Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

Indications
237
● The inferior pedicle mandates that the tissue resection is superior
and the tissue left behind is inferior. Does gravity have more of an
effect on inferior tissue left behind than superior tissue left
behind?
● Does leaving the breast tissue attached to the upper skin fl aps help
prevent bottoming-out (as in the superior type pedicles) or does
separating the breast tissue away from the upper skin fl aps (as with
an inferior pedicle) have any effect on bottoming-out?
● Can breast tissue be secured up to the chest wall so that it does
not drop out?
● Can the upper pole of the breast be improved by suturing breast
tissue up to the pectoralis fascia?
● Can the level of the inframammary fold (IMF) be changed? Does
it drop over time with certain procedures and does it rise with
others?
● Is there one pedicle with a more reliable blood supply?
● Is there one pedicle with better fi nal results as far as nipple and
areola sensation are concerned? What about breast skin sensation?
● Is there one pedicle or approach that is more likely to preserve the
ability to breastfeed?
● How important is the length of the pedicle in preserving circulation
to the nipple and areola? Did the vessels stretch during develop-
ment as much as the skin and parenchyma?
INDICATIONS
●
Symptoms associated with large breasts37–39 e.g.:
●
back pain
●
neck pain
●
shoulder grooving
●
breast pain
●
rashes
●
headaches
●
reduced ability to exercise
●
impaired psychological wellbeing
●
numbness and tingling in fi ngers and hands
Vertical approach
●
Small and medium-sized breast reductions with good skin
elasticity
Inverted T, inferior pedicle technique
●
Standard technique
●
All breast sizes
●
Especially good for:
●
large breast reductions
●
signifi cant excess of skin (especially when poor quality)
Periareolar technique
●
Small breast reductions
Liposuction-only breast reduction
●
Breasts that contain more fatty tissue than glandular tissue
(e.g. as occurs around menopause) with fairly high nipples and
good upper pole fullness
The volume of resection is not as important as suspected in improving
symptoms associated with large breasts. Postoperative improvement
may be as much dependent on other comorbidities such as osteo-
arthritis of the cervical spine. The breast reduction will not correct
any underlying disease, but can remove the weight that can aggravate
the resultant symptoms. The actual elevation of the breast tissue may
be as important as the amount of weight resected.
Choice of breast reduction operation
The most common skin resection patterns are the inverted T and the
vertical techniques.
Inverted T resection
The inverted T resection is used for larger reductions and for patients
with a large excess of skin, especially when there is poor skin elastic-
ity (e.g. in patients who have had a massive weight loss).40
The choice of pedicle can vary. There is no consensus on which
pedicle may have a more robust blood supply or which pedicle will
likely preserve better sensation. The most common pedicle choice is
the inferior pedicle because it is easy to create and has a reliable blood
supply. All other pedicles (central, superior, lateral and medial) can be
used with the inverted T skin resection patterns.
Many surgeons try to confi ne the inframammary scar to the breast
width itself, but in the larger reductions it is diffi cult not to extend the
lateral and medial incisions further to avoid dog-ear formation.
Vertical approach
The second most common skin resection pattern is the vertical
approach. The most common pedicles are the superior and the medi-
ally based pedicles. Both the lateral and the inferior (short scar peri-
areolar inferior pedicle reduction [SPAIR]30) pedicles are also used.
Some surgeons take up more skin into the areola and call the procedure
the ‘circumvertical’ approach.41,42 This is done to shorten the vertical
scar, but does require more fi nesse in closing the areola without
puckering and stretching.
Other techniques
Periareolar technique
For very small breast reductions, the periareolar technique can be used.
This is a commonly misunderstood technique because it does not just
involve suturing the skin under tension to the areola, but also involves
separation of the skin from the breast tissue. The breast tissue is
reduced and reformed35 with sutures or it is wrapped in various forms
of mesh.36
For very large breast reductions, variations of the Passot25 tech-
nique can be used. In these cases, the pedicle is a complete inferior
pedicle from medial to lateral. The upper skin fl ap is brought down
over the inferior tissue and a cutout is then created for the areola. The
upper skin fl ap is much longer than the incision along the IMF and a
considerable amount of gathering is needed. This procedure is some-
times called the ‘no vertical scar technique’ because the scar is confi ned
to the IMF and the periareolar areas. Pribaz43 has modifi ed the Rob-
ertson technique as a variation for the extremely large reductions.
Rubin40 has developed a variation that can restore some shape for
patients who have had massive weight loss.
Liposuction-only breast reduction
Liposuction-only breast reduction44,45 is useful in women with fatty
breasts, fairly high nipples and good upper pole fullness. Breasts
tend to contain more fatty tissue than glandular tissue around meno-
pause and these patients may be good candidates for liposuction only.
Volume can be reduced, but a good shape can be best achieved in
patients with high nipples and good upper pole fullness. Unfortunately
many older women have developed ptosis and loss of upper pole
volume. Large breasts in teenagers tend to be very glandular if they
are normal body weight, and liposuction-only is not likely to be
effective.

17
BREAST REDUCTION
238
Medial pedicle vertical breast reduction vs inferior
pedicle, inverted T reduction
Dog-ears
I prefer the medial pedicle vertical approach for most breast reductions.
The resection pattern is a vertical ellipse or wedge resection (Fig. 17.3),
which results in two dog-ears – one superiorly and one inferiorly:
● the superior one disappears into the areola;
● the inferior one (usually) disappears with time.
In contrast, the inferior pedicle, inverted T reduction involves a hori-
zontal elliptical excision of breast tissue and skin – also with two
dog-ears – one medially and one laterally. The advantage of a vertical
reduction is that the dog-ear can be easily corrected if it persists (about
5% of cases). The dog-ears with an inverted T approach are often more
diffi cult to correct.
Other differences
The vertical elliptical excision cones the breast, narrows the base, and
gives it more projection, whereas the inverted T inferior pedicle
compresses the breast by keeping the vertical limb short to prevent
bottoming-out.
The medial pedicle vertical breast reduction is my preferred
technique. I used an inferior pedicle, inverted T breast reduction
for the fi rst 10 years of my practice, but then in 1993 started using
the vertical approach, initially with a superior pedicle. Because of
problems insetting the superior pedicle, I switched to a lateral
pedicle with the assumption that it would provide good sensation,
but fi nally settled on a medial pedicle because it not only provides
good sensation but also allows complete access to the excess
breast tissue laterally.
The other difference is that in the medial pedicle vertical tech-
nique, the breast tissue is left attached to the skin and the heavy
inferior breast tissue is removed. I believe that because an inverted T
inferior pedicle removes the breast tissue superiorly and leaves behind
the heavy inferior breast tissue the resultant breast is more likely to
bottom out with time.
PREOPERATIVE CONSIDERATIONS
Patients who recover best from surgery appear to be those who are
closest to their ideal body weight. Obese patients take longer to recover
from the anesthetic, and are more likely to have wound healing com-
plications. The size of the breasts and amount of resection also play
important roles in the immediate healing phase.
The surgeon needs to look for previous biopsy scars and avoid any
pedicle where the scar crosses the base of the pedicle. Even a
superfi cial biopsy will likely have damaged the blood supply.
Smokers are more likely to have problems with blood supply and
healing. Although many patients are unable to quit smoking, it is best
to advise them to stop smoking before and after their surgery.
A history of medication use, needs to include alternative and herbal
therapies. Many medications and herbal preparations can increase
bleeding (e.g. acetylsalicylic acid, ibuprofen, gingko).
It is unclear whether diabetes mellitus plays a role in reducing
blood supply. The surgeon needs to take all the factors into consider-
ation when weighing the risks and potential benefi ts of breast reduc-
tion surgery.
MEDIAL PEDICLE VERTICAL
BREAST REDUCTION
OPERATIVE APPROACH
Preoperative markings
The markings are all made preoperatively with the patient in the stand-
ing position. It is important to make sure that the markings are sym-
metrical for what is left behind (not for what is removed). The sequence
below should be followed.
1. Inframammary fold level
The fi rst marking is the level of IMF. Some patients have high folds
and some have very low folds.
2. Breast meridian
The next marking should be the breast meridian (i.e. where it is
expected to be after the reduction). The current nipple position is
ignored and the breast meridian is marked in its desired position.
Because a medial pedicle vertical breast reduction allows extensive
lateral resection, it can be placed more medially than for an inverted
T, inferior pedicle breast reduction.
3. New nipple position
The ideal nipple position in a breast reduction is at the most project-
ing part of the breast. This should be about 2 cm lower than for an
inferior pedicle, inverted T reduction. If a patient has a great deal
of upper pole fullness, the new nipple position can be moved up
slightly. But if a patient has a concave upper pole then it is impor-
tant to ensure that the new nipple position is no higher than the
IMF.
Nipple position is determined preoperatively. Trying to decide
where to place the nipple during surgery is more likely to cause
misplacement, with the nipples being placed too high.
There is no point waiting to determine the new nipple position
intraoperatively because it can be more accurately determined with
the patient standing. The level of the IMF can change slightly, but the
amount of upper pole fullness will not.
Fig. 17.3 Comparison of inverted T and vertical markings.

Operative Approach
239
4. Areolar opening
The areolar opening should end up as a circle when closed. A 16 cm
circumference matches a 5 cm diameter and 14 cm matches a
diameter of 4.5 cm.
5. Skin resection pattern
The skin closure does not need to be tight. The shape of the breast is
determined by the nature of the resection and the closure of the breast
pillars, therefore the skin does not need to act as a tight brassiere.
The skin resection pattern can be designed so that the skin is loose
(but not redundant) at the end of the procedure. The areolar opening
and the skin resection pattern together take on the shape of a snowman.
The vertical limbs of the inverted T pattern will approximate the ver-
tical limbs of the vertical pattern. But instead of taking the vertical
limbs horizontally and medially to meet the IMF, the limbs are circled
around to meet each other about 2–4 cm above the IMF. It is important
not to bring the pattern down to the fold or the scar will end up below
the fold (because of the nature of closing an ellipse and because the
IMF does rise to some degree). It is also important to make the skin
resection inferiorly more of a ‘U’ than a ‘V.’ The ‘V’ may seem to
leave less of a pucker but it will, in fact, leave redundant skin.
6. Pedicle design
The medial pedicle is best designed keeping one half of the base in the
areolar opening and one half of the base below the areolar opening
(Fig. 17.4A). This design allows the pedicle to rotate easily into posi-
tion and allows the inferior border of the medial pedicle to become
the medial pillar. Too much tissue left below the areolar opening may
contribute to the appearance of pseudoptosis. The base is usually 6–
8 cm in length.
It is important to try to keep a vein in the design – these can be
easily seen through the skin lying just beneath the dermis.
Although the pedicle may appear to be superomedial when the
patient is standing it will look medial when the patient is lying down.
Vertical breast reduction using a medial pedicle
A

C

B
Full thickness
Resected breast tissue
Medial pedicle
rotated superiorly
Medial and lateral pillars
sutured together
Resected
breast tissue
Fig. 17.4 Vertical breast reduction using a medial pedicle. A, Area to be resected. B, De-epithelialized medial pedicle. C, Resection
specimen.

17
BREAST REDUCTION
240
The blood supply comes from the medial branches of the internal
mammary system.
A long pedicle looks much shorter when the patient is lying down
and may have a more risky blood supply, but the vessels must stretch
with the breast tissue and nipple as ptosis develops. Theoretically, at
least, a long pedicle should still have good blood supply.
Operative technique
Infi ltration
● The patient is completely supine and under a full general anesthetic.
● The breast is infi ltrated with either a solution of lidocaine with
epinephrine or with a tumescent type of fl uid. The infi ltration can
be used in the whole breast, but is mainly used for the areas marked
for liposuction tailoring.
Pedicle creation
● The pedicle is de-epithelialized leaving a 1 cm ring of tissue
around the new areolar circumference (Schwartzmann maneuver46)
(Fig. 17.4B).
● The pedicle is then created (either by knife or by cutting cautery)
full thickness down to breast meridian. It is important to leave
tissue over the pectoralis muscle to preserve innervation.47 The
medial pedicle will be mobile and appear to be undermined – much
as occurs with the creation of a full thickness inferior pedicle.
Tissue resection
● Breast tissue is removed en bloc. The skin is not undermined, but
the tissue resection is beveled medially and laterally (Fig. 17.4C).
● The inferior border of the medial pedicle will become the medial
pillar.
● Leave 1–2 cm of lateral pillar attached to the skin resection margin
laterally for about 7 cm in length. The rest of the tissue inferiorly
can be resected more aggressively. It is diffi cult not to under-resect
with this technique and it is important to remove as much breast
tissue as was estimated preoperatively. The extra tissue can be
removed laterally parallel to the chest wall while still maintaining
a lateral pillar.
● Do not remove too much tissue superiorly – just enough for the
medial pedicle to inset easily (Fig. 17.4D). Leave some tissue as a
E
Fig. 17.4, cont’d D, The medial pedicle rotated superiorly. E&F, The fi rst pillar suture is closed. Usually only three to four sutures are used.
Only superfi cial bites of fi brous tissue are taken – not deep bites of fat. G, Final closure. A good breast shape is left on the table at the end
of the procedure.
G
F
D

Postoperative Care
241
platform for the medial pedicle because it can often be thin distally
(even though full thickness) and this will prevent areolar retraction
postoperatively.
● Ensure an adequate resection by visualizing the Wise pattern –
leave a Wise pattern behind of breast tissue (not skin). This tissue
is left attached to the superior, medial and lateral skin fl aps and
the rest of the parenchyma is resected. Although this leaves redun-
dant skin, most of the skin will redrape over the new breast shape.
● The extra tissue below the Wise pattern can be excised directly or
removed via liposuction. (This is often similar to the procedure
used in gynecomastia where the central breast tissue is resected
and then liposuction is used for peripheral contouring and refi ne-
ment. One benefi t to completing the peripheral shaping with lipo-
suction is that the skin is likely to retract better than with direct
excision alone). Liposuction is performed to shape the remaining
breast into a Wise pattern and to reduce the excess in the preaxil-
lary and lateral chest wall regions. This is usually performed after
pillar and dermal closure to get a more accurate idea of the
remaining shape.
● Although the resection is beveled laterally and medially it is impor-
tant to actually undermine the tissue down to the IMF. Often the
pucker that can result is more a problem of excess subcutaneous
tissue than excess skin. It is also important not to denude the
underlying dermis of all fat or else scar contracture is likely to
develop. A 1-cm thickness to maintain some fat is essential, but
this undermining should extend laterally and medially because the
IMF will often rise to some degree with this technique. This ‘under-
mining’ is often best achieved with a combination of direct excision
and liposuction.
Pillar closure
● As the medial pedicle rotates into position, the inferior border
becomes the medial pillar.
● Pillar closure is made easier by placing the fi rst suture in the base
of the areola. The dermis does not need to be undermined in this
maneuver. The lateral pillar should be about 7 cm in length and
the inferior edge of the pillars starts about half way up the skin
resection opening – not at the IMF.
● The pillars are closed (Fig. 17.4E&F) to achieve a Wise pattern of
breast tissue left behind on the table. All tissue below is ignored
during pillar closure and later tailored with liposuction and/or
direct excision.
● Pillar closure is achieved without undue tension. Only enough
sutures are needed to bring the breast edges together to allow
healing to occur over the ensuing weeks. The author starts the
pillar closure inferiorly and then completes the closure toward the
areola. Only three to four sutures are needed. Large bites of breast
tissue are not only unnecessary but can potentially cause fat necro-
sis. Sutures should be placed in the fi brous tissue to allow fi brous
tissue to heal to fi brous tissue rather than asking fat to heal to fat
(which is unlikely to hold long term).
Skin closure
● The dermis is closed with deep interrupted sutures. It is important
not to use too many sutures and to place only enough so that dermis
approximates dermis.
● Liposuction for tailoring is then performed at this stage and the
skin is fi nally closed with a loose subcuticular suture. The skin is
not gathered. Although gathering was initially advocated by Lejour,
I found that the vertical limb either lengthened with time or
remained contracted with skin pleats that required revision. It is a
little more uncomfortable for the surgeon to leave a pucker that
protrudes at the lower end of the incision, but wound healing
problems virtually disappeared once gathering was abandoned.
● If the areola is not a complete circle on the table, then extra skin
can be de-epithelialized so that the fi nal result is a circle. Because
the vertical limb is not gathered, there is no issue with the areola
being pulled down into a tear-drop shape. The areola is closed
with four interrupted deep dermal sutures and then a subcuticular
suture to complete the closure.
● I use 3-0 Monocryl for all sutures in the breast reduction – pillars,
dermis, areola and subcuticular. Sutures are not used to control
tension, but are used only to hold edges together until healing
occurs.
Any tension on the pillars or skin is to be avoided. It can be diffi cult
for the surgeon who is converting from an inverted T method to
realize that the skin can be closed loosely and that tension is
detrimental to healing. The inverted T methods tend to rely on skin
tension to hold the shape whereas the vertical methods use the
vertical wedge excision and breast closure to shape the skin.
● The skin is not sutured up to the breast tissue and the pucker is not
sutured down to chest wall. Resolution occurs faster if the skin and
tissue can settle without interference. Suturing the skin down
results in indentations, which require time to resolve.
● Drains are only rarely used. They do not prevent hematomas and
would need to be left in for weeks to prevent a seroma. If tumescent
infi ltration is used in the breast, seek out the known blood vessels
and make sure that they are secured because the tumescent fl uid
will cause constriction during surgery, which will be released over
time postoperatively. Seromas do develop but tend to disappear
without treatment.
Antibiotic cover
All patients are treated with perioperative antibiotics. Cephalosporins
are given intraoperatively and for about 5 days postoperatively. I have
noticed that antibiotic use is associated with not only fewer wound
infections, but also a dramatic reduction in suture splitting and wound
healing problems.
Procedure completion
● All the incisions are covered with paper tape (Fig. 17.4G). The
paper tape is not applied across the incision, but directly over the
incision in the same direction. Steristrips often cause blistering
because of tension across the wound. The paper tape covers any
gaps in the skin that result from loose closure and is left in place
for 3 weeks. The patient showers directly over the tape and pats it
dry. When the tape eventually separates a nicely healed incision
is left behind. Some surgeons reapply the paper tape to try to
reduce long-term hypertrophic scarring.
POSTOPERATIVE CARE
The patient is placed in a loose brassiere to hold dressings in place.
Although it would be ideal to be able to compress the lateral chest wall
where liposuction was performed it is not recommended so that the
breast itself is not compressed.
Patients are allowed to shower the day after surgery and are told
to use the brassiere for about 2 weeks day and night. After the initial
bandages are removed, patients often fi nd that pantiliners (with the
adhesive strip attached to the brassiere) function well if there is any
more oozing from the incisions).
Patients are restricted to light activities for the fi rst couple of weeks,
with return to full activities in 3–4 weeks. They are not told to restrict
arm movement.
Pre and postoperative views for one patient are shown in Fig.
17.5A–L.

17
BREAST REDUCTION
242
A
B
C
D
E
F
G
H
I
J
K
L
Fig. 17.5 Before and after medial pedicle vertical breast reduction. This 22-year-old patient was 5′5″ tall, wore a 36G brassiere and weighed
160 pounds. She had 635 g removed from the right breast and 620 g from the left breast. Another 125 mL of fat was removed by liposuction
from the lateral chest wall and inferior breast. A, Preoperative frontal view. B, Preoperative lateral view. C, Preoperative frontal markings. D,
Intraoperative view. E&F, Frontal and later views 13 months’ postoperatively. She had full recovery of sensation on the right side and only
slightly decreased sensation on the left nipple. The distance from the inferior border of her areola to the IMF was 10 cm on the right side
and 9 cm on the left side. G&H She had small puckers 13 months’ postoperatively, which were revised under local anesthesia through a
small vertical incision where a minimal amount of skin was removed, but the excess subcutaneous tissue was removed horizontally through
the vertical incision. I&J, Correction of right pucker at 13 months through vertical skin excision and horizontal subcutaneous excision. K&L
Correction of right pucker at 13 months through vertical skin excision and horizontal subcutaneous excision.

Operative Approach
243
I have found that recovery time from a medial pedicle verticle
breast reduction is about 2–4 weeks, which is about half that required
for inverted T inferior pedicle reductions. Operating time is only about
2 hours and intraoperative blood loss is minimal.
INVERTED T, INFERIOR PEDICLE
BREAST REDUCTION
OPERATIVE APPROACH
Preoperative markings
The markings (Fig. 17.6A–E) are all made preoperatively with the
patient in the standing position. Some surgeons prefer to decide where
to place the nipple during surgery, but I believe that a more accurate
determination can be achieved preoperatively to avoid placing the
nipple too high or on the concave upper surface of the breast. It is
important to make sure that the markings are symmetrical for what is
left behind, not for what is removed and to make them in the following
sequence.
1. IMF level
The fi rst marking is the level of the IMF. Some patients have high folds
and some patients have very low folds.
2. Breast meridian
The next marking should be the breast meridian (i.e. where it is
expected to be after the reduction). The current nipple position is
ignored and the breast meridian is marked in its expected position
postoperatively. Because an inverted T, inferior pedicle breast reduc-
tion tends to leave a wider breast than a vertical procedure it is
important not to place the nipples too medially.
3. New nipple position
The ideal nipple position in a breast reduction is at the most project-
ing part of the breast. If a patient has a concave upper pole then keep
the new nipple position no higher than the IMF. It is also important
to realize that the IMF may drop out to some degree with the inverted
T, inferior pedicle procedure, so making the nipple appear too high.
I believe that the new nipple position can be more accurately
determined with the patient standing preoperatively rather than
intraoperatively.
4. Areolar opening
The areolar opening should end up as a circle when closed. A 16 cm
circumference matches a 5 cm diameter. The Wise pattern has a 14 cm
circumference, which matches a diameter of 4.5 cm. The areolar
opening may be designed intraoperatively to ensure that the fi nal
opening is a complete circle. The upper border of the areola should
be placed about 2 cm above the position determined for the new nipple
itself.
5. Skin resection pattern
The skin closure needs to be fairly accurate because the skin is used
as a brassiere to hold the fi nal breast shape. The Wise pattern is fol-
lowed with the vertical limbs extending laterally and medially to
achieve a good closure. Some surgeons design the divergence of the
vertical limbs at a specifi c angle, but many measure the upper skin
fl ap margins and attempt to match the resultant distance to the lower
skin fl ap margins. The vertical limbs are designed at 5–6 cm to take
into account the fact that the vertical limbs will lengthen postopera-
tively. The medial and lateral extensions are usually curved up
medially and laterally to help shape the breast and avoid dog-ear
formation.
6. Pedicle design
The inferior pedicle is designed to be about 8–10 cm wide at the base.
It is important to keep some of the pedicle medially to ensure that the
A
B
C
D
E
Fig. 17.6 Inverted T breast reduction procedure. A, Preoperative markings for inverted T, inferior pedicle breast reduction. B, Preoperative
markings shown with left breast lifted. It is important to try to match the fi nal horizontal distance of the upper fl aps to the distance along
the inframammary fold. C, Lateral appearance preoperatively. D, Frontal appearance 3 weeks’ postoperatively. E, Lateral appearance 3
weeks’ postoperatively.

17
BREAST REDUCTION
244
perforator from the internal mammary system is preserved. The artery
and its venae comitantes enter the pedicle just medial to the breast
meridian about 4–6 cm above the IMF. There are often several
branches, which supply the pedicle more laterally as well.
Several surgeons believe that it may be important to try to cant the
pedicle base laterally to some degree to include the deep branch of
the lateral fourth intercostal nerve to preserve nipple sensation. It is
probably more important, however, to leave tissue over the pectoralis
muscle to preserve this nerve around the level of the fourth interspace.
Operative technique
Infi ltration
● The patient is completely supine and under a full general
anesthetic.
● The breast is infi ltrated with either a solution of lidocaine with
epinephrine or with a tumescent type of fl uid. The infi ltration can
be used in the whole breast, but is mainly used for the areas marked
for liposuction tailoring.
Pedicle creation
● The new areolar diameter is determined and the pedicle de-
epithelialized. A cuff of de-epithelialized skin is left around the
areola following the Schwartzmann maneuver.46 The pedicle is
completely de-epithelialized and then carried down directly to the
chest wall with either a scalpel or a cutting cautery. Care must be
taken to make sure that the pedicle is full thickness. It will tend to
be quite mobile and will appear to have been thinned.
The inferior pedicle must be full thickness to preserve its blood
supply.
● Some surgeons will suture the pedicle to the chest wall after the
tissue is resected to try to hold it up and prevent later bottoming
out. This maneuver is controversial because no one is certain how
effective the suturing is long term.
Tissue resection
● The breast tissue is removed along with the skin along the previ-
ously marked lines in the keyhole pattern. The tissue can be
removed either with a scalpel or with cutting cautery. If a signifi -
cant amount of tumescent type infi ltration was used, the surgeon
will fi nd it easier to use a scalpel. There is a considerable amount
of bleeding laterally during direct excision.
● Liposuction can be used to tailor out the resection peripherally,
much as would be performed with a gynecomastia procedure.
Many patients have excess fat in the preaxillary areas and the
lateral chest wall. Avoid removing too much tissue under the supe-
rior fl ap to avoid losing upper pole fullness.
Flap closure
● The lateral and medial skin fl aps are brought together over the
inferior pedicle and closed. Occasionally sutures are placed in the
breast tissue itself, but most surgeons just close the deep dermis.
It is diffi cult to close the fl aps with enough tension to support the
breast, but without causing so much tension that wound healing
problems result.
Skin closure
● The skin is closed fi rst laterally and medially to prevent dog-ears
and to move as much of the lateral and medial fl aps toward the
center of the breast to try to give as much projection as possible.
● The deep dermis is closed and then the skin is closed with a sub-
cuticular suture.
POSTOPERATIVE CARE
Drains are usually brought out through a separate stab wound laterally,
secured into place as needed and usually removed the following day.
Patients are placed in a compression type brassiere or an elasticized
wrap. Care must be taken not to compress the areola area too much.
Patients are restricted from moving their arms above their head to
any signifi cant degree and asked to limit their activities for the fi rst
few weeks. Full return to activities usually takes 4–6 weeks.
Pre and postoperative views for one patient are shown in Figs
17.7A–D.
A
B
C
D
Fig. 17.7 Before and after inferior pedicle
inverted T breast reduction. This 25-year-old
woman was 5′6″ tall, wore a 42DD brassiere,
and weighed 185 pounds. A, Preoperative
frontal view. Her markings show
measurements of 7 cm medially and 11 cm
laterally designed to match the length of the
inferior incision along the inframammary fold.
B, Preoperative lateral view. C, Postoperative
frontal view at 4-month follow-up after
having had 1025 g removed from the right
breast and 1300 g removed from the left
breast. D, Postoperative lateral view at 4-
month follow-up.

245
Complications and Side Effects
Optimizing outcomes
●
Expertise at more than one operation:
●
a medial pedicle vertical breast reduction may not be
possible if a breast biopsy has been performed across the
base of the pedicle
●
there may be too much redundant skin at the end of a
vertical procedure necessitating the conversion from a
vertical skin resection pattern to an inverted T skin
resection pattern
●
a patient who has had massive weight loss may have little
breast tissue above the IMF and many of the standard
approaches will result in failure to achieve a good size and
shape
●
Understand the anatomy, especially when deciding which
pedicle to use:
●
a good knowledge of the arterial input is essential to safe
pedicle creation
●
visualizing and maintaining venous circulation is equally
important
●
preserving nipple and areolar sensation is not always
predictable, but a good understanding of innervation will
help
COMPLICATIONS AND SIDE EFFECTS
Scarring, loss of sensation and potential inability to breastfeed are
expected side effects:
● scarring depends on the length of the scars and the patient’s genetic
make-up;
● recovery of nipple sensation can be unpredictable, but results have
shown that approximately 85% of patients recover normal to near-
normal sensation;
● chances of breastfeeding are probably somewhat better than
50/50.48
Serious complications are rare and less serious complications tend to
be more common. As with any procedure, severe untoward events can
occur. Deep venous thrombosis and pulmonary emboli cannot always
be prevented, but intermittent compression devices, postoperative
mobilization and prophylaxis as indicated all help prevent their
occurrence.
Wound healing and infection
Wound healing problems (Figs 17.8A&B, 17.9A–F and 17.10A–D) are
more likely in obese patients. Smoking also appears to have an adverse
effect on wound healing. Perioperative antibiotics not only reduce the
infection rate (which is more common in the larger patients), but also
reduce wound healing problems. The breast ducts are contaminated
A
B
Fig. 17.8 Dehiscence of the areola. A, Dehiscence of the areola at 3
weeks. It healed in a few months by secondary intention. B, View at
18 months.
A
B
C
D
E
F
Fig. 17.9 Infection with tissue necrosis. This woman underwent an inverted T inferior pedicle breast reduction at age 55 years. She was 5′6″
tall and weighed 172 pounds. She had 770 g removed from each side. A, Preoperative frontal view. B, Preoperative lateral view. C&D, She
developed an infection with tissue necrosis, which was treated by debridement and healing by secondary intention. E&F, Postoperative
views at 15-year follow-up with no further surgery.

17
BREAST REDUCTION
246
A
B
C
D
Fig. 17.10 Infection. This 56-year-old woman
had a vertical breast reduction using a
medial pedicle. She was 5′4″ tall, wore a
40DD brassiere and weighed 155 pounds.
A, Preoperative frontal view. B, Intraoperative
view. She had 715 g removed from the right
breast and 550 g from the left breast and was
placed on perioperative cephalosporins, but
developed an infection in the right breast at
3 weeks. C, Postoperative view at 1 month.
The infection was successfully treated with
ciprofl oxacin and healed well without any
further treatment. She had full recovery of
sensation in her nipples and areolas. D,
Postoperative view at 1-year follow-up.
C
D
A
B
Fig. 17.11 Nipple necrosis healing by secondary intention. Nipple
necrosis can result from a lack of arterial input or venous
congestion. It is often unpredictable and diffi cult to assess and treat.
A, Preoperative view. B, Postoperative view at 2 weeks. C,
Postoperative view at 6 weeks. D, Postoperative view at 3 months.
These photographs show that it can be best to leave the areola to
declare itself and heal by secondary intention.
with Staphylococcus epidermidis and proprionibacteria. It makes sense
that some form of antibacterial pro-phylaxis may be indicated in breast
surgery. It is not completely ‘clean’ surgery.
Skin fl ap necrosis
Whenever skin fl aps are mobilized or undermined, the risk of necrosis
increases. Techniques that minimize both undermining and tension
on the skin are more likely to heal uneventfully. I have noted a sig-
nifi cantly reduced problem with skin fl ap necrosis using the vertical
approach. This is probably because the breast tissue is left attached to
the skin fl aps and the skin is closed loosely under little or no tension.
Nipple-areolar necrosis
Creation of a pedicle also involves a reduction of blood supply. The
four main arterial inputs to the breast may not all be equally dominant.
Nipple necrosis (Fig. 17.11A–D and see Fig. 17.10) can occur when
one of these vessels is weak or there is constriction, kinking or com-
pression of the pedicle obstructing venous return. External compres-
sion is unlikely to be strong enough to cause necrosis, but a hematoma
could be a problem.
If a nipple and areola look congested, removal of sutures and release
of compression are indicated.
Duskiness alone is hard to interpret. If all dusky nipples were
removed and replaced as grafts there would be more problems than
leaving them alone. Often a dusky areola has excellent circulation.
Sometimes some blistering can occur with complete recovery, though
sometimes with some irregular pigmentation. Sometimes only a
partial loss occurs and it is often best to leave this to heal by
secondary intention because the outcome can be excellent. Rarely
does full necrosis occur and this may require debridement and
reconstruction.
Hematomas and seromas
Meticulous hemostasis can prevent the development of a hematoma
(Fig. 17.12A–D), but drains cannot. If infi ltration is used, the vessels
may be constricted and the surgeon may not notice them. A careful
search for known vessels is important before closure.
Leaving a drain in for a couple of days is unlikely to prevent a
seroma. Seromas do occur, but do not behave in the same way as
abdominal seromas. They can drain on their own and tend to disap-
pear. Only rarely will a patient complain of a sudden ‘gush’ during the
postoperative period.
Asymmetry
Asymmetry can occur with any breast procedure. If it persists postop-
eratively it can often be treated with liposuction to the larger side. It

References
247
A
B
C
D
Fig. 17.12 Hematoma formation.
A, Preoperative markings for vertical
breast reduction using a medial pedicle.
B, Intraoperative photograph after 740 g was
removed from the right breast and 700 g
removed from the left breast. C, Hematoma
developed postoperatively. Tumescent
infi ltration had been used and the perforator
that would normally supply an inferior
pedicle was bleeding. It had probably been in
a constricted state because of the tumescent
infi ltration and had not been properly
cauterized. D. Patient seen at 2 months’
postoperatively.
is interesting that patients will tolerate asymmetry on the same side
better than if the asymmetry is reversed postoperatively.
Under-resection
It is more common to under-resect the breasts when a vertical approach
is used. It is important for the surgeon to estimate how much should
be removed preoperatively and to keep close to this estimate when
performing a reduction. Under-resection of lateral fat is also more of
a problem with the vertical approach because the IMF often rises.
Remove the excess fat between the old fold and the new fold or a bulge
of tissue will result.
Puckers
Puckers (see Fig. 17.5G–L) occur with both the vertical and the inverted
T procedures. The horizontal excision of skin and breast tissue with
the inverted T results in a lateral dog-ear and a medial dog-ear. The
lateral dog-ear is often diffi cult to correct without chasing it around
the back. The medial dog-ear presents a particular problem because it
is important not to let the scar cross the midline of the chest. It is
often better to accept a small dog-ear medially rather than a hypertro-
phic scar across the midline.
The vertical approach also results in two dog-ears, but at right
angles to those that develop with an inverted T. The one dog-ear
superiorly disappears into the areola. The lower dog-ear creates a
pucker inferiorly. This can require correction in about 5% of patients.
This is often easily performed through a small vertical incision under
local anesthesia in the offi ce.
Bottoming out and pseudoptosis
Bottoming out occurs when the breast tissue drops inferiorly. This can
occur because the surgeon mistakenly tries to push tissue up into the
upper pole of the breast. Experience has shown that it is very diffi cult
to improve upper pole fullness and anything that is pushed into the
upper pole is likely to drop and cause the appearance of bottoming out.
The problem is not really the fault of the technique, but the result of
under-resection inferiorly.
I believe that leaving the breast attached to the upper skin fl aps
and removing the heavy inferior breast tissue is less likely to result in
bottoming out. It is diffi cult to create an inferior pedicle that will not
be dragged down by gravity. The medial pedicle vertical breast reduc-
tion does allow some remodeling of the IMF level and it can often be
raised a couple of centimeters. Care must be exercised, however,
because aggressive raising of the IMF by removing tissue around it can
increase the revision rate.
The scar of an inverted T inferior pedicle operation tends to rise
up onto the breast over time. This appears to be more likely in patients
with poorer quality skin. I believe that the breast tissue drops out
under the IMF, in spite of the fact that the IMF is not violated. This
bottoming out then makes the nipples appear to be too high.
CONCLUSION
There are various indications for and approaches to breast reduction
surgery. The skin resection pattern is only one factor. Any of the
various pedicles (inferior, central, superior, medial and lateral) can be
adapted to any of the skin resection patterns. The parenchymal resec-
tion pattern can also vary.
There reasons for choosing different skin resection patterns and
different pedicles differ. Some of these decisions are based on an esti-
mated volume of reduction, previous surgery or biopsy scars, quality
of the skin, or surgeon or patient preference. The best technique is the
technique with which a surgeon is most comfortable with under the
circumstances.
REFERENCES
1. McKissock PK. Reduction mammaplasty with a vertical dermal fl ap.
Plast Reconstr Surg 1972; 49:245–252.

17
BREAST REDUCTION
248
2. Biesenberger H. Eine neue methode der mammaplastik. Zentralbl Chir
1928; 55:2382.
3. Strombeck JO. Mammaplasty: report of a new technique based on the
two-pedicle procedure. Br J Plast Surg 1960; 13:79–90.
4. Dufourmentel C, Mouly R. Plastie mammaire par la methode oblique.
Ann Chir Plast 1961; 6:45.
5. Skoog T. A technique of breast reduction – transposition of the nipple
on a cutaneous vascular pedicle. Acta Chir Scand 1963; 126:453–465.
6. Robbins TH. A reduction mammaplasty with the areola-nipple based on
an inferior pedicle. Plast Reconstr Surg 1977; 59:64–67.
7. Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior
pedicle technique. An alternative to free nipple and areola grafting for
severe macromastia or extreme ptosis. Plast Reconstr Surg 1977;
59:500.
8. Georgiade NG, Serafi n D, Morris R, et al. Reduction mammaplasty
utilizing an inferior pedicle nipple-areolar fl ap. Ann Plast Surg 1979;
3:211.
9. Wise RJ. A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg 1956; 17:367.
10. Arie G. Una nueva tecnica de mastoplastia. Rev Iber Latino Am Cir
Plast 1957; 3:28.
11. Pitanguay I. Surgical correction of breast hypertrophy. Br J Plast Surg
1967; 20:78.
12. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr
Surg 1975; 55:330.
13. Peixoto G. Reduction mammaplasty: a personal technique. Plast
Reconstr Surg 1980; 65:217.
14. Lassus C. A technique for breast reduction. Int Surg 1970; 53:69.
15. Lassus C. A 30-year experience with vertical mammaplasty. Plast
Reconstr Surg 1996; 97:373–380.
16. Marchac D, de Olarte G. Reduction mammaplasty and correction of
ptosis with a short inframammary scar. Plast Reconstr Surg 1982;
69:45–55.
17. Lejour M, Abboud M, Declety A, et al. Reduction des cicatrices de
plastie mammaire: de l’ancre courte a la verticale. Ann Chir Plast
Esthet 1990; 35:369.
18. Lejour M, Abboud M. Vertical mammaplasty without inframammary
scar and with breast liposuction. Perspect Plast Surg 1996; 4:67–90.
19. Wiener DL, Aiache AE, Silver L, et al. A single dermal pedicle for nipple
transposition in subcutaneous mastectomy, reduction mammaplasty or
mastopexy. Plast Reconstr Surg 1973; 51:115.
20. Palmer JH, Taylor GI. The vascular territories of the anterior chest wall,
Br J Plast Surg 1986; 39:287–299.
21. Balch CR. The central mound technique for reduction mammaplasty.
Plast Reconstr Surg 1981; 67:305.
22. Hester TR, Bostwick J, Miller L, Cunningham SJ. Breast reduction
utilizing the maximally vascularized central breast pedicle. Plast
Reconstr Surg 1985; 76:890.
23. Gradinger GP. Reduction mammaplasty utilizing nipple-areola
transplantation. Clin Plast Surg 1988; 15:641–654.
24. Gradinger GP. Discussion: maximizing breast projection after free-
nipple-graft reduction mammaplasty. Plast Reconstr Surg 2001;
107:961–964.
25. Passot R. La correction esthetique du prolapsus mammaire par la
procede de la transposition du mamelon. Presse Med 1925; 33:317.
26. Robertson DC. The technique of inferior fl ap mammaplasty. Plast
Reconstr Surg, 1967; 40:372.
27. Chiari AJ. The L Short Scar Mammaplasty: a new approach. Plast
Reconstr Surg 1992; 90:233.
28. Lejour M. Vertical mammaplasty and liposuction of the breast. St Louis:
Quality Medical Publishing; 1993.
29. Asplund O, Davies DM. Vertical scar breast reduction with medial fl ap
or glandular transposition of the nipple-areola. Br J Plast Surg 1996;
49:507–514.
30. Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR)
mammaplasty. Plast Reconstr Surg 1999; 103:890.
31. Hall-Findlay EJ. A simplifi ed vertical reduction mammaplasty:
shortening the learning curve. Plast Reconstr Surg 1999; 104:748.
32. Hall-Findlay EJ. Vertical breast reduction with a medially based pedicle.
Operative strategies. Aesthetic Surg J 2002; 22(2):185–195.
33. Berthe J-V, Massaut J, Greuse M, et al. The vertical mammaplasty: a
reappraisal of the technique and its complications. Plast Reconstr Surg
2003; 111:2192–2199.
34. Spear SL, Howard MA. Evolution of the vertical reduction
mammaplasty. Plast Reconstr Surg 2003; 112:855–868.
35. Benelli L. A new periareolar mammaplasty: The ‘round block’
technique. Aesthetic Plast Surg 1990; 14:93.
36. Sampaio-Goes JC. Periareolar mammaplasty double skin technique.
Breast Dis 1991; 4:111.
37. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an
outcome study. Plast Reconstr Surg 1997; 100(4):875–883.
38. Blomqvist l, Eriksson A, Brandberg Y. Reduction mammaplasty provides
long-term improvement in health status and quality of life. Plast
Reconstr Surg 2000; 106(5):991–997.
39. Kerrigan CL, Collins ED, Striplin D, et al. The health burden of breast
hypertrophy. Plast Reconstr Surg 2001; 108(6):1591–1599.
40. Rubin.
41. Mottura A. Circumvertical reduction mammaplasty. Aesthetic Surg J
2000; 20:199–204.
42. Graf R, Auersvald A, Bernardes A, et al. Reduction mammaplasty and
mastopexy with shorter scar and better shape. Aesthetic Surg J 2000;
20:99–106.
43. Pribaz.
44. Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr
Surg 1993; 92:1276–1284.
45. Gray LN. Liposuction breast reduction. Aesthetic Plast Surg 1998; 22:159.
46. Schwartzmann E. Beitrag zur Vermeidung von Mammillennekrose bei
einzeitiger Mammaplastik schwerer Fälle. [Avoidance of nipple necrosis
by preservation of corium in one-stage plastic surgery of the breast.] Rev
Chir Struct 1937; 7:206–209.
47. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-
areola complex: an anatomic study. Plast Reconstr Surg 2000; 105:905–
909.
48. Cruz-Korchin N, Korchin, L. Breast-feeding after vertical mammaplasty
with medial pedicle. Plast Reconstr Surg 2004; 114(4):890–894.

249
CHAPTER 18
Mastopexy
G Patrick Maxwell, Jeremy Waldman and Stephanie Stover
The additional challenge is to provide a correction that will endure the
test of time.
INDICATION
●
Breast ptosis
Breast ptosis is most often a consequence of aging tissues. Over time,
Cooper’s ligaments become attenuated and the breast loses its fascial
support, frequently with a concurrent decrease in volume. Age-related
changes are often hastened or mimicked by weight loss and involu-
tional changes seen with pregnancy/lactation, and menopause.
Regardless of the etiology, a useful tool for the surgeon is to classify
patients by the degree of ptosis present. The classifi cation system used
most frequently was fi rst described by Regnault1 and grades the breast
based on the position of the nipple relative to the inframammary fold
(IMF) (Table 18.1).7 The amount of preoperative ptosis can be used as
a guide to selecting the operation necessary to achieve correction.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
Appropriate and thorough preoperative evaluation will allow the
surgeon to select and plan a suitable operation. Choosing the proper
technique begins with designing incisions based on scar placement and
length. Minimizing scar appearance is fundamental to any operation
in plastic surgery. However, scars should not be avoided if they are
necessary to provide adequate and durable results. A balance must
be accomplished between scar placement and effi cacy because the
fi nal result will depend on the harmony of the breast shape and scar
appearance.
The terms ‘short scar’ or ‘limited scar’ have been used interchange-
ably and applied to many different techniques. As a result, virtually
any procedure that leaves a fi nal scar shorter then the classic inverted-
T has been classifi ed as such. Explanation of these terms can be
essential when counseling patients who are demanding minimal
incision lengths and maximal results.
For each patient, the surgeon should develop a strategy for reshap-
ing and positioning the breast parenchyma and determine the need, if
any, for additional soft tissue augmentation with an implant or autol-
ogous fl ap. Breast shaping can be elaborate or simple and may include
combinations of suturing, local fl aps, muscle slings, or placement of
internal mesh support.2–5
Combining augmentation with mastopexy can be accomplished
safely for many patients. Clearly, adding an implant to an already
complex operation will increase the number of variables that the
surgeon must consider. Many women with ptotic breasts focus more
on the loss of upper pole volume that has occurred as their breasts
Summary
1. The goal of mastopexy is to reshape the breast by tightening
the skin envelope with or without adding to the breast
volume.
2. Factors contributing to the etiology of the breast ptosis include
involution, aging, weight loss and multiple pregnancies.
3. Breast ptosis classifi cations include classes I–III based on
nipple areola position in relation to the inframammary fold and
breast mound position.
4. Patient evaluation should include history of breast surgery and
tumors related to the patient and the patient’s family.
5. Patients who lack suffi cient breast volume may require
augmentation as well as mastopexy.
6. Only patients with minor breast ptosis (grade I) may benefi t
from a periareolar mastopexy.
7. Marking of the patient starts with the patient in a sitting
position and the nipple-areola complex is measured from the
sternal notch and mid-clavicle area as well as the
submammary fold.
8. On patients requiring breast ptosis correction with
augmentation, augmentation is done fi rst followed by
mastopexy.
9. The complications of breast ptosis correction include
hematoma, infection, paresthesia, anesthesia, nipple areola
necrosis, and capsular contracture among other rare
complications.
10. Postoperative care includes continuation of oral antibiotics for
3 days, particularly if an implant has been used. Vigorous
exercise can be resumed in 2–4 weeks depending on the
magnitude of the surgery.
INTRODUCTION
Mastopexy is one of the most demanding operations in breast surgery.
Although it may increase the challenge, performing simultaneous
breast augmentation can be an effective way of producing an aesthetic
breast form. As the breast mound descends on the chest wall patients
will display variability in breast shape, tissue laxity, symmetry, paren-
chymal distribution, and nipple position. There are several options for
restoring a youthful appearing breast, but the common goals are to:
● raise the nipple areola complex;
● decrease the skin envelope;
● achieve symmetry;
● improve the breast shape;
● maintain or increase volume.

18
MASTOPEXY
250
have aged, than on the change in nipple position that has accompanied
it. An implant can be a very powerful tool in restoring youthful fullness
to the upper pole.
Patient assessment
The initial consultation for mastopexy should include a detailed dis-
cussion of the patient’s goals and expectations and a careful review of
medical and psychiatric histories. As with any breast surgery, a per-
sonal and family history of breast disease or cancer should be obtained.
The surgeon should specifi cally note a history of any previous breast
surgery or radiation therapy. Preoperative mammography is recom-
mended for any patient who has signifi cant risk factors and those over
35 years of age.
Prior surgical history should include previous augmentation or
reduction procedures. When possible, operative notes detailing tech-
niques and implant devices used should be reviewed. Information
about past or planned pregnancies and changes in weight and/or
brassiere size can also aid in preoperative assessment.
Preoperative planning and
dimensional analysis
Management of patient expectations is crucial to ensuring satisfaction.
The ideal breast aesthetic may vary greatly between patients and
surgeons. Every attempt should be made to understand the patient’s
motivations and anticipated results. Patients who are unrealistic or
unwilling to accept the necessary scars should be avoided.
Preoperative physical exam should include measurements as well
as an assessment of tissue qualities and distribution. Signifi cant asym-
metries will be noted in most patients when carefully examined.6 It is
important to recognize and point out any pre-existing asymmetries,
spinal curvature, or chest wall deformities because these may be dif-
fi cult to correct and can become noticeable in the postoperative period.
Preoperative photographs with multiple views are obtained on all
patients and maintained as part of the offi ce record.
Thorough palpation of the breast and axilla should be performed
and documented. Any palpable masses or lymph nodes must be eval-
uated before proceeding with surgery. Measurements of breast width
(BW), breast height (BH), intermammary distance, nipple to supraster-
nal notch (N : SSN), and nipple to inframammary fold (N : IMF)
should be made and documented. Measurements can aid in planning
the operation, recognizing asymmetries, and tracking postoperative
results.
The soft tissue envelope should be characterized and the desired
resultant breast form planned (Box 18.1). Once accomplished the
surgeon can assimilate the information to select an appropriate
implant, if desired, and plan the mastopexy approach. Use of
the BioDIMENSIONAL® preoperative planning system (INAMED
Corporation) can be used on patients requiring ptosis correction with
augmentation.
Patient marking
Preoperative markings are made with the patient in an upright position
and begin with:
● midline;
● current IMF;
● planned nipple position.
Additional marks, determined by the patient’s tissue characteristics,
are then made as guidelines for resection.
Nipple position is established using the current IMF as a guide, by
making the mark along the breast meridian while manually palpating
the fold. The location of this point is confi rmed by checking its dis-
tance from the suprasternal notch and mid-clavicle bilaterally. This is
usually 20 ± 3 cm from the suprasternal notch.
At this point, the surgeon should determine the planned excision
pattern (Figs 18.1 and 18.2) and proceed with the appropriate marks.
The degree of mastopexy will vary from a periareolar approach to a full
inverted-T scar based on the amount of ptosis present. Variations in
incision patterns are the same for augmentation mastopexy and mas-
topexy alone and are gradually increased to accommodate increasing
amounts of breast tissue and ptosis.
● Minor ptosis is usually addressed with a periareolar approach,
either concentrically or eccentrically designed. This pattern places
the scar at the border of the pigmented areola and the breast skin.
A point is fi rst made just superior to the planned nipple position
and represents the planned position of the upper areolar border.
This should be no more than 3 cm above the transposed infra-
mammary fold mark. The areola to be preserved is outlined using a
standard nipple marker at 38–42 mm. The distance from the nipple
to the planned position of the upper areolar border can be used as
the radius for designing a concentric pattern.7 Often it is necessary
to adjust this to a more oval shaped or eccentric confi guration to
correct for asymmetries and variations in tissue distribution.
● When addressing moderate ptosis, a vertical excision is marked.
This is done by fi rst repeating the initial steps above to determine
the position of the new nipple and upper areolar border. The dis-
tance from the center of the nipple to the new upper areolar border
is then used to set the width of the planned vertical excision.7 The
vertical limbs are drawn connecting to a point 1–2 cm above the
IMF. Adjusting the distance between the vertical limbs will accom-
modate individual tissue characteristics and asymmetries. This is
often done when tailor-tacking as described below.
● Patients with more severe ptosis usually require greater nipple
elevation and a horizontal excision to achieve adequate correction.
The horizontal component will vary from a traditional wise pattern
marking to a shorter version that is adapted into the vertical
pattern described above. Marking this pattern begins as described
as above and places the horizontal scar along the IMF with the
T junction designed to rest along the breast meridian. When
Table 18.1 Regnault classifi cation.1
Grade I
Nipple at the level of the IMF, above the lower
contour of the gland
Grade II
Nipple below the IMF, above the lower contour
of the gland
Grade III
Nipple below the IMF and at the lower contour
of the gland
Pseudoptosis
Normal nipple position with glandular tissue
below the IMF
IMF, inframammary fold.
Box 18.1 Steps in preoperative planning and
dimensional analysis
●
Careful analysis and measurement of the dimensions and
shape of the existing breast
●
Analysis of the character and evaluation of the adequacy of
the soft tissue envelope
●
Development of an anatomically well-defi ned goal for the
breast shape after mastopexy or mastopexy augmentation
●
Selection of the implant size, shape, height, width and
projection to accomplish the individual patient’s goals
●
Selection of the surgical approach (incisions) and implant
location

Operative Approach
251
planning simultaneous augmentation, these marks are made con-
servatively to allow for the excess tension that will be created when
an implant is placed. This helps to avoid problems with healing at
the T junction.
Regardless of the pattern chosen, all marks are customized to the
individual patient, carefully measured, and confi rmed with tailor-
tacking in the operating room before proceeding with excision.
OPERATIVE APPROACH
The patient is placed supine on the operating room table with the arms
carefully secured at 90º angles to the torso. Patient positioning is
crucial to permit for upright posture in the operating room as neces-
sary. After induction of general anesthesia the patients are sterilely
prepped to allow complete visualization of the anterior chest and
shoulders.
When planning a simultaneous augmentation, the author’s prefer-
ence is to divide the operation into two parts.
● First, a dimensionally based breast augmentation is completed.
● Then, the patient is placed in the sitting position at 90º, and pre-
operative markings are tailor-tacked and adjusted before complet-
ing the mastopexy.8
Implant selection and placement
Implant selection and placement are judged according to the
preoperative measurements.
Decisions on implant size, shape, surface texture, and fi lling mate-
rial are made based on the soft tissue components present. Selection
A
B
C
D
E
F
G
Inverted T (inferior pedicle)
Vertical (medial pedicle)
Vertical (superior pedicle)
Circumvertical
Circumvertical (Spair technique) inferior pedicle
Peri-areolar
Horizontal
Scar around areola
Scar in inframammary fold
Per regnault approach
Fig. 18.1 An individualized approach to skin tightening and excision is applied with increasing degrees of mammary ptosis.1 Thus lesser
degrees of ptosis require no or little skin excision whereas increasing degrees require the most skin tightening or excision. A, Periareolar
approach with internal rearrangement or insertion of implant. B, Periareolar excision. C, Circumareolar with vertical excision.
D, Circumareolar plus ‘J’ excision, which with increasing ptosis, turns into a wider ‘J’ or ‘B’ excision. E, Circumareolar with vertical and
small transverse excision. F, Wise pattern-type excision. With all these skin patterns an implant may be inserted, internal tissue
rearrangement performed, or simply skin tightening.

18
MASTOPEXY
252
A
B
Inferior pedicle
Central pedicle (is not attahced to skin but
based on chest wall)
C
D
Superior pedicle
Lateral pedicle
E
Medial pedicle
Purse string mastopexy
Fig. 18.2 The addition of a periareolar purse string gives enhanced power to the skin tightening adjustments and uplifts the lower skin
excess, so that all vertical to ‘T’ type scars are minimized with the addition of the purse string. A, Periareolar purse string mastopexy.
B, Extended periareolar purse string mastopexy. C, Circumvertical periareolar mastopexy. D, ‘J’ to ‘B’ excison plus periareolar purse string
mastopexy. E, Transverse ‘T’ excision plus periareolar purse string mastopexy. F, Wise type pattern plus periareolar purse string mastopexy.

Operative Approach
253
of an implant with enhanced projection can offer the mechanical
advantage of raising the position of the nipple–areola complex. In
patients with minor amounts of ptosis, this approach can sometimes
alleviate the need for a mastopexy. Likewise, it may in a sense ‘down-
stage’ a patient from one degree of ptosis to the next. Therefore, a
patient who would need a circumvertical scar to achieve an adequate
result may only need a periareolar tightening once the implant is in
place. Our preference is to use form-stable highly cohesive gel ana-
tomical implants with enhanced projection (F or X) for optimal
results.
Selection of an implant with enhanced projection can raise the
position of the nipple–areola complex and sometimes alleviates the
need for a mastopexy or may ‘downstage’ a patient from one
degree of ptosis to the next
Once a device is selected, the surgeon must determine the implant’s
location.
● Patients who have a superior pole pinch test result of 2 cm or more
can be considered for subglandular or subfascial implant
placement. The subfascial plane may offer additional soft tissue
coverage and support.9,10
● Thinner patients will be at risk for implant palpability and visibil-
ity and may also risk blood supply to the nipple–areola complex
when concurrent mastopexy is performed. For these patients, a
subpectoral dissection is planned. During submuscular implant
placement, our preference is to release the inferior portion of the
pectoralis major muscle leaving the implant in a partial subpec-
toral position (Figs 18.3 and 18.4).
At this point, the preoperative markings are confi rmed with tailor-
tacking in the sitting position before proceeding with mastopexy.
When using the periareolar approach, the outer and inner circumfer-
ences are incised and the intervening skin is de-epithelialized. Often
the dermis is then incised at the periphery to create a ledge for
closure.
When no glandular resection or undermining is performed, nipple
vascularity is maintained via perforating vessels. If the vascularity
is potentially compromised, care is taken to preserve the sub-
dermal plexus during de-epithelialization and dermal incisions are
avoided.
Closure is secured with a non-absorbable Gore-Tex® suture on a
straight needle using a ‘pin-wheel’ or ‘wagon-wheel’ technique.11
When correctly placed, this suture controls the areolar diameter, helps
to prevent areolar widening, and reduces periareolar wrinkling and
pleats by evenly distributing tissues. A running subcuticular 5-0
Monocryl is then placed superfi cially, with care not to disrupt the
previous suture (Fig. 18.5). (Post-operative results are in Figure 18.6.)
Moderate ptosis
Patients with moderate degrees of ptosis often require a vertical com-
ponent to the scar with or without a short horizontal excision (Figs
20.7–20.9). The vertical component can be part of the preoperative
design or added intraoperatively to distribute excess tissue encoun-
tered with the periareolar excision. In either situation, the inferior
extent of the resection is kept at least 1–2 cm above the location of the
IMF. As above, the preoperative markings are used as a guide and
are confi rmed and adjusted before making incisions.
Tightening of the lower pole helps redistribute fullness superiorly
to a more desired location, improving breast shape and projection.
This may be helpful when correcting glandular or pseudoptosis as
well, and in this instance can sometimes be done without a periareolar
scar. In addition, if the breast appears fl attened or the lower pole
prominent after the periareolar excision, vertical skin plication can
offer correction. In cases where a vertical excision can be easily
predicted, access for implant placement in any plane can be gained
through the center of the vertical incision.
Severe ptosis
Severe ptosis is corrected with an inverted-T excision, varying the
length of the horizontal scar to accommodate the soft tissue needs. As
this often requires greater degrees of nipple elevation, consideration
is given to maintaining vascularity on a dermoglandular pedicle. Our
preference is to use a superomedial pedicle because this offers ease
of nipple elevation and fl exibility for implant placement. However,
other pedicles could be safely used.
Skin patterns are conservatively designed when an implant is antic-
ipated. After implant insertion and tailor-tacking, fl aps are raised and
the breast mound is reshaped and secured over the implant. Peri-
areolar closure is performed as described above and a layered closure
of the vertical and horizontal limbs follows. Drains are considered
when more extensive dissection has been completed.
A
B
Augment mastopexy
Fig. 18.3 In performing the ‘two operations
in one’ augment mastopexy, the implant is
inserted via a periareolar (A) or
inframammary (B) approach. It is placed in its
desired respective pocket (subpectoral,
subfascial or subglandular), and the
parenchyma is sutured off securing the
implant in its proper position. Here the
implant is located in a subglandular pocket.

18
MASTOPEXY
254
Optimizing outcomes
●
Careful analysis of the breast dysmorphology.
●
Planning and carrying out two operations at once
●
Patient is marked sitting up 90º and tailor-tack technique is
used
●
Non-absorbable ‘pin-wheel’ closure for periareolar mastopexy
●
Maintain nipple vascularity
COMPLICATIONS AND SIDE EFFECTS
Complications can be subdivided temporally and by relation to breast
implantation. Patient education and photodocumentation cannot be
overemphasized. When combining mastopexy with augmentation,
complications inherent and unique to the implant device must be
anticipated and explained to the patient. Specifi cally, this includes
capsular contracture and implant rupture or defl ation.
Hematomas and infections may occur in the perioperative period.
Careful preoperative counseling regarding cessation of any prescription
or over-the-counter herbs or medications that may impair clotting or
platelet function is essential. Immediate evacuation of any recognized
hematoma is recommended to avoid possible late sequelae. Infections
can range from superfi cial cellulitis to purulent periprosthetic collec-
tions. Prophylaxis is administered prior to induction of anesthesia with
a single dose of intravenous antibiotics and is continued with an oral
regimen for 3 days postoperatively.
Careful preoperative counseling to stop any prescription or over-
the-counter herbs or medications that may impair clotting or
platelet function is essential.
A
B
C
Full thickness
Resected breast tissue
Medial pedicle
rotated superiorly
Medial and lateral pillars
sutured together
Resected
breast tissue
Periareolar purse string mastopexy
Fig. 18.4 Once the implant is secured, the second step of the ‘two operations in one’ is performed. Here a periareolar purse string
mastopexy is applied to the soft tissue envelope over the implant secured in its pocket.

255
Complications and Side Effects
Alterations in nipple sensation can be transient or permanent and
are often a major source of concern for the patient. Careful attention
is directed during implant placement to avoid overdissection or tran-
section of the lateral intercostal cutaneous nerves.
Errors in nipple placement can be diffi cult to correct, especially
when the nipple position in too high on the breast mound. This is
best treated by avoiding the problem with careful measurements. It is
crucial to place the implant fi rst and then tailor-tack the mastopexy
design into place before re-measuring and assessing the patient in an
upright position to avoid this problem.
Nipple–areola necrosis is avoided by maintaining blood supply via
glandular perforators or a dermoglandular pedicle. Caution is required
when a subglandular plane is dissected or in patients with diabetes
mellitus, collagen vascular disease, or a history of smoking.
Asymmetries can often be corrected at the time of operation, but
may persist or become more noticeable in the recovery period. Again,
photodocumentation and patient education are paramount to ensure
satisfaction. Minor asymmetries that persist can be addressed in a
second stage that should be delayed for at least 6 months. We prefer
to perform mastopexy augmentation as a single stage rather than as
two separate operations, even though this may increase the need for
minor revisions. These revisions are often much less invasive and are
regularly performed with local anesthesia in the offi ce setting when
necessary.
A
B
C
D
Fig. 18.5 32-year-old female with
pseudoptosis to fi rst degree ptosis treated
with subpectoral placement of a 280 mL
silicone gel implant with a periareolar purse
string mastopexy. A, Preoperative frontal
view. B, Postoperative frontal view.
C, Preoperative lateral view. D, Postoperative
lateral view.
A
B
C
D
Fig. 18.6 A 30-year-old patient with fi rst to
second degree ptosis treated with subfacial
placement of 250 mL silicone gel implants
with periareolar purse string mastopexy.
A, Preoperative frontal view. B, Postoperative
frontal view. C, Preoperative lateral view.
D, Postoperative lateral view.

18
MASTOPEXY
256
Late complications
Late consequences include:
● recurrent ptosis;
● scar widening or hypertrophy.
Problems with areolar spreading have been largely addressed with the
use of permanent sutures and the ‘pin-wheel’ technique. We avoid
horizontal scars on the medial and lateral aspects of the chest wall
when possible. Any scar hypertrophy is usually addressed with local
corticosteroid injections.
Recurrent ptosis is an unfortunate consequence of poor tissue
quality and lack of fascial support. Many different maneuvers have
been designed to minimize this as described above, but none can stop
the effects of gravity on aging tissues.
A
B
Augment mastopexy-stage two
Fig. 18.7 For more excessive degrees of
ptosis, the second stage of the ‘two
operations in one’ includes a circumvertical or
circumvertical plus transverse skin excision
component, performed over the implant
secured in its deep pocket.
A
B
C
D
Fig. 18.8 A 40-year-old female with second to
third degree ptosis treated with subpectoral
placement of 375 mL 410 form stable silicone
gel anatomical breast implants and a
periareolar purse string mastopexy with
vertical and transverse skin excision.
A, Preoperative frontal view. B, Postoperative
frontal view. C, Preoperative lateral view.
D, Postoperative lateral view.
POSTOPERATIVE CARE
Most of these procedures are performed in the outpatient setting.
Wounds are dressed with steristrips and a supportive gauze dressing.
Patients are allowed to shower on postoperative day 2.
After 3–5 days, the patients are seen in the offi ce for their
fi rst follow-up visit. At that time, patients with smooth implant
devices are instructed in implant mobility exercises. Patients consid-
ered to be at risk for superior implant displacement are managed with
an elastic band across the superior pole providing gentle downward
pressure. Upper body and vigorous exercise is restricted for 2–4
weeks.
Regular follow up appointments are scheduled at 1 month, 3
months and 1 year. All patients are photographed in the postoperative
period.

References
257
CONCLUSION
Mastopexy and mastopexy augmentation present a unique challenge
to the plastic surgeon. Emphasis should be placed on thorough preop-
erative evaluation combined with a biodimensional approach. Recently,
we have started using acellular dermal matrix (ADM) in the majority
of our secondary mastopexy augmentations with great results. We
believe that the role of this product will expand beyond the reconstruc-
tive arena and will be utilized more frequently in the aesthetic popula-
tion. Performing the operation in two parts in the same setting will
allow for safe, predictable outcomes.
REFERENCES
1. Regnault B. Breast ptosis. Defi nition and treatment. Clin Plast Surg
1976; 3(2):193–203.
2. Goes JC, Landecker A, Lyra EC, et al. The application of mesh support
in periareolar breast surgery: clinical and mammographic evaluation.
Aesthetic Plast Surg 2004; 28(5):268–274.
3. Benelli L. A new periareolar mammaplasty: the ‘round block’ technique.
Aesthetic Plast Surg 1990; 14(2):93–100.
4. Benelli LC. Mastopexy and reduction: The ‘round block’. In: Spear SL,
ed. Surgery of the breast: principles and art. 2nd edn. Philadelphia:
Lippincott, Williams and Wilkins; 2006:977–990.
5. Graf R, Biggs TM. Mastopexy with a pectoralis muscle loop. In: Spear
SL, ed. Surgery of the breast: principles and art. 2nd edn. Philadelphia:
Lippincott, Williams and Wilkins; 2006:1008–1020.
A
B
C
D
Fig. 18.9 A 45-year-old female with second to
third degree mammary ptosis treated with
subpectoral 350 mL silicone gel breast
implants and periareolar purse string
plus wise pattern type skin excision.
A, Preoperative frontal view. B, Postoperative
frontal view. C, Preoperative lateral view.
photographs. D, Postoperative lateral view.
6. Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall
asymmetry in breast augmentation: a retrospective analysis of 100
patients. Plast Reconstr Surg. 2003; 111(4):1513–1519.
7. Regnault P, Rolin DK, Breast ptosis. In: Regnault P, ed. Aesthetic plastic
surgery. Boston: Little, Brown and Co; 1984:539–558.
8. Whidden PG. The tailor-tack mastopexy. Plast Reconstr Surg 1978;
62(3):347–354.
9. Graf RM, Bernardes A, Auersvald A, et al. Subfascial endoscopic
transaxillary augmentation mammoplasty. Aesthetic Plast Surg 2000;
24:216–220.
10. Graf RM, Bernardes A, Rippel R, et al. Subfascial breast implant: a new
procedure. Plast Reconstr Surg 2003; 111(2):904–908.
11. Hammond DC. Augmentation mastopexy: general considerations.
In: Spear SL, ed. Surgery of the breast: principles and art. 2nd edn.
Philadelphia: Lippincott, Williams and Wilkins; 2006:1403–1416.
12. Rohrich, RJ, Thornton JF, Jakubietz RG, et al. The limited scar
mastopexy: current concepts and approaches to correct breast ptosis.
Plast Reconstr Surg 2004; 114(6):1622–1630.
13. Rohrich RJ, Beran SJ, Restifo RJ, et al. Aesthetic management of the
breast following explantation: evaluation and mastopexy options. Plast
Reconstr Surg 1998; 101(3):827–837.
14. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy.
Plast Reconstr Surg 1990; 85(6):961–966.
15. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast
Reconstr Surg 2001; 107(5):1294–1299.
16. Hammond DC. Reduction mammaplasty and mastopexy: general
considerations. In: Spear SL, ed. Surgery of the breast: principles and art.
2nd edn. Philadelphia: Lippincott, Williams and Wilkins; 2006:971–976.
17. Hammond DC. The SPAIR mammaplasty. Clin Plast Surg 2002;
29(3):411–421.

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259
CHAPTER 19
Liposculpture
Fábio X Nahas, Marcus VJ Barbosa and Lydia M Ferreira
adipose cell. These cells increase in number along childhood and ado-
lescence.10
Therefore, the number of cells is constant along adult life. The
accumulation of fat occurs by the increase in deposition of the
intracellular lipid, not by the increase of number of adipose cells.11,12
Fat cells are extremely delicate, and should be manipulated with
special care.13 Therefore, the amount of viable fat cells will depend on
the liposuction technique.
Adipose tissue is divided in two layers: the superfi cial layer and the
deep layer. The superfi cial layer, also named areolar, represents small
compact fat lobules that are separated by a greater number of mem-
branes (septa). Its thickness is uniform in all of the body parts. The
deep layer is also named reticular or lamellar ayer. In this layer fat
lobules present an irregular distribution as well as a small number of
membranes (septa) that show an irregular pattern when compared with
the superfi cial layer.14
The accumulation of fat occurs in the adipose tissue of the deep
layer. Patients who are classifi ed as obese present an increase in
thickness of this layer.15
Body adipose tissue deposits present variations depending on the
gender and the type of hormones. Therefore, presentation will be in
two distinct patterns: androgenic pattern and gynecoid pattern. Men
present with the androgenic pattern when fat deposits will occur in
the abdomen and dorsal regions. On the other hand, women present
with the gynecoid pattern when fat accumulation occurs in thighs and
ankles.16
INDICATIONS
Liposculpture is essentially used for body contouring for aesthetic and
reconstructive purposes by the removal of fatty deposits with or without
re-injection of the removed fat.10 The technique was described for the
treatment of localized fat deposits that may not have responded to
efforts of weight loss through exercise and dieting. It is important to
stress, however, that liposuction is not a weight-loss method.16 Patients
submitting to liposculpture should present with good skin elasticity
with no fl accidness or a less elastic skin, as skin in this condition does
not tighten so readily around the newly contoured shape.14
The main indications include fat deposits in the abdomen, fl anks,
ankles, thighs, calves, buttocks, back of the arms, neck or elsewhere.
Because of improvements in technique and the development of less
traumatic cannulas, liposuction is also used as an adjuvant to many
procedures with no increase in morbidity. The main indications include:
Summary
1. Liposculpture is a technique that remodels the body and facial
contouring by the removal and addition of fat
2. It is indicated for reconstructive and cosmetic purposes
3. A very convenient donor site is the infra-umbilical area
4. Outcomes have improved in the last few years because of the
improvement of technical details
5. Complications are rare but some of them are life threatening
and must be recognized and avoided
6. Pulmonary embolism is the most frequent cause of death in
liposuction
7. The limit of liposuction has not yet been defi ned
8. Removal of up to 5000 cc is related to a reduced number of
systemic complications
9. The main challenge of plastic surgeons in the future is to
decrease the rate of fat resorption in liposculpture
INTRODUCTION
Liposculpture is a technique used to restore or improve facial and body
contouring by removing localized fat deposits with small blunt-tipped
cannulas connected in a suction device. This procedure can be associ-
ated with injections of the removed autologous adipose tissue where
needed.1,2 It is also named as liposuction, lipoplasty, suction lipectomy
or suction-assisted fat removal.
The development of liposuction techniques made the autologous
fat injection a more reliable procedure. The term liposculpture was
initially used by Fournier to describe syringe liposuction associated
with fat injection.3 However, considering the etymology of the word
‘liposculpture’, its concept can be extended for all of liposuction tech-
niques because most of these procedures are performed to improve
body shape only by removing fat deposits.
Although many authors have reported good results with the use of
suction-assisted liposuction, power-assisted liposuction or ultrasonic-
assisted liposuction.4,5,6 or vibrating cannulas, others support the use
of syringe liposculpture,7,8,9 mainly because this technique is precise
and promotes less trauma of the adipose tissue. Therefore, this chapter
will detail the main liposculpture techniques with special attention for
syringe liposculpture.
CONSIDERATIONS ABOUT THE
ADIPOSE TISSUE
Adipose tissue is composed by fat cells organized in lobules. Each lobule
has its own vascularization. Adipose cells are originated from fi bro-
blast-like cells, called preadipocytes, which develop to become a mature

19
LIPOSCULPTURE
260
● liposuction of gynecomastia15
● liposuction of the jaw and neck area in the facelift17
● abdominoplasty with liposuction of the fl anks and to reduce ‘dog
ears’
● liposuction prior to lipoabdominoplasty18
● liposuction prior to the lifting of the thighs and arms.19
Penile augmentation can also be done with fat injection. Panfi lov
(2006)20 showed that the circumference of the penis increased 2 cm to
3 cm in 88 patients.
Liposuction techniques are also indicated for reconstructive pur-
poses mainly to reduce fl ap thickness. It also can be used in association
with fat transplantation to treat Romberg’s disease, HIV-related lipo-
dystrophy, hemifacial microsomia syndrome and to correct liposuction
sequelae.13,21
Other reconstructive indications include: laryngoplasty22 and treat-
ment of urinary incontinence by lipoinjections in the periurethral
area.23
ANESTHESIA AND PREOPERATIVE
PREPARATION
Liposuction can be performed under local anesthesia with or without
intravenous sedation, regional anesthesia (epidural or spinal) and
general anesthesia.14
Immediate preoperative preparation includes urethral catheteriza-
tion and the placement of an intermittent compressive device on the
lower legs to reduce the incidence of pulmonary embolism prevention.
PREPARATION OF THE ADIPOSE TISSUE
TO BE ASPIRATED, MATERIALS USED
TO PERFORM LIPOSUCTION AND
SURGICAL TECHNIQUES
Since the initial description of the liposuction technique, there has
been a signifi cant evolution regarding the preparation of the adipose
tissue to be aspirated as well as the operative techniques and the sur-
gical instruments used.24 Therefore, these three aspects of the liposuc-
tion techniques will be discussed in detail.
Preparation of the adipose tissue to
be aspirated
Preparation of the adipose tissue is also known as ‘injection of the
liposuction fl uid’. This is very important mainly because the fl uid
injection determines the amount of fat to be aspirated, the amount of
blood loss during the procedure and has a role on some postoperative
complications.25
The liposuction technique was initially described with an initial
injection of a hypotonic solution containing saline (100 cc), distilled
water (20 cc), hyaluronidase (100 U) and epinephrine (0.1 cc).15,21 The
purpose of this was to damage the fat cell membrane thus making the
later aspiration of the adipose tissue easier.
Fournier, in 1983, described the liposuction technique with no
previous injection of hypotonic fl uids. This technique was named the
dry method. According to this author the hypotonic solution did not
damage the surface of fat cells and also increased surgical time. The
main disadvantage of the dry method was the greater amount of peri-
operative blood loss, which required postoperative blood transfusion.3
This method is seldom used today.
Currently, the majority of plastic surgeons use a previous infi ltra-
tion of a fl uid containing saline solution (500 cc) with 1 ml of epineph-
rine (1 : 1000 000). The fi nal epinephrine concentration of this solution
is 1 : 500 000. In cases where there is a small amount of fat to be
aspirated (retouching or fat injection) a 20 cc of a 2% lidocaine could
be associated with the fl uid.
Therefore, liposuction methods can be classifi ed according to the
amount of fl uid to be injected in the adipose: dry, wet, super-wet and
tumescent method.
When the dry liposuction method is applied, there is no fl uid infi l-
tration and blood loss is estimated as being between 20% to 45% of
the fi nal aspirated volume.
The wet liposuction method includes the injection of 200 to 300 cc
of fl uid into the area marked prior to liposuctioning. The estimated
volume of blood loss is around 4–30% of the fi nal aspirated volume.
The super-wet method is considered when the volume of fl uid to
be injected into the area to be suctioned is about the same as the
volume of fat to be removed.
This is the preferred technique for liposuction by many plastic
surgeons, mainly because of the reduced blood loss, which is about 1%
of the fi nal aspirated volume.
In the tumescent method a larger amount of fl uid is injected into
the area to be aspirated; as much as 2–3 times the volume of adipose
tissue to be aspirated. The volume of blood loss is about 1% of the
fi nal aspirated volume.16
Materials used to perform liposuction
According to the initial descriptions of the technique, cannulas pre-
sented a greater evolution. Initially, blunt-tipped cannulas with more
than 5-mm bore were used. These cannulas allowed surgeons to
remove a greater amount of adipose tissue; however, it was noted that
the number of complications in the postoperative period was directly
proportional to the diameter of the cannula. The main and most
serious postoperative complication was blood loss and skin irregulari-
ties. Illouz demonstrated that if a 1500–3000 cc fat was removed, 25%
of total blood volume needed to be transfused in the immediate post-
operative period.15,26
With the purpose of avoiding these complications, new cannulas
were developed with small diameters and more perforations to reduce
trauma and blood loss, as well as improving the postoperative results.
New infi ltration fl uid formula (with epinephrine) aimed to reduce
postoperative skin irregularities and blood loss, and avoid the necessity
for postoperative blood transfusion.
Currently, most frequently used cannulas are thin, multi-perforated,
blunt-tipped cannulas with a 2–4-mm bore.
Despite the development of new liposuction techniques such as the
methods described above, syringe liposuction seems to be the one that
allows the best control over the fi nal volume of aspirated fat and results
in the best surgical refi nement, with the least risk of postoperative
complications and need for retouching. Syringe liposuction also allows
surgeons to remove a larger number of viable fat cells that can be used
for fat transplantation, because of the reduced trauma to the adipose
tissue. When fat transplantation is being considered, the removed fat
should be re-injected immediately in multiple tunnels, as recom-
mended by Coleman.27,28 This procedure is widely used to treat depres-
sions or irregularities, improve anatomical structures of the face and
body, and treat liposuction sequelae.29
Surgical techniques
Liposuction can be performed using many different techniques and the
mechanisms by which the cannulas work are also varied. The main

Results
261
liposuction techniques are: syringe liposuction, suction-assisted lipo-
suction (cannula attached to a vacuum device), power-assisted liposuc-
tion, ultrasound-assisted liposuction, laser-assisted liposuction and
external ultrasound-assisted liposuction. The last four techniques use
a standard suction device to remove the fat.
Syringe and suction-assisted liposculpture are the most commonly
used methods of liposuction. In these techniques localized fat deposits
are removed via a small cannula, which is inserted into a previously
marked treatment region through a stab incision and attached to a
syringe or a vacuum device.1
Power-assisted liposuction was developed to reduce both trauma to
nerves and vessels, and surgeon fatigue. In this technique a special
cannula is connected to a device that produces mechanized move-
ments so that the surgeon does not need to move the cannula manu-
ally.14 This device can be powered electrically or by compressed air.
Ultrasound-assisted liposuction is also named ultrasonic liposuc-
tion. In this technique fat is removed via a special cannula linked in
an ultrasound device that transmits vibrations to the treatment region.
The vibrations rupture the walls of the fat cells, liquefying the adipose
tissue and making it easier to remove. Afterwards, suction-assisted
liposuction is performed to remove the liquefi ed adipose tissue. It is
important to stress the potential for skin necrosis with this technique
if superfi cial liposuction is performed.4–6
Laser-assisted liposuction works in a similar way to ultrasound-
assisted liposuction. There are, however, many reports of skin burns
when this technique is used to perform superfi cial liposuction.30 There-
fore, when superfi cial liposuction is indicated this technique should
be avoided.
External ultrasound-assisted liposuction has been described to
facilitate fat emulsifi cation, making suction removal easier. Using this
technique external ultrasound energy is delivered to the target areas.
This technique is not widely used and its effectiveness is doubtful.
The techniques described above were developed to reduce trauma,
surgical time and surgeon fatigue, and to facilitate fat suction.16,30
However, as suction-assisted and syringe liposuction are the most
commonly used methods this chapter will detail syringe liposuction;
the technique outlined is associated with a previous infi ltration of a
fl uid containing saline (500 ml) and epinephrine (1 : 1000 000) – a
super-wet method.
After the application of an antiseptic solution (chlorhexidine glu-
conate) over the area to be treated, ‘liposuction fl uid’ is infi ltrated with
a 15–25-cm multi-perforated, blunt-tipped cannula inserted through stab
incisions made with a 15 blade, adjacent to the area to be aspirated.
The most commonly used cannulas are 2–4-mm bore, 20–35-cm
long blunt-tipped, which are attached to a 60 ml disposable syringe.
At the time of surgical planning it is important to verify which
areas are to be treated. When the regions to be aspirated include the
back, the procedure should be started with patient in prone position.
With the patient in this position it is possible to treat a number of
regions including: posterior thoracic region, fl anks, culottes, thighs,
knees and legs. After removal of the desired fat volume, incisions are
closed with single 5–0 nylon suture and an adhesive bandage is applied
over each incision.
The patient is then turned to the supine position and the antisep-
tic solution is applied over the previously marked area. In this position,
surgeons are able to treat the abdomen and/or the culottes, internal
region of thighs, knees and legs if necessary. Again, incisions are closed
with single 5–0 nylon suture and an occlusive bandage is applied.
At the end of the procedure a compression garment is applied over
all of the treated areas. This garment should be used for 30 days to
reduce postoperative swelling and distortions, allowing the skin to
adhere to its new position.
RESULTS
Patients with localized fat deposits (not obese) observe excellent long-
term results with a signifi cant improvement in body contour.
It is important to stress that liposuction is not an alternative to
exercise and diet. Patients should thereafter control their weight to
guarantee the best surgical results.
Some clinical examples using syringe liposuction plus super-wet
method are shown in the fi gures.
A
B
Fig. 19.1 A, Posterior view of a 31-year-old
male before liposuction of the lumbar area
and fl anks. B, One year postoperative result.
Liposuction was performed with syringe.

19
LIPOSCULPTURE
262
A
B
A
B
Fig. 19.2 A, Preoperative oblique view of a
42-year-old female who presented excessive
fat deposit in the anterior abdomen, fl anks
and at the lateral aspect of the chest wall.
B, One-year postoperative view after syringe
liposuction.
Fig. 19.3 A, A 34-year-old female who
presented excess fat in the lateral aspect of
the buttocks and thighs. B, Six-month
postoperative view after syringe liposuction.
COMPLICATIONS
Complications of liposuction can be minimized by correct selection of
the technique to be used, proper preoperative planning regarding the
site and volume of fat to be removed, and attention to the principles
of the surgical technique. When they do occur, complications can be
divided into two categories: 1) systemic and 2) local.
Systemic complications
Systemic complications are most often related to either the liposuction
technique or to the patient’s predisposition. Appropriated surgical
technique and preventive care should be considered, especially in
patients that present a higher risk for complications. The most fre-
quent systemic complications are:

Complications
263
● Pulmonary embolism: The risk of thrombosis is related to blood-
fl ow decrease in the lower limbs, trauma and hypercoagulability.
The two former factors occur during liposculpture because of the
patient’s position during surgery and the duration of the procedure.
Hypercoagulability can also occur in patients who present with this
condition or when patients are on medications such as birth control
pills. Smith et al31 checked the prothrombine time, partial active
thromboplastine time, antithrombine III and the thrombine–
A
B
Fig. 19.4 A, A 38-year-old female who
presented excess fat in the lateral aspect of
the buttocks and thighs. B, Eight-month
postoperative view after syringe liposuction.
A
B
antithrombine complex serum levels in patients who underwent
liposuction. These authors verifi ed that there were no changes that
could infl uence coagulation. Prevention can be achieved with the
use of compressive stockings, compressive devices for the lower
limbs and low-molecular-weight heparin.
● Fat embolism: It has been reported that clinical fat embolism can
occur frequently in liposuction. Kenkel et al32 performed liposuc-
Fig. 19.5 A, A 28-year-old famale who
presented excess fat in the lateral aspect of
the buttocks and lumbar area. B, One-year
postoperative view after syringe liposuction.

19
LIPOSCULPTURE
264
tion on six swine and verifi ed that all of them presented small
pulmonary emboli verifi ed on the autopsy, although no clinical
signs were noted during or after the procedure. It is diffi cult to avoid
this complication and the anesthesiologist should be prepared to
avoid progression to vessel obstruction.
● Abdominal perforation: This usually occurs during liposuction but
the abdominal wall can also be perforated during fl uid infi ltration.
Existing small hernias (1–2 mm in diameter) can not be diagnosed
clinically by ultrasound or by any other imaging methods. Their
usual location is in the midline at the umbilical and supraumbili-
cal area. Also, the subcostal area in some patients can be projected
and this condition facilitates the penetration of cannulas. As the
cannula is moued back and forth, the risk of visceral perforation
should always be considered.9
The most common serious complication of liposuction technique is
pulmonary embolism as a result of blood fl ow decrease to the
lower extremity, trauma and hypercoagulability.
Lidocaine toxicity: Lidocaine toxicity occurs when the serum level
of this medication is above 5 μg/ml. Its maximum dose is 7 mg/kg
of body weight; however, the maximum subcutaneous safe dose
has been estimated to be up to 35 mg/kg of body weight when the
super-wet technique is used.
A
B
Fig. 19.6 A, Frontal view of a 24-year-old
female who presented excess fat in the
anterior abdomen, fl anks and lumbar area.
B, One-year postoperative after syringe
liposuction. C, Lateral aspect of the
abdomen and lumbar area. D, Lateral view
on which the distance between the anterior
and posterior abdominal wall has decreased
signifi cantly one year after the procedure.
C
D

Limits
265
This became possible for several reasons. The volume injected
during liposuction promotes some com pression on the wall of the
vessels, thus decreasing reabsorption; lidocaine absorption is low in
subcutaneous tissue; this drug is diluted in a large amount of fl uid
which also decreases the reabsorption; and, fi nally, before the whole
amount of injected lidocaine is in the serum, part of it has already
been eliminated.
A relevant fact is that lidocaine, when injected into the
subcutaneous tissue, has a serum peak of 6–8 hours after the
injection. When local anesthesia is used, some of these patients
are discharged at the end of the operation so that the higher serum
levels can occur when patients are away from the hospital.
High serum levels of lidocaine can lead to seizures, coma and
cardiac arrest.
Infi ltration of lidocaine has been used in patients who had undergone
liposuction under general anesthesia. These plastic surgeons advocate
the use of lidocaine to prevent postoperative pain. Perry et al33 verifi ed
that there is no postoperative pain reduction when this method is
used.
● Infection: Localized infection is not rare in patients who have
undergone liposuction, especially in those who return to daily
activities prematurely. The main concern in these cases is that skin
retraction and subcutaneous atrophy may occur. Toxic shock syn-
drome is the complication of most concern to plastic surgeons. It
is a life-threatening complication and is the result of a toxin pro-
duced by Staphylococcus aureus. The initial symptoms and signs
are non-specifi c, such as high temperature, diarrhea and vomiting.
When hypotension, cutaneous rash and oliguria occur, diagnosis
of this syndrome should be considered. Necrotizing fasciitis in
liposuction treatment areas is part of the symptoms of this syn-
Fig. 19.7 A, A 36-year-old female who
presented excess fat in the lateral aspect of
the buttocks and thighs. B, Eighteen-month
postoperative view after syringe liposuction.
drome. These patients need immediate intensive care and radical
removal of the necrotic tissue.
Other cited34 though rare, complications are: vasculopathy,17 hyperpig-
mentation,19 third space fl uids shifts, and hemorrhage.7
Complications of liposuction beside pulmonary embolism and
lidocaine toxicity include infection, visceral perforation,
vasculopathy, fl uid overload, excessive bleeding, local irregularities,
persistent edema, induration, and fat necrosos.
Local complications
Local complications are more frequent than the systemic ones and
some of them could be avoided or the effects minimized. Edema,
ecchymosis and seroma at the aspirated areas are common events and
can occur in almost every surgical procedure.19 The effects usually
disappear 2–3 weeks after surgery.
Although rare, prolonged edema and induration can last for up to
1 year.26 Manual lymphatic drainage35 and the use of a compressive
dressing are adjuvant postoperative care procedures that can minimize
edema and pain.
Liponecrosis and pseudocyst formation are complications that can
occur when the volume of fat injected into one site exceeds 20 cc.14,15
These complications can be avoided with the injection of a small
amount of fat graft through multiple tunnels.20,21
Depressions or irregularities in the liposuctioned area may also
occur after any treatment.10 These deformities can be treated with fat
injection. These complications can occur when patients have excess
skin and also if aggressive superfi cial liposuction is carried out.
LIMITS
The maximum volume of fat that can be injected has not yet been
determined.36,37 It is known that if a large volume of fat is injected into
one area there is a greater possibility of fat necrosis and fat-graft reab-
A
B

19
LIPOSCULPTURE
266
sorption, and oily cysts may form. Also, calcifi cation may occur with
time.
The risks associated with the procedure increase when a large
volume of fat is aspirated. The safety limit for liposuction was around
2000 cc when the dry technique was used. However, after the super-
wet technique was described by Klein38 in 1987, surgeons began to
remove larger volumes of fat.
During the 1990s there was an increase in the number of fatalities
following these procedures in comparison with the previous decade.
These casualties did not occur due to hemorrhage but were secondary
to other factors. Grazer and de Jong39 found that the mortality rate for
patients who had undergone liposuction was approximately 1 : 5000.
The main causes of death were pulmonary embolism (23.1%) and
abdominal organ perforation (14.6%). Deaths related to anesthesia,
sedation and medication occurred in 10% of the cases; however, this
number is probably an underestimate, as most deaths related to lido-
caine toxicity occur at home and in 28.5% of the cases an etiologic
cause of death was not identifi ed.
The American Society of Plastic and Reconstructive Surgery
suggests that using the super-wet technique, removal of up to 5 L
of fat is considered within the safety limits.
Larger volume removal should be performed by a well-trained team
specialized in large-volume liposuction. Brazil is one of the only coun-
tries that have a resolution of the Federal Council of Medicine that
limits the maximum volume of fat tissue to be aspirated to 7% of the
patient’s body weight. Another limit that should be respected is 40%
of the body surface.
REFERENCES
1. Toledo LS. Syringe liposculpture: a two year experience. Aesth Plast Surg
1991; 15:321–326.
2. Har-Shai Y, Lindenbaum E, Bem-Itzhak O, Hirshowitz B. Large
liponecrotic pseudocyst formation following cheek augmentation by fat
injection. Aesth Plast Surg 1996; 20:417–419.
3. Fournier PF. Reduction syringe liposculpturing. Dermatol Clin 1990;
8:539–551.
4. Zocchi M. Ultrasonic liposculpturing. Aesth Plast Surg 1992; 16:287–
298.
5. Bruno G, Amadei F, Abbiati G. Liposculpture with ultrasound:
biomedical considerations. Aesth Plast Surg 1998; 22:401–403.
6. Grippaudo FR, Matarese RM, Macone A, Mazzocchi M, Scuderi N.
Effects of traditional and ultrasonic liposuction on adipose tissue: a
biochemical approach. Plast Reconstr Surg 2000; 106:197–199.
7. Fournier PF. Fat grafting: my technique. Dermatol Surg 2000; 26:1117–
1128.
8. Pereira LH, Radwanski HN. Fat grafting of the buttocks and lower
limbs. Aesth Plast Surg 1996; 20:409–416.
9. Toledo LS, Mauad R. Complications of body sculpture: prevention and
treatment. Clin Plast Surg 2006; 33:1–11.
10. Ishizuka MMA. Lipoaspiração e enxerto de gordura. In: Ferreira LM
(ed.) Manual de cirurgia plástica. São Paulo: Ed. Atheneu; 2000:295–
297.
11. Illouz Y-G. Reutilização do tecido adiposo lipoaspirado. In: Avelar
JM e Illouz Y-G (eds) Lipoaspiração. São Paulo: Ed. Hipócrates;
1986:117–122.
12. Illouz Y-G. Estudo do adipócito nas lipodistrofi as. In: Avelar JM e Illouz
Y-G (eds) Lipoaspiração. São Paulo: Ed. Hipócrates; 1986:19–23.
13. Barcellos J. Enxerto de gordura. In: Mélega JM, Zanini SA, Psillakis JM
(eds) Cirurgia plástica reparadora e estética. São Paulo: Ed. Medsi;
1992:801–804.
14. Pitman GH. Liposuction and body contouring. In: Aston SJ, Beasley RW,
Thorne CHM. Grabb and Smith’s Plastic Surgery.
Philadelphia:Lippincott-Raven; 1997.
15. Barcellos J. Lipoaspiração. In: Mélega JM, Zanini AS, Psillakis JM.
Cirurgia Plástica – Reparadora e Estética. Medsi. 2ª. Edição; 1992:791–
800.
16. Beran SJ. Contorno corporal. In: Weinzweig J. Segredos em Cirurgia
Plástica. Porto Alegre: Artmed; 2001:422–425.
17. Mottura AA. Facelift postoperative recovery. Aesth Plast Surg 2002;
26:172–180.
18. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al.
Lipoabdominoplasty with selective and safe undermining. Aesthetic
Plast Surg 2003; 27(4):322–327.
19. Erazo PJ, de Carvalho ACO. ‘Lipolifting’ de braço com tratamento da
fáscia superfi cial (‘Lift’ Fascial). In: Badin AZ, Ferreira LM.
Videoendoscopia no Contorno Corporal e Procedimentos
Complementares. Ris de Janeiro: Revinter; 2007:317–26.
20. Panfi lov DE. Augmentative phalloplasty. Aesth Plast Surg 2006;
30:183–197.
21. Feinendegen DL, Baumgartner RW, Vuadens P, Scroth G, Mattle HP,
Regli F, Tschopp H. Autologous fat injection for soft tissue
augmentation in the face: a safe procedure? Aesth Plast Surg 1998;
22:163–167.
22. Sato K, Umeno H, Nakashima T. Histological investigation of
liposuctioned fat for injection laryngoplasty. Am J Otolaryngol 2005;
26:219–225.
23. Palma PC, Riccetto CL, Herrmann V, Netto NR Jr. Repeated
lipoinjections for stress urinary incontinence. J Endourol 1997; 11:67–70.
24. Toledo LS, Mauad R. Fat injection: a 20-year revision. Clin Plast Surg
2006; 33:47–53.
25. Nahas FX. Is the measurement of the fat volume removed in
liposuction realistic? Plast Reconstr Surg 2001; 108:1834–1835.
26. Illouz YG. Body contouring by lipolisis: A 5-year experience with over
3.000 cases. Plast Reconstr Surg 1983; 72:591.
27. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesth Plast Surg 1995; 19:421–425.
28. Coleman SR. Hand rejuvenation with structural fat grafting. Plast
Reconstr Surg 2002; 110:1731–1744.
29. Illouz YG. Utilização da gordura aspirada. In: Badin AZ, Ferreira LM.
Videoendoscopia no Contorno Corporal e Procedimentos
Complementares. Ris de Janeiro: Revinter; 2007:287–300.
30. Badin AZD, Teixeira V. Laserlipólise. In: Badin AZ, Ferreira LM.
Videoendoscopia no Contorno Corporal e Procedimentos
Complementares. Ris de Janeiro: Revinter; 2007:301–316.
31. Smith KA, Levine RH. Infl uence of suction-assisted lipectomy on
coagulation. Aesthetic Plast Surg 1992; 16(4):299.
32. Kenkel JM, Brown SA, Love EJ et al. Hemodynamics, electrolytes, and
organ histology of larger-volume liposuction in a porcine model. Plast
Reconstr Surg 2004; 113(5):1391–1399.
33. Perry AW, Petti C, Rankin M. Lidocaine is not necessary in liposuction.
Plast Reconstr Surg 1999; 104(6):1900.
34. Anwar UM, Ahmad M, Sharpe DT. Necrotizing fasciitis after
liposculpture. Aesth Plast Surg 2004; 28:426–427.
35. Rubin A, Hoeffl in SM, Rubin M. Treatment of postoperative bruising
and edema with external ultrasound and manual lymphatic drainage.
Plast Reconstr Surg 2002; 109:1469–1471.
36. Nahas FX. Lipoaspiracad-Ricsos e Limites. In Toledo LS (ed.)
Lipoplastia. Sâo Paulo: Di-liveos Editora 2006:21–28.
37. Nahas FX, Ferreira LM. Lipoasperacão. In Ferreira LM (ed.) Guia de
Medicina Ambulatorial e Hospitalar UNIFESP – Escola Paulista de
Medicina. São Paulo: Ed Marole 2007:717–722.
38. Klein JA. Tumescend technique. Am J Cosmetic Surg 1987; 4:623.
39. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey
of cosmetio surgeons. Plast Reconstr Surg 2000; 105(1):436.

267
CHAPTER 20
Abdominoplasty
Al Aly, Silvia Cristina Rotemberg and Albert Cram
INTRODUCTION
The modern history of abdominal contouring began in 1899 with
Kelly1,2 performing an abdominal apronectomy or dermolipectomy to
eliminate a large abdominal pannus. In 1957, Vernon3 described umbi-
licus transposition. Gonzalez-Ulloa4 in 1959 popularized the abdomi-
noplasty technique describe by Somalo5 in 1946 where he resected a
circular skin pattern from the lower abdominal region extending
around the waist in a belt lipectomy fashion. In 1967, Pitanguy6 pre-
sented his technique consisting of inconspicuous scars in the lower
abdomen and groin, wide superior dissection up to the costal margins
and xiphoid, plication of the transverse abdominal rectus muscle and
umbilicoplasty. Regnault,7 in 1972, introduced the concept of abdom-
inoplasty in a ‘W’ pattern, and in subsequent years described modifi ca-
tions of the technique including a fl eur-de-lis and modifi ed belt
lipectomy. Grazer,8 in 1973, reported 44 cases of abdominoplasty
hiding the incision in the bikini line. The concept of miniabdomino-
plasty was introduced by Elbaz and Flageul9 in 1971, and later modifi ed
by Glicenstein10 in 1975. The introduction of liposuction in the late
70s added a signifi cant tool to abdominoplasty and body contouring
in general.11 Matarasso,12,13 in the late 80s, made a signifi cant contri-
bution by introducing his classifi cation scheme and by describing the
incorporation of liposuction with modifi ed abdominoplasty procedures.
Lockwood,14 in 1991, described a new concept – the superfi cial fascial
system (SFS), which is a highly organized collagen structure respon-
sible for anchoring the skin of the body and for supporting the weight
of the fat throughout life. In 1995 he introduced a high lateral tension
abdominoplasty (HLTA), which was designed to create more lateral
abdominal improvement and anterior thigh elevation.15 Within the
past decade Saldanha16 introduced and popularized ‘lipoabdomino-
plasty’, which has become fairly popular in South America and Europe.
It is a technique that utilizes extensive liposuction of the entire
abdomen combined with minimal undermining in the hope of reduc-
ing the risks of tissue necrosis and seroma formation.
INDICATIONS
Abdominoplasty
Indications
●
Skin and subcutaneous tissue excess and/or laxity limited to
the anterior abdomen
●
Abdominal wall musculoaponeurotic laxity
Contraindications
●
Generalized obesity
●
Excessive intra-abdominal content
Summary
1. Abdominoplasty is indicated for skin and subcutaneous tissue
excess and/or laxity limited to the anterior abdomen and
abdominal wall musculoaponeurotic laxity
2. Contraindications include generalized obesity, excessive intra-
abdominal content, circumferential lower truncal excess,
smoking, and planned pregnancy in the near future.
3. A subcostal, open cholecystectomy scar is a relitive
contraindication for traditional abdominoplasty
4. Lipoabdominoplasty is an alternative technique to traditional
abdominoplasty that may be safer and associated with less
complications.
5. A high lateral tension abdominoplasty (HLTA) is fundamentally
different from the traditional abdominoplasty in that maximum
tension is created laterally, rather than centrally and it
attempts to not only improve abdominal contour, but also
enhance the appearance of the anterior thighs.
6. Regardless of the technique used, vascular territories are
interrupted and should be taken into account, especially when
upper abdominal scars are present. Zone I is supplied by the
deep epigastric arcade and these vessels are almost always
interrupted by fl ap elevation.
7. Many abdominoplasty scar patterns have been introduced
over the past fi ve decades to accommodate different clothing
patterns and potential improvements in contour.
8. The surgeon has to balance the needs of limiting the width of
the scar, eliminating lateral standing cones or dog-ears, and
appropriately positioning the mons pubis in the vertical
dimension.
9. Postoperatively patients are kept fl exed, in ‘beach chair’
position, but are expected to be walking later on the day of
surgery bent at the waist. They are not allowed to straighten
up for 1 week after surgery.
10. Abdominoplasty is an extensive operation and complications
include wound dehiscence, hematoma, wound infection
(including toxic shock syndrome), seroma, tissue necrosis,
contour irregularity, scarring, umbilical deformity, paresthesia,
deep vein thrombosis, and pulmonary embolus.

20
ABDOMINOPLASTY
268
●
Circumferential lower truncal excess (requires circumferential
treatment)
●
Unrealistic expectations
●
Medical or psychiatric instability
●
Smoking (considered to be a contraindication by most plastic
surgeons)
●
Planned pregnancy in the near future
Relative contraindications
●
Previous abdominal scars compromising blood supply
●
History of diabetes mellitus, chronic obstructive pulmonary
disease, cardiovascular disease, thromboembolic events
Mini-abdominoplasty
Indications
●
Abdominal laxity restricted to the infraumbilical region
High lateral tension abdominoplasty (HLTA)
●
To improve abdominal contour and enhance the appearance of
the anterior thighs
Lipoabdominoplasty
●
Alternative technique to traditional abdominoplasty but may
be safer and associated with less complications
Patients seeking abdominoplasty most often complain of excess skin
and subcutaneous tissue in the abdomen and abdominal protrusion
due to laxity of abdominal wall caused by previous pregnancy, weight
fl uctuations and/or aging. Many of these patients will present with
lipodystrophy of the hips and lateral thighs as well.17 A traditional
abdominoplasty is indicated when the deformities involve both the
supra and infraumbilical regions whereas a mini-abdominoplasty is
usually indicated if the problems are limited to the infraumbilical
region. Although most patients are female, males do present with
similar problems, but often complain of adiposity in the fl ank areas
and supraumbilical rectus diastasis.18–20
The ideal candidate for abdominoplasty is a young healthy woman
who is a nonsmoker and whose weight is within, or slightly above, the
normal range. In many cases, especially in middle-aged and older
women, patients present with concomitant lipodystrophy of the hips
and lateral thighs, as well as the abdominal deformities. These patients
are still amenable to abdominoplasty in combination with liposuction
of the areas of lipodystrophy. However, if the deformities involve the
lower trunk circumferentially, as in the massive-weight-loss patient or
some overweight patients, abdominoplasty can have disappointing
results. These patients usually require a circumferential truncal der-
matolipectomy to treat their deformities.
Obese patients are not good candidates for abdominoplasty because
they have excess intra-abdominal or visceral fat. The intra-abdominal
cavity can be thought of as a balloon that fi ts inside a second external
skin balloon. If the internal balloon is overly infl ated by visceral fat, it
cannot be effectively fl attened by musculoaponeurotic plication. Thus
it will maintain a convex profi le, which is translated to the external
balloon and will lead to a convex appearance for the entire abdomen.
This defeats the major reason why most patients seek abdominoplasty
surgery.
As with any elective plastic surgery procedure patients who have
unrealistic expectations of the potential results should either be advised
by their surgeon to change their expectations or should not be operated
on. Similarly patients who present with unstable psychiatric or medical
conditions should be avoided. The question about whether the risk
of carrying out an abdominoplasty in an individual who has well-
controlled diabetes mellitus is too high is controversial. Many surgeons
consider the risk posed by the decreased ability to fi ght infection,
potential vascular compromise, and decreased wound healing ability
too high.
Smoking has been implicated in occlusive microvascular thrombo-
sis and delayed wound healing and when associated with a procedure
that already compromises the blood supply of the abdominal skin fl ap,
can result in tissue necrosis and jeopardize the outcome. Active
smokers are excluded by most surgeons, but some surgeons are willing
to operate on them utilizing techniques that reduce abdominal fl ap
elevation to reduce the risk of vascular compromise.21–23
Abdominal wall plication can increase intra-abdominal cavity pres-
sure and this can potentiate certain problems.
● First, the increased intra-abdominal pressure may elevate the
diaphragm and compromise pulmonary function, especially in
patients who have chronic obstructive pulmonary disease. Thus it
is important to work-up these patients and make sure that they
can withstand further pulmonary stress prior to contemplating
abdominoplasty surgery.
● Second, increased intra-abdominal pressure after abdominoplasty
results in decreased venous blood fl ow through the common iliac
vessels, which predisposes patients to deep venous thrombosis
(DVT) and pulmonary embolus (PE). Therefore, patients with a
history of DVT and/or PE should undergo a thorough evaluation
for potential recurrence, and in some, surgery may be contraindi-
cated. A temporary or traditional Greenfi eld fi lter may be consid-
ered in this instance in conjunction with a vascular surgery
consultation.
Although it is always best for women to undergo abdominoplasty after
they have had children and when they do not plan any more, many
patients do become pregnant and have children after the procedure.
Some of the benefi ts of abdominoplasty may be reduced or eliminated
by pregnancy, thus it is wise to postpone the procedure if a pregnancy
is anticipated in the near future.
Previous abdominal scars
Patients with previous abdominal scars may require special consider-
ations if abdominoplasty is contemplated.
● McBurney-type appendectomy scars have little effect on surgical
planning because they are simply resected during panniculus
excision.
● Lower abdominal transverse scars, usually utilized for hysterec-
tomy, are similarly nonproblematic because they are generally
resected during abdominoplasty.
● A subcostal, open cholecystectomy scar can contraindicate a tradi-
tional abdominoplasty, with its extensive abdominal fl ap under-
mining, which reaches up to the costal margins and xiphoid. The
only feeding vessels to the elevated abdominal fl ap in that instance
consist of the lateral intercostals, subcostal, and lumbar perforator
vessels, which course anteriorly in the fat superfi cial to Scarpa’s
fascia. These vessels are interrupted by a subcostal scar and this
can lead to abdominal fl ap necrosis inferomedial to the scar.
Recently created subcostal scars, within the past 2–3 years, usually
contraindicate traditional abdominoplasty. Patients who present
with old subcostal scars can sometimes undergo an abdomino-
plasty, but with techniques that limit fl ap elevation.
● A midline abdominal scar does not usually prevent abdominoplasty
surgery. If the scar is limited to the infraumbilical level, it will
usually be removed with the abdominal panniculus and should not
prevent the procedure from creating the best possible abdominal
contour. If the incision is supraumbilical, it usually does not
prevent the fl ap from being advanced appropriately. However in
some patients, the scar may be hypertrophic and may restrict

Preoperative Considerations
269
abdominal fl ap advancement during the tailoring process. In these
patients resecting the scar only, without the underlying fat layers,
will allow the advancement. However, even this maneuver may
lead to an increased risk of fl ap necrosis, because dermal vessels
cross over in the midline and can lead to a decrease in blood supply
of the inferomedial aspects of the abdominal fl ap. A less risky way
to attain the desired fl ap advancement is to create multiple small
puncture stab incisions along the hypertrophic scar allowing release
of the contracted tissues. If a patient desires a revision of the
midline scar, it is generally best to perform that in a subsequent
procedure after the fl ap has had enough time to revitalize its blood
supply in its new position.
Mini-abdominoplasty
Indications for mini-abdominoplasty are limited to patients who
present with abdominal laxity restricted to the infraumbilical region.24
The laxity has to be minimal and may be of the abdominal wall and/
or of the skin/fat envelope. Physical examination of the abdomen in
the supine position will demonstrate infraumbilical rectus diastasis,
which can be confi rmed by the ‘diver’s test’ (see Fig. 20.1). These
patients are usually young women who have had one or two pregnan-
cies, have good skin elasticity, and are not overweight. Mini-abdomi-
noplasty, with any of its modifi cations, is not a procedure that is often
employed because it is the unusual patient that will fi t its required
criteria.
High lateral tension abdominoplasty
An HLTA15,25 is fundamentally different from the traditional abdomi-
noplasty in the following ways:
● maximum tension is created laterally, rather than centrally as in
traditional abdominoplasty;
● HLTA attempts to not only improve abdominal contour, but also
enhance the appearance of the anterior thighs by lifting that area
and creating a narrowing at the waist as a result of the lateral
emphasis;
● tension is maximized laterally, so the defect created by the circum-
umbilical incision is often not excised;
● the procedure allows for extensive liposuction of the abdominal fl ap
because of the dependence on discontinuous undermining for fl ap
mobilization, which leaves the fl ap with a more robust blood supply
when compared to a traditional abdominoplasty;
● because of the emphasis on lateral tension, HLTA often requires
an extension of the scar laterally to accommodate for the more
aggressive lateral resection.
Lipoabdominoplasty
Lipoabdominoplasty was introduced and popularized by Saldanha16
from Brazil. This technique, with a variety of its forms, is becoming
more popular around the world especially in South America and
Europe. For the surgeons who espouse lipoabdominoplasty, it is an
alternative technique that accomplishes many of the same goals as
traditional abdominoplasty but maybe safer and associated with less
complications (Box 20.1). Currently many American plastic surgeons
are starting to utilize the technique in its entirety or at least in some
of its main aspects. Lipoabdominoplasty has some similarities to
HLTA.
PREOPERATIVE CONSIDERATIONS
Preoperative evaluation of potential abdominoplasty patients includes
a good history and physical examination, and determination of their
primary concerns and expectations. Special attention should be paid
to weight fl uctuations, any history of pregnancy, diet and exercise
regimens, and previous abdominal surgery and/or hernias. A careful
medical history should be obtained along with a smoking history.
Physical examination
On physical examination the patient’s weight and height should be
determined. The body mass index (BMI), should be calculated based
on the formula: weight in kg/(height in m)2. The patient is initially
examined circumferentially in the standing position to evaluate the
abdominal contour from the rib cage to the mons pubis. However it
is also important to pay attention to the surrounding contours of the
posterior trunk, thoracic region, and thighs.
Three main components need to be evaluated in the physical
examination of the abdomen: the skin, the subcutaneous fat, and the
abdominal wall.
Skin
The overall quality of skin, including scars and stretch marks should
be noted. The skin should be examined to determine its vertical excess
and the extent of its laxity in the different regions of the abdomen.
Often multiparous women present with stretch marks that involve the
infra and supraumbilical regions.26 The patient needs to understand
that infraumbilical skin will most often be removed, but supraum-
bilical stretch marks will not. These remaining stretch marks are often
less unattractive when stretched by the procedure and can be hidden
by some bikini patterns because of their transference to the lower
abdomen.
Subcutaneous fat
The thickness of the subcutaneous fat of the anterior abdomen and
the surrounding lateral and posterior lower truncal regions should be
determined.
A protruding abdomen may be caused by a number of factors, alone
or in combination.
● In obese patients and some male patients, intra-abdominal fat
excess is responsible. In male patients, in particular, who have a
fat deposition pattern that predisposes them to large visceral fat
deposits, the abdominal panniculus thickness may be minimal
despite an extremely protrudent abdomen.18–20 These patients are
defi nitely not good candidates for abdominoplasty.
● Another reason for a protruding abdomen is a thick panniculus,
which is often encountered in overweight, obese, or post-massive
weight loss patients. If abdominoplasty surgery is contemplated on
a patient with a thick panniculus, it is important to choose a tech-
nique that allows for thinning of the fl ap. This usually involves
liposuction and limited undermining.
Box 20.1 Theoretical advantages of
lipoabdominoplasty
●
Reduction in seroma rate because of a lack of abdominal wall
fascia exposure, which has been implicated in increasing the
risk of seromas by some authors. Also, if lymphatic tissues,
especially of the femoral region, are left intact, seromas should
be less likely.
●
Because there is minimal elevation of the supraumbilical
abdominal fl ap, there should be an abundance of remaining
abdominal wall muscle perforators intact to supply the
abdominal skin and thus decrease the risk of tissue vascular
compromise.
●
In cases of a thick abdominal fl ap, liposuction and thinning
can be performed safely.

20
ABDOMINOPLASTY
270
Abdominal wall laxity
A third reason for a protruding abdomen is abdominal wall laxity. It
is essential to ascertain the integrity of the abdominal wall, whether
there are any hernias present, and the extent of intra-abdominal or
visceral fat. The exam is fairly easy in thin patients, but can be more
cumbersome and diffi cult in the overweight or obese patient.
A number of tests can be performed, which alone or in combina-
tion, can give the examiner a feel for the degree and extent of any
laxity. Initially the patient is asked to stand and relax their abdominal
wall completely. For many this is not easy and they must be coaxed
into cooperating. An appreciable amount of abdominal protrusion in
this position usually indicates signifi cant abdominal wall laxity. To
confi rm the result of this simple test, the patient is asked to perform
the classic ‘diver’s test’ (Fig. 20.1).
To get a more accurate estimation of abdominal wall laxity, the
patient is placed in the supine position and asked to lift the head and
upper back off the table while the examiner palpates the abdominal
wall. The extent of generalized laxity and the separation between the
rectus muscles should be noted. Most patients presenting for abdom-
inoplasty will demonstrate at least some degree of rectus diastasis.
Men have a propensity toward a supraumbilical diastasis, whereas
women most often present with infraumbilical muscle separation.
Abdominal wall laxity can be diffi cult to examine in patients with
thick panniculi. A distinction between subcutaneous and visceral fat
must be made because none of the techniques of abdominal contour-
ing are designed to address excess intra-abdominal fat. A helpful test
for these patients is to place them in the supine position and observe
their abdominal contour. If it dips below the level of the ribs, it is likely
that rectus fascia plication will be effective; if not, it can be presumed
that there is an excessive amount of intra-abdominal adipose tissue.
Attempting to perform an abdominoplasty on a patient with excessive
intra-abdominal content most often yields an unfavorable outcome.
Other features
The abdominal physical exam should also include an evaluation of the
mons pubis. The amount of excess fat should be determined. Any
degree of ptosis should be noted because it should be treated as part
of any abdominal contouring procedure. This is especially important
in high-BMI patients and those who have experienced appreciable
weight fl uctuations.
In examining the back, attention should be paid to the waist, hips,
localized fat deposits especially in the fl ank and lateral thigh regions,
any deviations in the spine, the depth of lumbar lordosis, and the
extent of buttock’s projection.
Counselling
Finally the patient is counseled about the risks, benefi ts, and alterna-
tives to surgery. He or she should have the opportunity to ask ques-
tions and express concerns and doubts. The patient should be well
informed about major and minor complications, how they may occur,
and how to prevent and treat them, should they occur. A good rapport
between patient and surgeon is essential and protects both patient and
surgeon when results are unfavorable.
Preoperative photographs
Preoperative photographs are taken in the anterior, posterior, lateral
and oblique views to demonstrate the full extent of deformities; they
guide surgical planning and serve as an important tool in the post-
operative assessment of the results.
OPERATIVE APPROACH
Relevant anatomy
In young, healthy men and women the waist is the narrowest circum-
ference of the torso, usually 2.5 cm cephalad to the umbilicus, which
lies on the midline at about the level of the iliac crests. Ideally, the
distance from the umbilicus to the anterior vulvar commissure is
18–21 cm, and the pubic hair line is 5–7 cm cephalad to the anterior
vulvar commissure.
The anterior abdominal muscle wall may be considered to have
two parts:
● an anterolateral portion composed of the external oblique, internal
oblique, and transversus abdominis muscles;
● a midline portion composed of the rectus abdominis muscle
(Fig. 20.2).
Fig. 20.1 The classic ‘diver’s test’. When the patient is fl exed at the
waist the lower abdominal musculature is relaxed enough to
demonstrate laxity in the infraumbilical region.
The classic “diver’s test” is shown
Anterior abdominal wall musculature
Anterior rectus
sheath
Transected rectus
abdominis muscle
Arcuate line
Posterior rectus
sheath
External oblique
muscle
Internal oblique
muscle
Fig. 20.2 Anterior abdominal wall musculature.

Operative Approach
271
The rectus muscle is enclosed in a stout sheath formed by a bilaminar
aponeurosis, which passes anteriorly and posteriorly around the
muscle, decussating in the midline to form the linea alba. Anteriorly
the sheath is made up of the external oblique fascia and the anterior
portion of internal oblique fascia. Posteriorly the sheath is made of
the posterior portion of the internal oblique fascia and the transversus
abdominis muscle fascia. Halfway between the umbilicus and the
pubis, the posterior sheath layers pass anteriorly at the arcuate line
of Douglas. The lack of support below the line of Douglas leads to a
natural tendency toward lower abdominal fullness.
The umbilicus lies in the midline at varying distances between the
xiphoid and the pubis symphysis, but usually level with the anterior
superior iliac spines (ASIS). It has a dual blood supply, from the deep
layer and from the skin, and it is able to survive on either. Caution is
warranted in patients with large umbilical hernias and previous
transections of the umbilicus.
Subcutaneous abdominal fat is compartmentalized into superfi cial
and deep layers divided by the superfi cial fascial system, which in this
region of the body is called Scarpa’s fascia. In patients who are rela-
tively thin, the two layers of fat are fairly close to each other in thick-
ness. In patients who have a large BMI the superfi cial fat layer is often
much thicker than the deep layer (Fig. 20.3). The superfi cial fat layer
is compact, dense with fat cells contained within well organized fi brous
septa, whereas the deep fat is a loose areolar layer.
Vascular zones
Regardless of the technique used when performing abdominoplasty,
vascular territories are interrupted and should be taken into account
especially when upper abdominal scars are present.27 Thus a thorough
knowledge of the blood supply of the abdominal skin and fat is essen-
tial. Huger28 studied the blood supply to the abdomen and designated
three vascular zones (Fig. 20.4):
● Zone I is supplied by the deep epigastric arcade. It extends from
the xiphoid to the pubis and from one lateral edge of the rectus
sheath to the other. The deep superior and inferior epigastric
vessels run through the rectus muscle, emitting musculocutaneous
perforators to the overlying fat and skin.
● Zone II extends from one ASIS to the other, down to the inguinal
creases and pubis. Its blood supply is derived from the superfi cial
branches of the circumfl ex iliac and external pudendal vessels.
Some branches of the deep circumfl ex iliac vessels, which course
above the ASIS course inferiorly into zone II from zone III above
as well.
● Zone III provides the blood supply to the anterolateral abdominal
wall, extending above the ASIS just lateral to the rectus sheath on
either side of zone I. It is supplied by intercostals, subcostal, and
lumbar arteries. Because these vessels travel inferomedially in the
superfi cial layer of abdominal fat, they overlap zone I vessels in
supplying medial skin.
Zone I vessels are almost always interrupted by fl ap elevation in an
abdominoplasty, leaving zone III vessels as the only remaining blood
supply. If zone III vessels are interfered with, such as in a subcostal
cholycystecomy scar, tissue inferomedial to the interruption may
necrose.
Sensory innervation
The sensory innervation of the anterior abdominal wall originates
laterally from the 6th to 12th thoracic nerves and 1st lumbar nerve.
The lateral femoral cutaneous nerve ( L2–L3) provides sensation
to the anterolateral thigh, is located 1–6 cm medial to the ASIS and
can be injured during dissection and closure of an abdominoplasty,
resulting in painful neuroma or anterolateral thigh paresthesia.
Iliohypogastric and ilioinguinal nerves supply sensory innervation
to the groin and symphysis pubis, proximal portions of the scrotum
and labia, and small adjacent area on the inner aspect of the thigh.
These nerves can be entrapped during plication of the anterior rectus
sheath in the lower abdomen.29,30
Fascial attachments
The lower trunk has fascial attachments between the skin and underly-
ing muscle fascia that act as anchoring points or zones of adherence31
(Fig. 20.5), which tether the overlying skin to the underlying
musculoskeletal anatomy, not allowing either descent or elevation
with aging, weight fl uctuation, or surgical manipulation.
● Posteriorly the midline has a zone of adherence that overlies the
spine.
● The anterior midline of the abdomen has a less defi ned zone of
adherence overlying the linea alba.
● There are three horizontal zones of adherence in the inferior aspect
of the lower trunk, which are responsible for the fact that
abdominoplasty scars do not end up in much higher positions
because they prevent unrestricted superior movement. The fi rst is
bilaterally located at the inguinal ligament extending towards the
Layers of the abdominal wall
Skin
Deep muscular fascia
Deep fat layer
Muscle
Superficial fascial
system (Scarpa’s fascia
anteriorly)
Superficial fat layer
Fig. 20.3 Layers of the abdominal wall.
Three zones of vascularity
Superior epigastric
artery
Superficial epigastric
artery
Ascending branch
of deep circumflex
iliac artery
Lumbar branches
Subcostal artery
Intercostal artery
Inferior epigastric
artery
Zone I
Zone II
Zone III
Fig. 20.4 Blood vessels that supply the abdominal wall. There are
three zones of vascularity.

20
ABDOMINOPLASTY
272
ASIS. The second is located just above the mons pubis, and though
this particular zone of adherence may occasionally not be vigor-
ously adherent, it is usually a strong zone of adherence. The third
is located bilaterally between the hip and lateral thigh fat
deposits.
Truncal tissues become lax due to aging, pregnancy, and/or massive
weight loss. They descend the greatest distance laterally, caused by a
combination of tissue laxity and central tethering of the midline zones
of adherence. As tissues descend around the pelvis they also migrate
centrally.
Operative techniques
Plastic surgeons vary in their approaches to any surgical procedure
and abdominoplasty is no exception. We present our preferred tech-
nique, though we tend to vary the technique depending on the patient
and his or her particular desires.
Markings
Many abdominoplasty scar patterns have been introduced over the
past fi ve decades. They have evolved over time to accommodate dif-
ferent clothing patterns and potential improvements in contour. We
prefer a ‘French Bikini’ pattern because it places the scar at the
natural junction between the abdominal and thigh units. However,
because of recent fashion trends we often utilize lower patterns to
accommodate patient wishes.
Preoperative markings are performed 1–2 two days prior to the
procedure to allow photography of the markings and evaluation of any
need for adjustments. However, some surgeons perform the markings
immediately prior to surgery or in the operating room.
In abdominoplasty the surgeon has to balance the needs of limiting
the width of the scar, eliminating lateral standing cones or dog-ears,
and appropriately positioning the mons pubis in the vertical dimen-
sion. The inferior aspect of the elliptical excision is generally longer
than the superior aspect creating a mismatch, which can lead to the
dog-ears. Patients who present in the lower BMI range generally do
not cause as much diffi culty with dog-ears as the patients who have a
larger BMI. Patients who have relatively inferiorly positioned umbilici
are also less troublesome with respect to dog-ears compared to those
who have fairly high umbilici.
To eliminate dog-ears three general approaches, individually or
in combination, can be utilized.
● First, the excision and scar can simply be extended laterally.
● Second, the lateral aspect can be closed fi rst to create a fl at surface
and subsequently the abdominal fl ap is cheated medially.
● Third, in cases of a superiorly located umbilicus, the umbilical
defect created by the circumumbilical incision can be closed on
itself leaving behind a vertical scar in varying positions. This will
reduce the vertical distance resected thus leading to less lateral
fullness.
The marking process begins by delineating the midline from the
xiphoid to the mons pubis. Centrally, the proposed lower abdominal
incision is marked in the natural suprapubic crease in most patients
who are within the normal weight range. For most patients undergo-
ing abdominoplasty the superior pubic hairline coincides with the
natural crease, but if there is no natural crease present then the
mark can usually be placed at the edge of the hairline. In massive-
weight-loss patients, and occasionally in fairly lax non-massive-
weight-loss patients, the mons pubis is ptotic and it is necessary to
place the incision a few centimeters within the hair-bearing pubic skin.
A good guide for most patients is a 7 cm distance from the top of the
fourchette or penis to the incision line.
It is obviously important to control fi nal scar position in abdomi-
noplasty, and it is therefore helpful to think of an abdominoplasty
closure in the same way as the closure of any elliptical defect. The
greatest tension and tissue distortion occurs centrally, with minimal
to no tension or distortion laterally (Fig. 20.6).
In abdominoplasty the fi nal position of the central scar, between
the lateral edges of the mons pubis, is a result of the balance of the
upward pull of the tailored abdominal fl ap and the opposing inferior
pull down of the zone of adherence at the suprapubic crease. A great
deal of attention should be paid to how this central area of greatest
tension will be manipulated to allow for the resection of the appropri-
ate amount of vertical excess without lifting the mons pubis to an
unnatural superior position. Once central tension is set, which actu-
ally takes place at the time of surgical resection, scar position lateral
to the mons pubis is much easier to predict because there is little tension
on either a superior or inferior direction by the lateral aspects of the
resected ellipse. Thus to complete the inferior aspect of the abdomi-
noplasty ellipse the marking is extended laterally, based on the desired
pattern of the fi nal scar. In a French-bikini pattern the extension is
made towards the ASIS. If a fl atter scar is desired, the mark is angu-
lated at the desired level. In general the scar will end up 1–2 cm above
the initial inferior incision in the area lateral to the mons pubis.
To approximate the superior extent of the ellipse, the patient is
placed supine and fl exed at the waist, and the ‘pinch technique’ is
utilized to approximate the superior extent of the incision. Ideally the
patient should have enough excess skin to allow for excision of the
skin from above the umbilicus to the inferior mark. Lipodystrophy of
any surrounding regions such as the fl anks, hips, and lateral thighs is
also marked for liposuction.
A
B
C
Fig. 20.5 Zones of adherence of the upper and lower trunk. A–C, The anterior midline of the abdomen has a less defi ned zone of adherence
overlying the linea alba. Posteriorly the midline has a zone of adherence that overlies the spine. There are three horizontal zones of
adherence in the inferior aspect of the lower trunk: bilaterally at the inguinal ligament extending towards the ASIS; just above the mons
pubis, and bilaterally between the hip and lateral thigh fat deposits.

Operative Approach
273
Fig. 20.6 Tension created by abdominoplasty across the abdomen.
Note that tension is signifi cant centrally and essentially goes to zero
laterally.
Fig. 20.7 Traction sutures. These put traction on the umbilicus to
facilitate the circumumbilical incision.
Fig. 20.8 Abdominal fl ap dissection is performed at the level of
Scarpa’s fascia, or just deep to it, in the femoral regions bilaterally.
This leaves behind important lymphatic channels to help drain the
lower abdominal region and presumably reduce seroma formation.
Abdominoplasty
● In the operating room, the patient is placed in the supine position,
intermittent compression devices are applied to the lower extrem-
ities, and a dose of perioperative antibiotic is given.
● Most plastic surgeons prefer to perform abdominoplasty under
general anesthesia because it allows complete muscle relaxation,
which is helpful during abdominal wall plication.
● If the procedure is going to require a long operative time, which
can occur when multiple other procedures are planned, an indwell-
ing urinary bladder catheter is placed.
● After the patient is prepped and draped, the operation begins by
circumferentially incising around the umbilicus. To facilitate the
incision and the subsequent creation of a neoumbilicus, retraction
sutures are placed at 12 and 6 o’clock (Fig. 20.7).
● A periumbilical dissection down to the level of the surrounding
rectus fascia is then performed making sure that a generous amount
of fat is left attached to the umbilicus to preserve its blood
supply.
● Next, the inferior mark of the proposed elliptical excision is incised
and abdominal fl ap elevation is performed. In traditional abdomi-
noplasty, an abdominal fl ap is elevated at the level of the underly-
ing muscle fascia, around the umbilicus, and up to the xiphoid and
costal margins. This type of wide undermining allows the greatest
amount of inferior abdominal fl ap advancement at the time of fl ap
tailoring, but it also compromises the greatest number of muscle
wall perforating vessels that directly supply the overlying fat and
skin. We, like many plastic surgeons, prefer to leave the subscarpal
fat down in the femoral region during abdominal fl ap elevation in
the hope of maintaining the prominent lymphatics of that region to
help reduce postoperative seroma formation (Fig. 20.8).
● Some surgeons prefer not to liposuction an extensively elevated
abdominal fl ap in fear of injuring its remaining blood supply – the
intercostal, subcostal, and lumbar vessels, which run in the fat
superfi cial to Scarpa’s fascia. Others liposuction the fl ap only if
they limit their elevation to either side of the midline, which is only
wide enough to allow for the needed plication (Fig. 20.9). This
conservative central elevation maximizes the number of intact
muscle perforator vessels to supply the tailored abdominal fl ap. As
a general rule, fl ap elevation should be restricted to just what will
allow both appropriate abdominal wall plication and adequate fl ap
advancement. Thus no matter which type of fl ap elevation is con-
templated in any particular patient, it is usually best to limit the
elevation initially and then release the tissues incrementally to
allow for appropriate plication and contour.
● Next, the patient is fl exed at the waist, abdominal wall laxity is
examined, and a vertical elliptical plication is marked from the
xiphoid to the symphysis pubis (Fig. 20.10).
● Often the anesthesiologist is asked to relax the patient prior to
starting the plication, especially in patients who seem to have tense
abdominal walls. If there are any concerns about excessive gastric
air content, nasogastric tube aspiration should also be performed.
The authors prefer a two-layer vertical plication. The fi rst layer is

20
ABDOMINOPLASTY
274
performed utilizing interrupted permanent braided suture and the
second layer is performed with permanent monofi lament running
suture (Fig. 20.11).
● In some patients vertical laxity may persist after the two-layer
plication is completed. In these instances, one or two rows of
horizontal plications can be performed to further fl atten the
abdominal wall.
● With the plication accomplished, the patient is maintained in the
fl exed position. The abdominal fl ap is advanced inferiorly to facil-
itate the process of fl ap tailoring (Fig. 20.12). The tailoring process
must be a balance between eliminating vertical abdominal fl ap
excess, not elevating the mons pubis too high, and limiting scar
width. Often, however, it is necessary to make adjustments to
accommodate all three desires. For example if eliminating the
umbilical defect will lead to an abnormally high mons pubis, the
defect can be left as part of the remaining fl ap and closed on itself
leading to a midline vertical scar located at varying distances
Fig. 20.9 Extent of abdominal fl ap dissection in the supraumbilical
region, if abdominal fl ap liposuction is to be performed.
Fig. 20.10 First layer of plication.
Fig. 20.11 Second layer of plication. This is completed
infraumbilically, and partially completed in the supraumbilical
region.
between the newly created umbilicus and the horizontal abdominal
scar. If the mons pubis is overly thick, it can be defatted by reduc-
ing subscarpal fat to balance its proportions in relation to the new
abdominal contour. If the mons pubis appears to rise too high, its
superfi cial fascial layer may be anchored to the underlying muscle
fascia to hold it in the appropriate position. The abdominal fl ap is
then tailored based on that position.
● To aggressively improve waist defi nition and elevate the anterior
thighs, proponents of the HLTA technique place a great deal of
tension laterally, from the lateral border of the mons to the ASIS.15,25
This method of abdominal fl ap tailoring decreases central tension
on the mons pubis. However, it often necessitate a lateral extension
of the scar to eliminate the dog-ears created by the lateral tension.
Conversely limiting scar width, and thus lateral tension, will lead
to less aggressive improvements in waist defi nition and anterior
thigh elevation. We tend not to choose a particular method to use
on all patients, but rather adjust the resection to the particular
patient’s condition and desires, at the time of surgery.
Our preferred method of umbilicoplasty
● With the abdominal fl ap tailored and temporarily tacked in place,
the position of the underlying umbilicus is marked in preparation
for umbilicoplasty. The particular method of umbilicoplasty is
quite variable from surgeon to surgeon. As a general rule however,
the neoumbilicus should be fairly small, vertically oriented,

Operative Approach
275
inverted, and its suture line should be buried within the cone
shaped structure. We describe our preferred method because of its
simplicity and the results it produces.
● A 1.5–2.0-cm vertical incision is made in the midline overlying the
buried umbilicus and a path is created by bluntly dissecting a
passageway for the stalk to be brought through to surface.
● We prefer not to de-fat this area to avoid possible vascular
compromise of the abdominal fl ap and because the desired inver-
sion can be accomplished by the suture technique we describe
here.
● At 3, 6, and 9 o’clock, three point fi xation sutures are placed from
the surrounding abdominal wall fascia, to the subcuticular level of
the umbilicus, and through the subcuticular level of the abdominal
fl ap (Fig. 20.13). As these sutures are tied, the neoumbilicus is
inverted. The remainder of the closure is accomplished with simple
inverted, subcuticular, nonpermanent sutures from the abdominal
fl ap to the umbilicus.
Closure of the abdominal wound
● Prior to beginning closure of the abdominal wound two closed-
suction drains are placed through the hair-bearing skin of the
mons pubis.
● Closure is accomplished in multiple layers, with the most impor-
tant layer being the superfi cial fascial system, or Scarpa’s fascia.14
It is assumed that reapproximating this layer reduces the signifi -
cant tension on skin that can be generated in an abdominoplasty.
It also prevents acute wound dehiscence and reduces scar widen-
ing in the long run. Traditionally it has been accomplished with a
0- or #1-sized permanent braided suture. We, however, have aban-
doned permanent sutures and currently utilize a longlasting non-
permanent, non-braided, 0 suture, with no discernible decrease in
the quality of the scars.
● The skin is closed with either interrupted or a running subcuticular
layer of 2-0 to 3-0 non-permanent, non-braided, suture followed
by an overlying layer of medical grade skin glue.
● Recently, we have started utilizing an indwelling pain pump cath-
eter that drips local anesthetic in the operative fi eld, which helps
decrease pain over the fi rst 3–4 days after surgery. Some surgeons
Fig. 20.12 Abdominal fl ap after being advanced. The amount to be
resected is determined at key points.
prefer to thread the pain pump catheter below the rectus fascia,
but we have not found that to be necessary for it to function
well.
● We use an epidural infusion for postoperative pain management
for patients who are going to be admitted to the hospital.
● An abdominal binder is applied to the patient’s abdomen at the
end of the surgical procedure and is utilized for a few weeks after
surgery.
Mini-abdominoplasty
● Preoperative markings are performed 1 or 2 days prior to the
procedure in the offi ce. The midline from the xiphoid to the umbi-
licus and midline of the mons pubis is marked. A lower abdominal
incision in the natural suprapubic crease is marked and often can
be limited to the width of the pubic hair or just beyond its lateral
borders.
● In the operating room intermittent compression devices are applied
to the lower extremities, a dose of perioperative antibiotic is given,
and general anesthesia is induced.
● The operation begins with the lower abdominal incision. The
abdominal fl ap is raised to the level of the umbilicus. The patient
is fl exed at the waist and abdominal muscle wall laxity is examined.
The rectus abdominis muscle fascia is vertically plicated from the
umbilicus to the pubis (Fig. 20.14).
● The abdominal fl ap is then advanced inferiorly and tailored to
remove the excess skin and fat. This advancement will usually pull
the umbilicus down 1–3 cm, and should be taken into consideration
if the patient has a low umbilicus preoperatively.
● A closed suction drain is placed through a separate stab incision.
● The incision is closed in layers, with interrupted 0-sized longlast-
ing nonpermanent monofi lament suture used to reapproximate the
superfi cial fascial system, followed by interrupted, inverted 2-0 to
3-0 monofi lament nonpermanent suture and an overlying layer of
medical grade skin glue.
Modifi cations
A modifi cation of this technique can be applied to patients who present
with minimal lower abdominal skin and subcutaneous tissue excess,
but have both supra and infraumbilical abdominal muscle wall
laxity.
Three point fixation sutures at 3, 6 and 9 o’clock
Fig. 20.13 Three point fi xation sutures at 3, 6, and 9 o’clock are
placed from the subcuticular level of the abdominal fl ap to the
subcuticular level of the umbilicus and through the fascia of the
surrounding abdominal wall. These sutures allow inversion of the
neoumbilicus without having to de-fat the surrounding tissues.

20
ABDOMINOPLASTY
276
Mini-abdominoplasty
Fig. 20.14 Mini-abdominoplasty. The extent of fl ap dissection and
abdominal wall plication is shown.
● In order to obtain access to the supraumbilical rectus diastasis,
the umbilical base is amputated as the abdominal fl ap is elevated
from pubis to xiphoid and the umbilicus is ‘fl oated’ with the
abdominal fl ap.
● The supraumbilical fl ap elevation is limited to a distance on either
side of the midline that allows for the planned plication. The
muscle diastasis is repaired from the xiphoid to the pubis in a
similar manner to a routine abdominoplasty.
● The abdominal fl ap is then advanced inferiorly and tailored; the
umbilical stalk is resutured to the plication at its more inferiorly
positioned fi nal level.
In a variation of this technique, a superior periumbilical incision is
made and an endoscopic elevation of the abdominal fl ap, from umbi-
licus to xiphoid, on either side of the midline is performed to allow for
rectus fascia plication. The inferior abdominal fl ap is tailored in a
similar manner to a more traditional mini-abdominoplasty with the
umbilicus inferiorly advanced a few centimeters.
High lateral tension abdominoplasty
● Preoperative markings are performed in the offi ce a day or two
prior to surgery. First, the fi nal location of the scar is determined
with the patient in standing position. This is accomplished by
marking a horizontal line 7 cm superior to the anterior vulvar
commissure (or base of the penis) and two lateral marks at either
ASIS. These three marks are then connected to create the proposed
fi nal scar position in the shape of ‘French bikini’ pattern. However,
the proposed fi nal scar shape can be manipulated to fi t beneath
any preferred underwear pattern by altering the position of the
lateral marks.
● Next, the inferior margin of excision is marked. This is accom-
plished by holding the marking pen at the level of the previously
made central mark and displacing the central abdominal tissues
superiorly to the extent that the appropriate mons pubis contour is
created. A mark is made on the elevated skin at the level where the
pen has been steadily held in position. This maneuver is repeated
all along the path from the central mark to the lateral marks
creating multiple points that are connected and thus form the
lower proposed incision.
● Next, the superior proposed incision line is marked utilizing the
pinch technique, with the thumb placed on the inferior proposed
incision, pinching, and then observing that the appropriate abdom-
inal contour is created by the pinch. As previously mentioned, the
central aspect of the superior proposed incision often does not
reach the level of the umbilicus because the emphasis of maximal
resection and tension in a HLTA is lateral.
● In the operating room intermittent compression devices are applied
to the lower extremities and a dose of perioperative antibiotic is
given. General anesthesia is induced and an indwelling urinary
catheter is placed if required.
● The umbilicus is circum-incised and left attached by a generous
subcutaneous pedicle.
● The lower reference line is incised and the abdominal fl ap is
elevated off the rectus fascia up to the umbilicus.
● Above the level of the umbilicus, undermining is limited to a narrow
strip around the midline centrally, just enough to allow the desired
supraumbilical plication. This type of central undermining pre-
serves more rectus muscle perforators, which allows the surgeon
to liposuction the fl ap if it is deemed too thick.
● Vertical plication of the abdominal wall fascia is accomplished in
a similar manner to the traditional abdominoplasty.
● Next the abdominal fl ap is advanced inferiorly to start the tailoring
process. Whether the abdominal fl ap has been liposuctioned or not,
at this point in the operation, the attachments of the abdominal
fl ap to the underlying muscle fascia can be discontinuously under-
mined using large scissors that are opened parallel to the path of
the remaining vessels. This maneuver allows for further abdominal
fl ap inferior advancement.
● The actual tailoring process is begun by pulling on the abdominal
fl ap laterally and inferiorly, thus placing the greatest tension later-
ally. The excess tissue is then tailored appropriately.
● Often the incision has to be extended laterally to eliminate dog-
ears.
● With the abdominal fl ap tacked to the inferior incision, the neoum-
bilicus position is determined. The performance of the umbilico-
plasty and the closure are similar to that described in the more
traditional abdominoplasty technique.
Lipoabdominoplasty
● The markings can be performed in a similar manner to the more
traditional abdominoplasty or the HLTA pattern.
● The operation begins by tumescent infi ltration of the entire
abdomen.
● Both infra and supraumbilical regions are liposuctioned, superfi -
cial and deep to Scarpa’s fascia.
● Realistically, most of the liposuction occurs superfi cial to the fascia
because subscarpal fat is often fairly thin and would be diffi cult to
signifi cantly reduce in thickness without injuring abdominal muscle
wall fascia. Some surgeons aggressively liposuction the infraum-
bilical fat, and so when it is time to tailor the fl ap the skin will
essentially just peel off the underlying liposuctioned tissue, which
should contain a large component of the lymphatic system. Other
surgeons, including us, aggressively liposuction the supraumbili-
cal region and then raise the infraumbilical abdominal fl ap at, or
just below Scarpa’s fascia. In either case the intent is to leave some
fat behind to maintain lymphatic tissues, which theoretically
reduces the risk of seromas.
● Supraumbilically a narrow swath of central elevation is performed
on either side of the midline to allow for plication.

Complications
277
● In the infraumbilical region a small strip of fat is resected or
elevated from either side of the midline to allow for plication.
● Plication is performed in a similar manner to any other abdomi-
noplasty technique.
● Although there is minimal elevation of the fl ap, fl ap advancement
is possible due to the indirect undermining caused by the liposuc-
tion aspect of the procedure. If more advancement is required
further blunt dissection can be performed, as in a HLTA, to allow
for release of the fl ap.
● Umbilicoplasty and fl ap tailoring are similar to the other tech-
niques. Some surgeons do not utilize any drains with this tech-
nique, especially if they use quilting sutures from the abdominal
fl ap to the underlying tissues.
Optimizing outcomes
●
Avoid patients who have excessive intra-abdominal fat
content because the results of abdominoplasty will be
unsatisfactory.
●
Patients best suited for abdominoplasty surgery present with
lower truncal excess limited to the anterior abdomen.
●
Evaluate and treat areas surrounding the abdomen, usually
with concomitant liposuction, to attain better overall lower
truncal contour.
●
The extent of fl ap elevation in abdominoplasty, no matter
which technique is utilized, should be as minimal as possible
to reduce vascular compromise and accomplish the desired
contour.
●
If liposuctioning of the abdominal fl ap is contemplated,
supraumbilical fl ap undermining should be only wide enough
to allow for the needed plication, thus reducing the risk of fl ap
necrosis.
●
Wide undermining in smokers, diabetics, hypertensives, and if
there are pre-existing scars in the upper abdomen should be
auoided.
●
During fl ap tailoring the mons pubis should not be elevated to
an aesthetically unappealing level.
●
Most lateral dog-ears should be taken care of at the time of
surgery by either extending the scars or cheating the
abdominal fl ap medially.
●
Reapproximation of the superfi cial fascial system is essential
to obtain a high-quality fi ne-line scar.
●
The neoumbilicus should be small, vertically oriented, and
superiorly hooded, with a slight hollow around it.
●
Patients who present with a high BMI greater than or equal to
30 have a greater complication rate.
●
Use of sequential compression devices, early ambulation,
vigorous pulmonary toilet, appropriate hydration, discontinuing
nicotine, birth control pills, and hormone replacement therapy,
and avoiding lengthy operations improve outcome.
●
The technique utilized in any particular patient should be
individualized to accommodate the patient’s anatomy and
desires.
COMPLICATIONS
Abdominoplasty is an extensive operation with potential risks and
complications that need to be considered by both the patient and
plastic surgeon.21,32–38 Abdominoplasty, alone or in combination with
other procedures, carries the highest risk among body contouring pro-
cedures. As a general rule complications are more common in higher
BMI patients and because many patients that present for abdomino-
plasty may be in the overweight-to-obese range, they need to be
approached with caution and full disclosure.
Wound dehiscence
Wound dehiscence, described as separation of the wound at the level
of the superfi cial fascial system, can occur after abdominoplasty. It can
arise due to inadequate deep closure or inadvertent straightening up
during the early postoperative period. It can usually be avoided by
strong reapproximation of Scarpa’s fascia and good preoperative patient
education about staying fl exed at the waist for 5–7 days after surgery
and maintaining that position even during sleep. Small areas of non-
healing, defi ned as superfi cial wound separations that do not reach the
level of Scarpa’s fascia, may occur anywhere along the wound after an
abdominoplasty. Generally, as long as they are small, conservative
wound management and avoiding further stretch on the wound will
allow these areas to heal by secondary intention with no signifi cant
long-term effect on the overall quality of the scar.
Hematoma
Hematomas are potential complications of any surgery including
abdominoplasty. They can be minimized by meticulous intraoperative
hemostasis; and by avoiding bucking and coughing during extubation.
They generally occur between the fi rst and second postoperative
day.
Large hematomas present with swelling, pressure and pain,
and require evacuation and drainage to avoid compromise of the
abdominal fl ap. Some small hematomas can be managed expectantly,
especially if they happen to be adequately drained by a drain. Often
this will lead to prolonged periods of drainage from that area of the
wound.
Wound infection
Wound infections can occur after abdominoplasty, but tend to occur
in patients with increased risk factors such as obesity, diabetes, and
smoking. They can present in the form of wound cellulitis and/or an
infected seroma. The most common organisms are Staphylococcus,
Streptococcus, and Pseudomonas spp. and Escherichia coli.
Infection is manifested by redness, heat, pain and then purulent
collection.
The treatment is appropriate antibiotics, evacuation and drainage
of an abscess if present, debridement and dressing changes.
Toxic shock syndrome has been reported after abdominoplasty.
Any postoperative patient, who presents with signs of malaise, appears
very ill, and complains of generalized discomfort, with or without
fever, should always be evaluated to rule out toxic shock syndrome
even if there is no signifi cant evidence of sequestered fl uid in the
abdominal wound. These patients can be diffi cult to diagnose because
they may not have any obvious pus-containing collections, an elevated
wide blood cell count, or fever, but they will appear very ill. Thus
a high index of suspicion is needed to pick up this dangerous pro-
blem early and treat it appropriately. Treatment involves expeditious
return to the operating room, opening up the wound, and washing
it out vigorously. A consultation with an infectious disease specialist
and good intravenous staphylococcus coverage is also warranted,
but incision and drainage should not be delayed for any laboratory
tests or consultations if a signifi cant potential for this problem is
suspected.
Seroma
Seromas can occur after any abdominoplasty technique. The etiology
is not completely understood and is probably multifactorial. Thus it
is not clear how they form or how to prevent them.

20
ABDOMINOPLASTY
278
Most surgeons believe that closed suction drainage is the best way
to prevent seromas from occurring, along with compression. Surgeons
who utilize lipoabdominoplasty techniques consider that the etiology
of seromas is related to creating a very large dissection pocket and the
elimination of lymphatics, especially of the femoral region. Thus this
technique tries to minimize both problems in the hope of reducing
seroma occurrence. Other surgeons feel that it is the lack of adherence
of the abdominal fl ap to the underlying abdominal wall that is respon-
sible for seroma formation and advocate eliminating as much dead
space as possible with mattress sutures.
No matter which approach is used, should a seroma occur it is
usually initially treated by repeat aspiration. If it persists some sur-
geons try to adhere the two sides of the seroma pocket by injecting a
sclerosing agent into the pocket. If this is not successful and the
seroma volume is large, sometimes reinsertion of a closed suction
drain is required. At this stage if a seroma still persists the surgeon
may choose to either go back to the operating room and excise the
seroma capsule that has formed and mattress suture the two walls, or
open the seroma pocket to the outside through a dependent point of
the wound and leave a wick in place to essentially exteriorize the
seroma pocket. We do not believe that the presence of a seroma capsule
necessitates surgical excision as previously advocated because we have
found that almost all prolonged drainage wounds have capsules that
may or may not produce a clinically relevant seroma. We also do not
drain relatively small nonexpanding seromas because we have found
that they tend to resolve without any therapy, but may take an extended
period of time to do so.
Tissue necrosis
Tissue necrosis can occur after abdominoplasty due to vascular com-
promise of the abdominal fl ap which can be made worse by the tension
at closure. Predisposing factors include:
● a history of smoking;
● the presence of transverse upper abdominal scars;
● excessive tension at wound closure;
● liposuction in zone III;
● unrecognized and undrained postoperative hematomas.
The patient initially presents with a bluish and ecchymotic area, cooler
than the surrounding tissue and between the third and fi fth post-
operative day skin slough will be noticed clinically.
Postoperative skin necrosis should be treated with conservative
debridement and dressing changes. Some surgeons believe that hyper-
baric oxygen therapy may reduce the extent of necrosis. Most wounds will
heal within 6 weeks and scar revision will improve aesthetic outcome.
As discussed on p. 5, the blood supply of the abdominal fl ap skin
and fat is reduced to varying degrees depending on the particular tech-
nique utilized and whether the patient has any concomitant risk factors
such as a history of smoking or diabetes. Based on the pattern of the
blood supply, the area most likely to necrose is located in a triangle of
the abdominal fl ap that has its apex at the umbilicus and its base along
the scar on either side of the midline, especially if there is T-shaped
closure. To help reduce the risk of tissue necrosis it is wise to avoid
operating on high-risk patients such as diabetics and smokers if possi-
ble, though not all surgeons steer clear of them. As a general rule, it is
wise to perform as little elevation of the abdominal fl ap as possible that
will create the desired contour, no matter which technique is utilized.
Contour irregularity
Contour irregularity is not an uncommon complication after
abdominoplasty.
Epigastric bulging after abdominoplasty results from inadequate
plication of the superior abdominal wall superiorly, near the xiphoid.
To avoid this problem, appropriate midline undermining of the fl ap
up to the xiphoid must be performed, to allow complete access for the
full extent of superior plication.
Lateral dog-ears can occur, especially in patients with a larger BMI,
and are best managed at the time of the actual procedure, though some
fairly small dog-ears will disappear over time without formal treat-
ment. Intraoperatively, one way to avoid dog-ears is to start out with
the lateral closure fi rst, creating perfect contour there, and then adjust-
ing the remainder of the incision accordingly. A second method is to
extend the incision laterally, with or without de-fatting the lateral soft
tissues to allow for a straight-line closure.
The position of the mons pubis can be altered for better or worse
after abdominoplasty. If the mons is ptotic prior to surgery, it should
be lifted, which is easy to accomplish because of the tension created
by the resection of an abdominoplasty. It is more diffi cult, however,
to keep the mons pubis from ending up too high, especially in patients
who have a highly positioned umbilicus. To avoid this problem it best
to place the mons pubis where it is felt to be most ideal and then tailor
the abdominal fl ap based on that position. This may necessitate
leaving the umbilical defect behind as a vertical scar either as part of
a midline T-shaped closure or a vertical scar between the neoumbilicus
and the mons. If such scars are contemplated, it is imperative that the
patient is warned about the possibility prior to surgery with an expla-
Box 20.2 Inverted ‘T’ or fl eur-de-lis
abdominoplasty
Some plastic surgeons prefer to utilize inverted ‘T’ or fl eur-de-lis39-
pattern procedures in patients that present with circumferential
lower truncal excess, especially if the patient presents with a
midline abdominal scar. We have almost abandoned this pattern as
a primary procedure, especially since circumferential
dermatolipectomy procedures have become main stream in plastic
surgery as a reaction to the frequent presentation of the massive-
weight-loss patient. The theoretical advantage of utilizing this
technique is that it can eliminate horizontal as well as vertical
excess and create waist narrowing by pulling the lateral tissues
centrally. It is important to note that to safely utilize this technique
it must not be thought of as a traditional abdominoplasty with a
simple addition of a vertical wedge.
Disadvantages
It is dangerous to combine extensive undermining of the
abdominal fl ap up to the xiphoid and costal margins with vertical
midline resection because it further compromises the blood supply
of the fl ap, and combined with a great deal of tension on the
closure can lead to an increased risk of fl ap necrosis, especially at
the T intersection. Thus if a T-type resection is contemplated, it is
wise to not undermine any of the vertical pillars on either side of
the vertical resection, and limit the dissection to only what is
required to accomplish the central plication.
Other disadvantages of a T-type resection are:
●
in eliminating the central vertical wedge, the epigastric region
can be left with fullness secondary to a ‘dog-ear’ and attempts
to eliminate the fullness by extending the incision may lead to
a scar that is carried onto the sternal region;
●
if the vertical component of the T is overly aggressive in one
region versus the other, the resultant contour can create a
bizarre shape to the abdominal wall (Fig. 20.15A–F);
●
if the umbilicus is not intentionally made small, then it will
eventually widen due to the lateral tension created by the
vertical excision;
●
no matter how expertly the T resection is performed, it does
not adequately address problems with the lateral thighs,
buttocks, and back; all problems that are much better
addressed by a circumferential procedure.

Conclusion
279
nation of why this may be necessary. To further hold the position
of the mons in its ideal position, its underlying Scarpa’s fascia can
be sutured to the underlying muscle fascia to prevent superior
migration.
Scar symmetry can often be accomplished by a careful marking
process; however, some patients have intrinsic musculoskeletal
asymmetries that are not amenable to surgical manipulation. It is best
to warn the patient about this problem prior to surgery to avoid post-
operative diffi culties.
Scarring
Widened depressed scars are often the result of inadequate reapproxi-
mation of the deeper tissues. Thus, closure of Scarpa’s fascia is essen-
tial to avoid tension and wound distortion. Unsatisfactory scars are
diffi cult to predict and should be discussed at length preoperatively,
especially if the patient has a previous hypertrophic scar or history of
keloids. Drawing the incision in the lower abdomen may help patients
visualize the scar postoperatively. Scars can be revised after a year
when the scar has attained full maturation.
Umbilical deformity
Umbilical malposition or deformity can occur after abdominoplasty
and can be avoided with careful preoperative marking of the midline,
assessment of the position of the umbilicus preoperatively and discus-
sion with the patient if the asymmetries are noted. Previous surgery
or pregnancy can alter the umbilicus position and should be noticed
preoperatively. Lateral malposition of the umbilicus can be seen with
asymmetric musculoaponeurotic plication, and avoided by marking
the midline of the abdominal wall after fl ap elevation.
Paresthesia
Paresthesias are often temporary, but may in certain cases be perma-
nent or longlasting. Almost all patients will have an area of numbness
located below the umbilicus in the shape of a triangle with its apex at
the umbilicus and its base on the transverse scar. The area of numb-
ness tends to decrease with time with the last remnant located at the
most inferior midline point. Paresthesias result from the undermining
process, regardless of the extent.
Nerve injuries and pain have been reported in the lateral femoral
cutaneous, ilioinguinal and iliohypogastric nerves. Patients present
with persistent paresthesia and pain in the lower abdomen despite a
negative gastrointestinal and gynecologic workup. A nerve block will
alleviate the symptoms and work as a diagnostic tool. Treatment
consists of neurectomy with proximal resection into the peritoneum
to avoid painful recurrent neuroma within the anterior abdominal
wall.
Deep vein thrombosis/pulmonary embolus
The increased intra-abdominal pressure caused by abdominal wall
plication has been implicated as the cause of decreased venous return
from the lower extremity back into the pelvis, thus leading to an
increased risk of DVT and pulmonary embolus. Thus intrinsically
abdominoplasty may predispose patients to these complications.
Although it is impossible to eliminate the risks completely, they
can be minimized. Simple measures that can be taken include the
following.
● Utilization of sequential compression garments prior to the induc-
tion of general anesthesia and maintaining their use while patients
are still nonambulatory.
● Very early ambulation, as early as the same day of surgery, is
probably the best method known to reduce the risk of DVT and
PE and should be part of all postoperative abdominoplasty
regimens.
● Because birth control pills are associated with thrombotic compli-
cations, it is best to stop their use for at least one cycle in the
perioperative period.
● Some plastic surgeons use chemoprophylaxis, treating high-risk
patients with low-molecular-weight heparin routinely, but their use
may be associated with an increased risk of bleeding.
● We utilize an epidural catheter infusion for postoperative pain
control and have found a defi nite decrease in DVT and PE when
this modality is utilized. However, this is an empirical fi nding that
needs to be confi rmed in larger studies.
● Overall a high index of suspicion looking for DVT and PE should
be maintained in the postoperative period along with an aggressive
approach to investigating patients with any symptoms suggestive
of these problems.
POSTOPERATIVE CARE
Abdominoplasty
Intravenous fl uids and antibiotics are given for 24 hours. Patients
are kept fl exed, in ‘beach chair’ position. Intermittent compression
devices continue to be used until full ambulation is obtained. A
clear liquid diet is started and advanced to regular as tolerated.
Postoperative pain is controlled with narcotic analgesics and a pain
pump. The pain pump is turned on before leaving the operating
room.
Patients are expected to be walking later on the day of surgery bent
at the waist. They are not allowed to straighten up for 1 week after
surgery, and then they are instructed on exercises that will allow them
to straighten to full extension. The exercises entail the patients
straightening until they feel tension and holding that position for 30 s,
then releasing the tension by re-bending at the waist. This is repeated
20–30 times during the day, and most patients are able to get to a fully
erect position in 2–3 days.
Abdominoplasty can be performed as an outpatient procedure, but
we usually keep our patients overnight. They are discharged home with
drains and instructed to record their output daily. Each drain is
removed when its output is less than 40 mL/24 hours. Showering, but
no bathing, is allowed while drains are in place.
The abdominal binder is kept on for the fi rst week and then the
patients are instructed to wear a tight garment that is more comfort-
able, for as long as they can tolerate wearing it.
Patients are instructed not to apply heating pads to the abdomen,
take hot showers, or sunbathe until they regain sensation in the
abdominal skin to avoid potential burns.
Driving is allowed when narcotic pain medication is no longer
required and the patient can perform emergency driving maneuvers
without the fear of pain from the surgical sight.
Light, lower extremity exercises, like walking or stationary biking,
can be resumed 2–3 weeks after surgery. Abdominal muscle exercises
are discouraged for 3 months after surgery to protect the abdominal
wall plication suture.
Photographs before and after abdominoplasty performed on three
different categories of patient are shown in Fig. 20.16A–F, Fig. 20.17A–F
and Fig. 20.18A–F.
CONCLUSION
Patients best suited for abdominoplasty surgery present with lower
truncal excess limited to the anterior abdomen. Those with a high BMI
greater than or equal to 30 have a greater complication rate. The tech-
nique used in any particular patient should be individualized to accom-
modate the patient’s anatomy and desires, but the extent of fl ap should
be minimal to reduce vascular compromise. Complications are mini-
mized by use of sequential compression devices, early ambulation,

20
ABDOMINOPLASTY
280
A
B
C
D
E
F
Fig. 20.15 A poorly performed T-type abdominoplasty. A–F, These photographs demonstrate resultant epigastric fullness, asymmetries, and
a bizarre-appearing pubic region.

Conclusion
281
A
B
C
D
E
F
Fig. 20.16 Before and after abdominoplasty. A–C, White woman in her late 20s who presented with complaints of a protrudent lower
abdomen after having two children. D–F, The postoperative photographs demonstrate a French-bikini-pattern scar 6 months after surgery.

20
ABDOMINOPLASTY
282
A
B
C
D
E
F
Fig. 20.17 Before and after abdominoplasty. A–C, A 32-year-old woman patient who underwent an abdominoplasty with liposuction of the
hips and lateral thighs. She desired her scar to fi t under a fairly low underwear line. D–F, 7 weeks after surgery. Note the swelling above
the incision line, which typically resolves over a few months. (Note: this patient is shown on the accompanying video.)

References
283
vigorous pulmonary toilet, appropriate hydration, discontinuing nico-
tine, birth control pills, and hormone replacement therapy, and avoid-
ing lengthy operations.
REFERENCES
1. Kelly HA. Report of gynecological cases. John Hopkins Med J 1899;
10:197.
2. Kelly HA. Excision of the fat of the abdominal wall – lipectomy. Surg
Gynecol Obstet 1910; 10:229.
3. Vernon S. Umbilical transplantation upward and abdominal contouring
in lipectomy. Am J Surg 1957; 94:490.
4. Gonzalez-Ulloa M. Belt lipectomy. Br J Plast Surg 1967; 13:179.
5. Somalo M. Cruciform ventral dermal lipectomy swallow-shaped
incision. Prensa Med Argent 1946; 33:75.
6. Pitanguy I. Abdominal lipectomy: an approach to it through an analysis
of 300 consecutive cases. Plast Reconstr Surg 1967; 40:384.
7. Regnault P. The history of abdominal dermolipectomy. Aesthetic Plast
Surg 1978; 2:113.
8. Grazer FM. Abdominoplasty. Plast Reconstr Surg 1973; 51:617.
9. Elbaz JS, Flageul G. Chirurigie plastic de l’abdomen. Paris: Masson; 1971.
10. Glicenstein J. Diffi culties of surgical treatment of abdominal
dermodystrophies. Ann Chir Plast 1975; 20:147.
11. Illouz YG. Body contouring by lipolysis: a 5 year experience with over
3000 cases. Plast Reconstr Surg 1983, 72:591.
12. Matarasso A. Abdominoplasty. Clin Plast Surg 1989; 16:289.
13. Matarasso A. Abdominolipoplasty: a system of classifi cation and
treatment for combined abdominoplasty and suction-assisted lipectomy.
Aesthetic Plast Surg 1991;15:111.
14. Lockwood T. Superfi cial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg 1991; 87:1009.
15. Lockwood T. High-lateral tension abdominoplasty with superfi cial fascial
system suspension. Plast Reconstr Surg 1995; 96:603.
16. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al.
Lipoabdominoplasty with selective and safe undermining. 2003; 27:322.
17. Aly AS. Approach to the massive weight loss patient. In: Aly AS, ed.
Body contouring after massive weight loss. St Louis: Quality Medical
Publishing; 2006: 49.
18. Borkan GA, Norris AH. Fat redistribution and the changing body
dimensions of the adult male. Hum Biol 1977; 49:495.
A
B
C
D
E
F
Fig. 20.18 Before and after
abdominoplasty. A–C,
Preoperative markings of an
abdominoplasty on a 65-year-old
female. She is atypical because
of her older age and how it
appears that she might have too
much intra-abdominal content
prior to surgery. Her abdomen
became scaphoid in the supine
position during her preoperative
exam, which confi rmed that she
would benefi t from the surgery.
D–F, 1 year postoperatively.

20
ABDOMINOPLASTY
284
19. Bouchard C, Bray GA, Hubbard VS. Basic and clinical aspects of
regional fat distributions. Am J Clin Nutr 1990; 52:946.
20. Fried SK, Kral JG. Sex differences in regional distribution of fat cell size
and lipoprotein lipase activity in morbidly obese patients. Int J Obes
Relat Metab Disord 1987; 11:129.
21. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with
emphasis on complications. Plast Reconstr Surg 1977; 59:513.
22. Forrest CK, Pang CY, Lindsay WK. Detrimental effect of nicotine on
skin fl ap viability and blood fl ow in randon skin fl ap operations on rats
and pigs. Surg Forum 1985; 36:611.
23. Krueger JK, Rohrich RJ. Clearing the smoke: the scientifi c rationale for
tobacco abstention with plastic surgery. Plast Reconstr Surg 2001;
108:1063.
24. Greminger RF. The mini-abdominoplasty. Plast Reconstr Surg 1987;
79:356.
25. Lockwood T. Maximizing aesthetics in lateral-tension abdominoplasty
and body lifts. Clin Plast Surg 2004; 31:523.
26. Elling SV, Powell FC. Physiological changes in the skin during
pregnancy. Clin Dermatol 1997; 15:35.
27. Boyd JB, Taylor GI, Corbett R. The vascular territories of the superior
epigastric and deep inferior epigastric systems. Plast Reconstr Surg
1984; 73:1.
28. Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am J
Surg 1979; 45:612.
29. Choi PD, Nath R, Mackinnon SE. Iatrogenic injury to the ilioinguinal
and iliohypogastric nerves in the groin: a case report, diagnosis, and
management. Ann Plast Surg 1996; 37:1.
30. Liszka TG, Dellon AL, Manson PN. Iliohypogastric nerve entrapment
following abdominoplasty. Plast Reconstr Surg 1994;93:181.
31. Aly AS. Options in lower truncal surgery. In: Aly AS, ed. Body
contouring after massive weight loss. St Louis: Quality Medical
Publishing; 2006: 59.
32. Teimourian B, Rogers WB III. A national survey of complications
associated with suction lipectomy: a comparative study. Plast Reconstr
Surg 1989; 84:628.
33. Laub DR Jr, Laub DR. Fat embolism syndrome after liposuction: a case
report and review of the literature. Ann Plast Surg 1990; 25:48.
34. Hunter GR, Carpo RO, Broadbent TR, Woolf RM. Pulmonary
complications following abdominal lipectomy. Plast Reconstr Surg 1983;
71:809.
35. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of
venous thromboembolism in the plastic surgery patient. Plast Reconstr
Surg 2004; 114:43e.
36. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal
contour surgery: a national plastic surgery survey. Plast Reconstr Surg
2006; 117:1797.
37. Van Uchelen JH, Werker PMN, Kon M. Complications of
abdominoplasty in 86 patients. Plast Reconstr Surg 2001;
107:1869.
38. Kim J, Stevenson TR. Abdominoplasty, liposuction of the fl anks and
obesity: analysing risk factors for seroma formation. Plast Reconstr Surg
2006;117:773.
39. Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg 1985; 9:27.

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CHAPTER 21
Bodylifts and Post Massive Weight Loss
Body Contouring
J Peter Rubin and Jeffrey Gusenoff
EVALUATION OF THE MASSIVE WEIGHT
LOSS BODY CONTOURING PATIENT
Plastic surgeons should bear in mind that massive weight loss is a
major life-changing event for patients. Despite weight loss, self-esteem
may not be fully restored, and thus a sensitive approach helps build
the initial patient–doctor relationship. This is critical, given the mag-
nitude of the procedures and the potential multiple stages of recon-
struction. Initially, in an effort to comfort the patient and acknowledge
their accomplishments, all patients should be congratulated on their
weight-loss success. This also serves as an introduction to obtaining
a detailed history including:
● History of their weight loss: mechanism of weight loss, highest
weight and BMI, lowest weight since bariatric surgery or other
weight-loss method, current weight and BMI, how long weight has
been stable, and goal weight.
● History of pregnancy: number of pregnancies, natural or surgical
childbirths.
● History of prior surgery: intra-abdominal surgery, gastric bypass,
and time since the patient last met with their bariatric team.
● History of prior plastic surgery: liposuction, body contouring, and
any complications.
● History of deep vein thrombosis (DVT), pulmonary embolism (PE)
or hypercoagulable state.
● Nutritional status: protein intake (Goal >70 g per day), vitamins
(calcium, B12, iron), nausea, emesis, or dumping syndrome.
● History of other medical comorbities: hypertension, diabetes, sleep
apnea, cardiac disease, smoking, or mental illness.
Additional information that should be obtained during the patient
evaluation includes: attendance at support groups and support from
family and/or friends. Consultations with cardiology, pulmonology,
internal medicine, nutrition, and psychiatry are ordered as indicated
to evaluate and optimize medical issues prior to major surgery. As with
any new patient consult, establishing patient goals and identifying
main areas of concern are key components of the initial body-contour-
ing discussion. Patients must be prepared to trade in excess skin and
fat for new contours and new scars. Setting expectations at realistic
levels is an essential part of the body-contouring consult.
MWL patients often present with a variety of deformities, based on
their initial body-fat distribution. While some may have a preponder-
ance of truncal excess, others may exhibit signifi cant lower-extremity
deformities. An overall assessment of the patient should be made
taking into account the distribution of the skin laxity, remaining adi-
posity, rolls, folds, skin tone, integrity, scars, abdominal-wall structure
(rectus diastasis, hernias, thickness), and overall constitution (i.e. poor
mobility, chronic pain, stigmata of malnutrition). With the patient
standing in front of a mirror, the surgeon may demonstrate possible
improvements that can be achieved with resection by manually
Summary
1. Proper evaluation of the massive weight loss (MWL) patient
and careful selection is vital to the success of the operation.
2. The lower the patient’s body mass index, the wider the scope
of the surgical procedures that can be offered safely.
3. Traditional abdominoplasty techniques must often be modifi ed
for the MWL patient.
4. The circumferential lower body lift has a powerful effect on the
lateral thighs, buttocks, and anterior trunk in a single operative
setting.
5. Vertical thigh lift is best performed in a separate operative
setting on the lower body lift.
6. Vertical thigh lift, performed as a staged procedure relative to
the lower body lift, will complete the aesthetic contouring of
the thighs. Vertical thigh plasty performed without a lower
body lift in the staged plan will provide adequate results less
often.
7. Brachioplasty techniques must address the axilla to achieve
satisfactory results.
8. Brachioplasty performed using a segmental resection method
can avoid over-resection.
9. Mastopexy in the MWL patient can be performed using a
dermal suspension technique and autologous tissue
augmentation.
10. Staging multiple procedures can maximize safety and
aesthetic outcomes.
INTRODUCTION
There has been a tremendous surge in excisional body contouring
procedures in recent years fueled by the growing obesity epidemic and
the success of weight-loss surgery. In the USA, obesity is a major
problem and its incidence is increasing worldwide.1–3 The potential
benefi ts of substantial weight loss, most notably, a reduction in obesity-
associated morbidity, such as hypertension, diabetes, and atheroscle-
rosis, has grabbed the attention of public health agencies. While
medical weight-loss methods often prove diffi cult and ultimately
unsustainable, bariatric surgical procedures are now recognized as a
more reliable method of weight loss for morbidly obese patients.4–6 The
demand for bariatric surgery is expected to rise as long as no alternative
treatment for morbid obesity exists.7 As a result, the number of patients
seeking surgery to remove or reposition redundant skin and tissues is
expected to increase proportionally. Data from 2006 reveal that 65 000
massive weight loss (MWL) patients underwent body-contouring pro-
cedures.8 As the scope and magnitude of body contouring procedures
increases each year, the plastic surgeon must pay close attention to
issues of patient safety.