fascial tight­
ening due to pre-existing diastasis recti or scar hernia, this
procedure may improve the abdominal contouring.
Umbilicoplasty
For umbilical preservation and recreation, multiple techniques
have been published to date. The reconstructed umbilicus
should be fairly small, vertically oriented, superiorly hooded,
and with a slight circular depression 4–6 cm in diameter.
Additionally, it is advantageous to accentuate the natural
abdominal midline.
When raising an abdominal flap, the umbilicus is
released with a circumumbilical incision made in a round
or rhombic shape; the stalk is then prepared and separated
from the abdominal flap. Re-insetting the umbilicus is done
first by attaching the umbilical stalk to the anterior rectus
sheath with four point fixation sutures at 3, 6, 9, and 12
o’clock, using long-term resorbable sutures. The abdominal
flap is then drawn over the umbilicus and temporarily
closed.
After determination of the new umbilicus location by uti­
lizing the Pitanguy-type flap demarcator (or Lockwood
marker) or measurement of the umbilicopubic distance below
and above the abdominal flap, the umbilical incision can be
made in different patterns, depending on the surgeon’s pref­
erence. The horizontal crescent-shaped incision with the
convexity up or the similar inverted “V” are the most fre­
quently used incision patterns with the best achievable results,
in our experience (Fig. 23.32
).
Fig. 23.32 appears online only.
In MWL patients, it is usually necessary to shorten the
umbilical stalk to avoid a stalk herniation, despite sufficient

599.e1
Surgical techniques and results
Fig. 23.33  Intraoperative schematic view of an externus belt procedure with preservation and fascial tightening.
A
B
C

600
SECTION II
CHAPTER 23 • Abdominoplasty procedures
Complications
Patients can expect postoperative pain or soreness, numb­
ness of the abdominal flap, bruising, general fatigue, and
discomfort due to increased abdominal tension for many
weeks.
Complications can be localized or systemic. Local com­
plications include hematoma, seroma, wound infection, fat
necrosis, wound dehiscence, paresthesias, and persisting
numbness. Of these, seromas are the most common problem
and are usually handled with serial punctures and drainage.
Persistent seromas may require an indwelling drain, or in
the case of a late encapsulated seroma, a secondary surgical
procedure. If a seroma pocket becomes infected, cellulitis
will first be apparent and the patient may become febrile
and systemically ill. If suspected, an infected seroma must
be surgically drained. In general, if seromas are detected
in time, a simple aspiration may prevent a deteriorating
course.
Minor wound dehiscence is common and is normally a
self-limiting problem. Significant dehiscence may be due to
excess tension or marginal wound necrosis. If necrosis occurs,
it is usually in the distal portion of the abdominoplasty flap
near the midline where tension is greatest. Appropriate treat­
ment is conservative wound care, although once a significant
area of necrosis has demarcated, it should be surgically
debrided. If secondary wound healing is ineffective, a skin
graft may be necessary for wound closure. It is seldom
possible, and almost never indicated, to attempt additional
flap advancement to close a postoperative wound healing
defect.
Many local problems of a cosmetic nature can result from
abdominoplasty. These include lateral dog-ears, widened or
hypertrophic scars, malpositioned scars, and numerous cos­
metic problems directly related to the umbilicus. Most of these
In cases of cranial transverse scars after abdominal lapa­
rotomy, the lower incision should be planed higher to be
included in the final abdominoplasty scar (see Fig. 23.31
).
Management of the mons pubis
Secondary findings in patients with abdominal wall laxity and
tissue excess are often hypertrophy or mild to severe ptosis
of the mons pubis. Especially in MWL patients, the mons
pubis is deflated not only in a vertical but also horizontal
vector. Patients may complain about a pseudo-hypertrophy
of the mons pubis, which is created by an imbalance between
abdominal flattening and mons pubis laxity. This can be
accentuated by the disruption of lymphatic drainage to
the mons.
Additive liposuction of the mons pubis is sufficient in most
abdominoplasty cases without local skin excess. In patients
particularly after MWL with hypertrophy and surplus skin
in the mons pubis region, we routinely perform a horizontal
monsplasty, which is integrated into the lower abdominal
incision. It is recommended that a distance of 6–7 cm
from the incision line to the anterior vulva commissure is
respected.
In cases of severe hypertrophy and ptosis of the mons
pubis, as may be seen in MWL patients, a combined horizontal
and vertical monsplasty is indicated. In this context, an addi­
tional V-shaped excision at the midline can be conducted.
Surgical dissection should be carried out cautiously due to the
ilioinguinal nerve, which innervates the mons pubis and
inguinal crease together with a very anteroproximal part of
the root of the penis or labia majora.42 In cases of extreme
surplus skin, a bilateral monsplasty can be included into a
medial thigh plasty, which is frequently performed in MWL
patients, preferably as second-stage procedures following
abdominoplasty or lower circumferential trunk procedures
(see Fig. 23.11).
Fig. 23.34  Intraoperative view of an
externus belt procedure with preservation
and fascial tightening. After release of
midline adhesions, the fascial flap is
designed. Following diastasis recti
plication, the flaps are crossed and fixated
with reconstruction of fascial layers.
A
B
C
D

601
Contraindications
problems can be avoided with proper preoperative planning
and attention to surgical detail. If liposuction has been done
simultaneously, issues pertaining to that procedure include
contour irregularities and dermal tethering.
Systemic complications include DVT, pulmonary embo­
lism, respiratory compromise due to increased intra-abdominal
pressure, and systemic infections including toxic shock syn­
drome. All of these complications are potentially lethal and
must be dealt with expeditiously. Surgeons should be aware
that abdominoplasty, especially when combined with other
procedures such as liposuction, has a higher systemic compli­
cation rate than any other type of routine cosmetic surgical
procedure.
Evidence on abdominoplasties
Evidence on preoperative assessment
■ Smokers have a significant increase in wound healing
problems and infections (50% vs. 15% in non-smokers):
evidence level (EV level) II.
■ Obese patients with a BMI >30 and those who have
significant soft-tissue resection of more than 1500 g have
an increased risk of developing pulmonary embolus: EV
level II.
■ Wound healing complications are more common in
patients after bariatric surgery compared to natural
weight loss before abdominoplasty: EV level II.
■ Operation times of about 2 h have been identified to
increase the risk of pulmonary embolism intensively: EV
level II.
Evidence on antibiotic prophylaxis
■ A single dose antibiotic prophylaxis can be recommended
to all patients undergoing abdominoplasty to reduce the
incidence of wound infection: EV level II.
Evidence on thrombosis prophylaxis
■ The Davison–Caprini risk assessment model proves to be
applicable in abdominoplasties: EV level II.
■ Patients with a BMI >30 have an exponential risk of DVT:
EV level II.
■ Chemoprophylaxis decreases the risk of DVT significantly
but raises the incidence of bleeding complications: EV
level II.
Bonus images for this chapter can be found online at

Fig. 23.1 Anatomical landmarks. Normal abdominal anatomic proportions. The
approximate measurements for an average female abdomen are listed.
Fig. 23.2 (A) Anatomy of the musculature of the abdominal wall with arterial
supply. (B) Arcuate line and linea semilunaris.
Fig. 23.8 Assessment of intra-abdominal pressure in the supine position. The
non-scaphoid abdomen will be prone to pressure increase after abdominoplasty.
Fig. 23.9 Markings are to be performed with respect to the anterior vulva
commissure and the umbilicus.
Fig. 23.10 Pinching of the abdominal tissue in upright and supine position.
Fig. 23.20 Excision pattern of the umbilical stalk from the previous abdominal
wall (red line A–F) and the incision pattern at the new umbilical insertion (blue
line A′–F′).
Fig. 23.21 Fixation of the umbilical stalk to the anterior rectus sheath after
midline plication.
Fig. 23.30 A 41-year-old female patient after 22 kg weight loss and two
pregnancies. (A) Preoperatively and (B) 3 months postoperatively after a
standard abdominoplasty, including a bilateral Scarpa lift.
Fig. 23.31 A 52-year-old patient after an atypical open laparotomy procedure
with a transverse scar.
Fig. 23.32 Multiple umbilicoplasty techniques.
Fig. 23.33 Intraoperative schematic view of an externus belt procedure with
preservation and fascial tightening.
Evidence on surgical planning
■ Combination of different surgical procedures during one
operation does not increase intraoperative complications
or major postoperative complications: EV level IV.
■ Seroma reduction can be achieved by using subcutaneous
drains, progressive tension sutures, and involving a more
superficial plane of dissection with preservation of
lymphatics: EV level I–III.
Contraindications
Patients with significant health risks, with unrealistic surgical
goals, and with body dysmorphic disorder are primary con­
traindications for an elective abdominoplasty procedure. Rela­
tive contraindications to abdominoplasty include right, left,
or bilateral upper quadrant scars; further severe comorbid
conditions (e.g., heart disease, diabetes, morbid obesity, ciga­
rette smoking); eventual future plans for pregnancy; history
of thromboembolic disease; and morbid obesity (BMI >35).
Patients with disposition to keloids or hypertrophic scars
have to be informed and must accept the postoperative scar­
ring associated with these conditions.
1. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA:
Saunders Elsevier; 2009. This major work on all current abdominoplasty
procedures is written by a leading authority on this subject, covering all
topics from patient selection, incision placement, ancillary procedures, up
to all possible complications by highlighting key considerations for a safe
and successful performance.
8. Pitanguy I. Abdominolipectomy. An approach to it through an
analysis of 300 consecutive cases. Plast Reconstr Surg. 1967;40:384.
13. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg.
1985;9:27–32. Dellon first published, in 1985, his approach to a vertical
and horizontal restoration of the abdominal wall through a combined
resection, the “fleur-de-lis” technique.
15. Lockwood T. High lateral-tension abdominoplasty with
superficial fascial system suspension. Plast Reconstr Surg.
1995;96:603–608. This article describes the principles and details of
this new approach to abdominoplasty. It offers an alternative technique,
especially in patients after massive weight loss with limited treatment of
the flanks.
16. Saldanha OR, Pinto EB, Matos WN Jr, et al. Lipoabdominoplasty
without undermining. Aesthet Surg J. 2001;21:518–526.
Access the complete reference list online at

602
SECTION II
CHAPTER 23 • Abdominoplasty procedures
21. Costa-Ferreira A, Rebelo M, Vásconez LO, et al. Scarpa fascia
preservation during abdominoplasty: a prospective study. Plast
Reconstr Surg. 2010;125:1232–1239.
22. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am
Surg. 1979;45:612–617.
27. Bozola AR. Abdominoplasty: same classification and a new
treatment concept 20 years later. Aesthetic Plast Surg.
2010;34:181–192.
28. Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour
deformities after bariatric weight loss: the Pittsburgh Rating Scale.
Plast Reconstr Surg. 2005;116:1535–1546. Rubin, as a currently “leading
post-bariatric surgeon” has published an interesting work on the different
deformities in patients after bariatric weight loss, which may serve as a
guideline for plastic surgeons during preoperative planning and for
evaluation of their postoperative outcomes.
35. Aly AS. Body Contouring after Massive Weight Loss. St Louis, MO:
Quality Medical Publishing; 2006. This work is published by a
currently “leading post-bariatric surgeon”, Aly has composed a unique
work on all reliable techniques for body contouring of patients after
massive weight loss.

602.e1
References
References
1. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA:
Saunders Elsevier; 2009. This major work on all current abdominoplasty
procedures is written by a leading authority on this subject, covering all
topics from patient selection, incision placement, ancillary procedures, up
to all possible complications by highlighting key considerations for a safe
and successful performance.
2. Kelly HA. Report of gynecological cases (excessive growth of fat).
Johns Hopkins Med J. 1899;10:197.
3. Kelly HA. Excision of fat of the abdominal wall lipectomy. Surg
Gynecol Obstet. 1910;10:229–231.
4. Babcock WW. The correction of the obese and relaxed abdominal
wall with special reference to the use of buried silver chain. Am J
Obstet Gynecol. 1916;74:596–599.
5. Thorek M. Plastic Surgery of the Breast and Abdominal Wall.
Springfield, IL: Thomas; 1924.
6. Thorek M. Plastic reconstruction of the female breast and abdomen.
Am J Surg. 1939;43:268–278.
7. Vernon G. Umbilical transplantation upward and abdominal
contouring in lipectomy. Am J Surg. 1957;94:490–492.
8. Pitanguy I. Abdominolipectomy. An approach to it through an
analysis of 300 consecutive cases. Plast Reconstr Surg. 1967;40:384.
9. Regnault P. Abdominal Lipectomy, a Low “W” Incision. New York, NY:
New York International Society of Aesthetic Plastic Surgery; 1972.
10. Grazer FM. Abdominoplasty. Plast Reconstr Surg. 1973;51:617–623.
11. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey,
with emphasis on complications. Plast Reconstr Surg. 1977;59:
513–517.
12. Psillakis JM. Abdominoplasty: some ideas to improve results.
Aesthetic Plast Surg. 1978;2:205–215.
13. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg.
1985;9:27–32. Dellon first published, in 1985, his approach to a vertical
and horizontal restoration of the abdominal wall through a combined
resection, the “fleur-de-lis” technique.
14. Matarasso A. Abdominolipoplasty: a system of classification and
treatment for combined abdominoplasty and suction-assisted
lipectomy. Aesthetic Plast Surg. 1991;15:111–121.
15. Lockwood T. High lateral-tension abdominoplasty with superficial
fascial system suspension. Plast Reconstr Surg. 1995;96:603–608. This
article describes the principles and details of this new approach to
abdominoplasty. It offers an alternative technique, especially in patients
after massive weight loss with limited treatment of the flanks.
16. Saldanha OR, Pinto EB, Matos WN Jr, et al. Lipoabdominoplasty
without undermining. Aesthet Surg J. 2001;21:518–526.
17. American Society for Aesthetic Plastic Surgery (ASAPS). Cosmetic
Surgery National Data Bank Statistics. Available at: >; 2016.
18. Arem AJ, Kischer CW. Analysis of striae. Plast Reconstr Surg.
1980;65:22–29.
19. Mitz V, Elbaz JS, Vilde F. [Study of dermal elastic fibers during
plastic surgery of the trunk]. Ann Chir Plast. 1975;20:31–43.
20. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141.
21. Costa-Ferreira A, Rebelo M, Vásconez LO, et al. Scarpa fascia
preservation during abdominoplasty: a prospective study. Plast
Reconstr Surg. 2010;125:1232–1239.
22. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am
Surg. 1979;45:612–617.
23. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric
system. Plast Reconstr Surg. 1988;82:815–832.
24. Querleux B, Cornillon C, Jolivet O, et al. Anatomy and physiology
of subcutaneous adipose tissue by in vivo magnetic resonance
imaging and spectroscopy: relationships with sex and presence of
cellulite. Skin Res Technol. 2002;8:118–124.
25. Grosfeld JL. Pediatric surgery. In: Sabiston DC, ed. Textbook of
Surgery: The Biologic Basis of Modern Surgical Practice. 14th ed.
Philadelphia, PA: WB Saunders; 1991:1167.
26. Bozola AR, Psillakis JM. Abdominoplasty: a new concept and
classification for treatment. Plast Reconstr Surg. 1988;82:983–993.
27. Bozola AR. Abdominoplasty: same classification and a new
treatment concept 20 years later. Aesthetic Plast Surg.
2010;34:181–192.
28. Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour
deformities after bariatric weight loss: the Pittsburgh Rating Scale.
Plast Reconstr Surg. 2005;116:1535–1546. Rubin, as a currently “leading
post-bariatric surgeon” has published an interesting work on the different
deformities in patients after bariatric weight loss, which may serve as a
guideline for plastic surgeons during preoperative planning and for
evaluation of their postoperative outcomes.
29. Orpheu SC, Coltro PS, Scopel GP, et al. Collagen and elastic content
of abdominal skin after surgical weight loss. Obes Surg. 2010;20:
480–486.
30. Light D, Arvanitis GM, Abramson D, et al. Effect of weight loss
after bariatric surgery on skin and the extracellular matrix. Plast
Reconstr Surg. 2010;125:343–351.
31. Sajid MS, Shakir AJ, Khatri K, et al. The role of perioperative
warming in surgery: a systematic review. Sao Paulo Med J.
2009;127:231–237.
32. Richter DF, Stoff A, Blondeel PN, et al. A comparison of a new skin
closure device (PRINEO™) and intradermal sutures in the closure of full
thickness surgical incisions. Submitted.
33. Richter DF, Stoff A, Velasco-Laguardia FJ, et al. Circumferential
lower truncal dermatolipectomy. Clin Plast Surg. 2008;35:53–71,
discussion 93.
34. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg. 1991;87(6):
1009–1018.
35. Aly AS. Body Contouring after Massive Weight Loss. St Louis, MO:
Quality Medical Publishing; 2006. This work is published by a
currently “leading post-bariatric surgeon”, Aly has composed a unique
work on all reliable techniques for body contouring of patients after
massive weight loss.
36. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in
smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr
Surg. 2003;111:2082–2089.
37. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale
for tobacco abstention with plastic surgery. Plast Reconstr Surg.
2001;108:1063–1077.
38. Blickstein D, Blickstein I. Oral contraception and thrombophilia.
Curr Opin Obstet Gynecol. 2007;19:370–376.
39. Richter DF, Stoff A. The Scarpa lift – a novel technique for minimal
invasive medial thigh lifts. Obes Surg. 2011;21:1975–1980.
40. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg. 1991;87:1009–1018.
41. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential
truncal excess: the University of Iowa experience. Plast Reconstr
Surg. 2003;111:398–413.
42. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal
and genitofemoral nerve: implications for the treatment of groin
pain. Plast Reconstr Surg. 2001;108:1618–1623.
Further reading
Various authors. Clinics in Plastic Surgery. London: Saunders Elsevier;
July 2010. All issues in abdominoplasty are covered in this July 2010
volume, including the latest updates on different abdominoplasty
procedures.

SECTION II • General Aesthetic Surgery
24 
Lipoabdominoplasty
Osvaldo Saldanha, Paulo Rodamilans Sanjuan, Sabina Aparecida Alvarez de Paiva,
Osvaldo Ribeiro Saldanha Filho, Cristianna Bonnetto Saldanha, and Andrés Cánchica
SYNOPSIS
The results of lipoadominoplasty include:
■ Better body contour, because liposuction decreases abdominal
measurement.
■ Less morbidity due to preservation of the perforating vessels and the
absence of dead space.
■ Low percentage of complications.
■ It is easy to perform, because all surgeons working in this field are
used to performing both liposuction and abdominoplasty.
■ Rejuvenated abdomen with a more natural profile.
■ Preservation of suprapubic sensitivity.
■ Quick postoperative recovery and shorter scar.
■ It can be associated with vibroliposuction or ultrasound liposuction.
■ Safe in smokers and post-bariatric patients.
Introduction
Most people are concerned about their physical appearance.
When body contour shows aesthetic and functional deformity
because of a genetic condition or as an acquired characteristic
resulting from obesity, weight loss, pregnancy, or any other
cause, the abdomen is one of the most frequently affected
regions. Functional and aesthetic deformities of the abdominal
wall due to skin flaccidity, lipodistrophy, and diastasis of the
fascia and muscles cause many negative psychological, physi­
ological, and aesthetic effects.
History shows that from 1899 to 1957, progressive under­
mining of the abdominal wall was performed, and in 1957 the
extensive undermining was standardized by Vernon to make
possible the umbilicus transposition. Modern abdominoplasty
techniques were developed since 1980, when Illouz developed
liposuction; primarily in the last decade, the evolution of
lipoabdominoplasty techniques has motivated surgeons to
search for innovations to decrease surgical morbidity and to
obtain a faster recovery, a better body shape, low rates of
complications, and a decrease in necrosis.1,2,3
Abdominoplasty and liposuction attempt to correct those
problems. For many years abdominoplasty was considered to
be a relatively easy procedure to perform, but its results were
not always satisfactory from a cosmetic point of view. In the
evolution of aesthetic abdominal surgery many surgical treat­
ments have been proposed, as surgeons searched for innova­
tions.1,4–19 For the past few years, there has been considerable
progress in methods to undermine the abdominoplasty flap
and treat abdominal wall fat.
Lipoabdominoplasty was developed as a safe aesthetic and
functional option combining complete abdominal liposuction
and full abdominoplasty in the same surgical procedure,
promoting the benefits of both techniques. It was the result of
clinical–surgical observation, anatomic cadaver studies, and
scientific research of the abdominal perforating vessels. There
are two components: (1) superficial liposuction, which under­
mines the flap, making it free to slide to the pubis; and (2)
preservation of the abdominal perforating vessels.
This technique is more than simply using liposuction while
performing abdominoplasty. It is a wider concept that respects
abdominal anatomy and substitutes cannula undermining
instead of traditional undermining. As a consequence, blood
supply from abdominal perforating vessels is preserved. In
addition, this procedure creates a narrow central tunnel that
makes possible safe and direct plication of the rectus abdomi­
nis muscles.
Basic science/disease process
Anatomic principles of the lipoabdominoplasty
The main principle of this technique is the anatomic study.
Lipoabdominoplasty is based on an understanding of the
vascular anatomy of the abdominal wall, particularly the
perforating vessels, which come from the deep epigastric
arteries. Many studies have evaluated the vascular anatomy
of this region based on cadaver dissections, clinical observa­
tions, and non-invasive radiological examinations.20–22
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Taylor et al. (1991) studied skin vascularity, describing the
angiosomes, which separate the abdominal area into superior,
inferior, and lateral regions.22 In the superior region, the
superior epigastric vessels are responsible for blood supply.
In the lateral region, the superficial and deep circumflex
vessels and branches of the intercostal vessels provide blood
supply. In the inferior region, the main vascularity comes
from the inferior deep epigastric vessels (Fig. 24.1).
According to Huger,22 in classical abdominoplasty, normal
vascular flow is interrupted by section of the perforating
vessels coming from the rectus abdominis muscle. Conse­
quently, the vascularity of the remaining flap is supplied by
the intercostals, subcostal, and lumbar perforating branches,
situated superiorly and laterally. Therefore, when combined
with liposuction, extensive traditional undermining may
damage the vascularity of the flap, increasing the risk of tissue
necrosis. This anatomy is described in Chapter 23.
An important paper published by Graf,23 using Doppler
flowmetry, looked at perfusion in the periumbilical perforating
Fig. 24.1  (A) Surgical undermining in conventional abdominoplasty interrupts the vascular perforators from the rectus muscles. (B) Lipoabdominoplasty preserves vascular
perforators from the rectus muscles but allows for a relatively avascular midline tunnel to perform rectus plication. The broken lines indicate the incisions; note that they are
shorter in lipoabdominoplasty.
A
Abdominoplasty
100%
B
Lipoabdominoplasty
‘Saldanha’s technique’
30%
vessels on the 15th day after lipoabdominoplasty, showing
that liposuction did not damage vessels whose diameters
were 1 mm or more. Furthermore, there was a 9% increase
in the caliber of the arteries and a 56% increase in the flow of
these perforators. The explanation for this increase in flow is
uncertain, but may be due to the physiopathology of surgical
trauma generating vasodilatation.
Munhoz et al.24 identified and quantified the perforating
vessels, which allowed for a comparative evaluation of the
blood supply of the flap in the pre- and postoperative periods
of patients who had undergone lipoabdominoplasty. In
this study, more than 81.21% of perforating vessels were
preserved.
Another relevant paper was published by De Frene et al.,25
in which the authors performed breast reconstruction using
flaps based on vessels that perforate the rectus abdominis
muscles, in patients who had previous abdominal liposuction.
The successful outcomes demonstrated that liposuction had
not harmed the larger perforating vessels.

605
Treatment/surgical technique
Fundamental principles of
the technique
The two fundamentals of this technique are preservation of
abdominal wall perforating vessels and the use of superficial
liposuction. In this anatomic location, superficial liposuction,
originally introduced by De Souza Pinto, involves aspiration
of fat superficial to Scarpa’s fascia.9,26 The key finding that
makes lipoabdominoplasty possible is that superficial cannula
liposuction significantly mobilizes the abdominal wall flap.
The flap can then be advanced inferiorly to the pubis without
the need for classical undermining in the area of the vascular
perforating vessels. A narrow central tunnel between the
vascular perforators can then be safely opened in order to
accomplish rectus plication.
This technique makes it possible to preserve at least 80%
of blood supply to the abdominal wall, to preserve sensory
nerves and lymphatic vessels, and to have fewer complica­
tions than with traditional abdominoplasty.
Diagnosis/patient presentation
Preoperative ultrasound
Although a careful clinical abdominal examination may detect
small abdominal masses suspected to be hernias, not all
hernias are totally palpable. The systematic use of ultrasound
in the preoperative phase of lipoabdominoplasty improves
safety by identifying the presence of a hidden ventral hernia
before carrying out liposuction of the abdominal wall.
Although the incidence of incisional hernia is low (about
4.3%), taking into consideration that the mortality index is
50% when intestinal perforation occurs due to liposuction, the
use of preoperative ultrasound is justifiable.
Patient selection
All patients with the traditional indications for abdomino­
plasty are candidates for lipoabdominoplasty. Typical findings
are lipodystrophy of the abdomen, flaccidity of the abdominal
wall skin, and the possibility of rectus muscle diastasis.
Smokers require special care, but the conservative principles
inherent in this technique make lipoabdominoplasty possible
in these patients.
Treatment/surgical technique
(Video 24.1 )
Marking
The abdomen is marked in the traditional manner, as described
by Pitanguy,8 with a 12–14 cm horizontal component and
7–8 cm oblique components on each side, inclined approxi­
mately 30–35° in the direction of the iliac crests. The distance
from vaginal furcula to the horizontal marking is 6–7 cm
(Fig. 24.2).
For better orientation at the beginning of tunnel undermin­
ing, the rectus diastasis is marked (Fig. 24.3). If indicated,
dorsal areas to be aspirated are marked.
Fig. 24.2  Horizontal marking (12–14 cm), oblique marking (7–8 cm), and initial
distance from the pubis (6–7 cm).
Infiltration
The wet or superwet technique is used, infiltrating the
abdominal wall fat with a solution of saline and epinephrine
(1 : 500, 000), using an average infusate of 1.0–1.5 L.
Epigastric and subcostal liposuction
In order to perform liposuction safely, the patient is placed in
a hyperextended position on the surgical table. Liposuction is
started in the supraumbilical region with a 3- and 4-mm
cannula, removing the fat of the deep and superficial layers,
going out to the flank (Fig. 24.4). As in classic liposuction,
enough fat thickness is maintained to avoid vascular impair­
ment and contour deformities.
Lower abdomen
Before removing the skin excess, the Scarpa’s fascia is visual­
ized and preserved until the umbilicus, when the undermin­
ing changes plane going to the muscle aponeurosis (Fig. 24.5).
The flap mobility is assessed before the umbilicus is isolated,
and resection of the infraumbilical skin is done as in a tradi­
tional abdominoplasty (Fig. 24.6).
Selective undermining
A tunnel is then undermined in the midline of the upper
abdomen between the internal borders of the rectus abdomi­
nal muscles, avoiding the midportion of these muscles, which
is an area of the perforating vessels (Figs. 24.7 & 24.8).
Tunnel undermining may reach the xiphoid process,
depending on the degree of plication necessary. For a better
view of the anatomic structures, and to facilitate the plication,
a special retractor has been created that exposes the surgical
area and avoids trauma on the edge of the flap (Fig. 24.9). The
larger the diastasis, the larger the undermining of the tunnel,
because the vessels will be further apart, emanating from the
substance of the rectus abdominis muscles.
Preservation of Scarpa’s fascia
In the lower abdomen, there is no aspiration. Scarpa’s fascia
should be preserved, leaving it intact after the removal of the
lower abdominal skin.

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CHAPTER 24 • Lipoabdominoplasty
Fig. 24.5  The Scarpa’s fascia is preserved.
Fig. 24.6  The flap descent evaluation.
Fig. 24.7  Perforating vessels and Scarpa’s fascia preservation.
Fig. 24.3  Previous demarcation of diastasis.
A
B
C
Fig. 24.4  Superior abdominal liposuction.