Aesthetic Surgery Techniques

210
    CHAPTER 26  •  Breast Reduction: Superomedial Pedicle Wise-Pattern Approach
A
D
E
F
G
B
C
FIGURE 26.8  (A) Preoperative frontal view. (B) Operative view—closure of the right breast pillars and de-epithelialization of the left pedicle. (C) Closure of the incisions.
(D) Postoperative day 7, showing partial right nipple-areola complex (NAC) necrosis. (E) Postoperative day 14, showing partial right NAC necrosis. (F) Débridement of
necrotic tissue and resuturing. (G) 1-year postoperative—favorable outcome.

211
Tips and Tricks
References
1.
Finger, R.E., Vasquez, B., Drew, G.S., Given, K.S., 1989. Superomedial
pedicle technique of reduction mammaplasty. Plast. Reconstr. Surg.
83, 471–480.
2.
Hall-Findlay, E.J., 1999. A simplified vertical reduction mammaplasty:
shortening the learning curve. Plast. Reconstr. Surg. 104, 748.
3.
Spear, S.L., Howard, M.A., 2003. Evolution of the vertical reduction
mammaplasty. Plast. Reconstr. Surg. 112, 855–868, quiz 869.
4.
Davison, S.P., Mesbahi, A.N., Ducic, I., et al., 2007. The versatility of
the superomedial pedicle with various skin reduction patterns. Plast.
Reconstr. Surg. 120, 1466–1476.
5.
Zhu, V., Lentz, R., Sturrock, T., et al., April 2015. Three dimensional
analysis of postoperative volumetric distribution in reduction mam­
moplasty using a superomedial pedicle versus an inferior pedicle.
Plast. Reconstr. Surg. 135 (4), 1258. Abstract P98.
6.
Antony, A.K., Yegiyants, S.S., Danielson, K.K., et al., 2013. A matched
cohort study of superomedial pedicle vertical scar breast reduction
(100 breasts) and traditional inferior pedicle Wise-pattern reduction
(100 breasts): an outcomes study over three years. Plast. Reconstr.
Surg. 1068, 132–135.

213
Surgical Preparation and Technique
213
27 
Mastopexy With Mesh for Breast Ptosis
Petrus V. van Deventer MBChB, BSc, MMedSc (UOVS), MMed (US)
The Clinical Problem (Fig. 27.1)
Synopsis
■ Different classifications of breast ptosis have been put
forward by Regnault1 and Kirwan,2 depending on the
extent of the nipple-areola complex (NAC) descent below
the submammary fold.
■ The surgically corrected ptotic breast must be supported
internally to prevent recurrence.
■ Implants can help in marginal ptosis.
■ An internal bra mesh system (Breform, Triangle
Surgical, Buckinghamshire, England) is indicated for
women who are having no more children, with
acceptable breast volume, who are not seeking
augmentation.
The Aesthetic Problem
Breast ptosis occurs when the supporting structures of the
breast fail. Structures that support the breast relative to the
chest wall include the ligamentous suspension, described by
Wueringer and Tschabitscher,3 and the supporting ligaments,
described by Matousek et al.4 The ligamenta suspensoria
described by Cooper,5 stretching from the lobules to the skin,
are responsible for breast shape but cannot support the breast
relative to the chest wall; it was described very accurately
in his book. The supportive function of the skin could be
questioned because of the frequent recurrence of breast ptosis
in techniques relying on the skin for postoperative breast
support.
Surgical Preparation and Technique
Treatment Options
It is also important to take the breast volume into account
when dealing with breast ptosis. There are basic principles
that should be applied when treating breast ptosis.
The hypotrophic breast requires an augmentation. During
the procedure, the nipple-areola complex (NAC) may rise to
the required level, but, if not, a formal mastopexy must be
performed, with excision of the excessive skin and NAC eleva­
tion. It is advisable that the augmentation should precede the
mastopexy; otherwise, too much skin could be removed at the
initial surgery.
Hypertrophic breasts need reduction of the excessive breast
mass to reduce the effect of gravity on the supporting system.
Any surgical technique can be used, and those reducing the
inferior pole have a better chance for maintaining a long-term
result.
It has been well documented that renowned plastic surgeons
agree that mastopexy procedures generally have a temporary
result. Recurrent ptosis or pseudoptosis can occur, regardless
of the technique used.
Replacing the supporting structures, which maintain the
normal breast position relative to the thoracic wall, with
biocompatible nonabsorbable mesh can result in satisfactory
long-term results.
CORRECTING BREAST PTOSIS: INTERNAL BREAST
SUPPORT PROCEDURE
For this technique, patient selection is important. The amount
of breast tissue to be supported must be adequate but not too

214
    CHAPTER 27  •  Mastopexy With Mesh for Breast Ptosis
large. The best results are obtained by supporting breasts with
a mass of between 300 and 500 g. If the breast is too large, a
breast reduction should be done simultaneously. The breast
tissue must be disease-free. A body mass index (BMI) of between
20 and 27 is preferable.
The mesh must be nonabsorbable and biocompatible. The
best material is polyester, with an adequate pore size. Com­
mercially preshaped polyester meshes are available but only
in four different sizes. Alternatively, a flat mesh cut into a U
shape can be used with any sized pedicle, adjusting the size
by overlapping the edges by varying degrees (Fig. 27.2).
The key to success entails wide undermining to attach the
mesh effectively; knowledge of the blood supply and its
anatomic variations in the pattern of supply to the NAC is
mandatory.6 Previous breast surgery must be taken into account
to ensure that the blood supply to the NAC is not jeopardized.
It is recommended that the posteroinferomedial pedicle with
the retained medial vertical ligament be used in the surgical
technique (Fig. 27.3).7–9
By anchoring the mesh at fixed stable points to the chest
wall, the breast mass is effectively supported and recurrent
FIGURE 27.1  The clinical problem.
FIGURE 27.2  Templates of different shapes that can be used to shape the mesh for internal breast support.
ptosis prevented. The tension on the skin flaps is reduced,
resulting in lessening the tension on suture lines and improved
and shorter scars. By using mesh as a supporting system, the
ideal breast shape, nipple projection, and upper breast fullness
can be obtained as well. The anchorage points for the mesh
on the thoracic wall are the second sternochondral junction
superomedially and the fourth rib laterally, behind the upper
free border of the pectoralis major muscle.
Preoperative Markings (Fig. 27.4)
The patient is marked in the upright position. The jugular
notch is used as a landmark. The chest midline is marked at
the level of the submammary fold; the submammary folds are
also marked.
The breast meridian is drawn from the side of the neck
downward, ignoring the nipple position if it is in an abnormal
position. On this meridian, the nipple height is determined
2 cm above the submammary fold and marked bilaterally at
equal distances from the midline. The upper areolar border is
marked 2 cm higher than the nipple. Markings are then placed
in the submammary folds at the same distance from the midline
compared to the new nipple position. The lateral extent of the
medial flap is determined by moving the breast laterally and
connecting the nipple and submammary markings with a
vertical line.
The lateral flap is determined in a similar way by displacing
the breast medially. On these vertical lines, the future areolar
opening is marked 5 to 6 cm from the new upper areolar
position, according to the patient’s preference regarding the
areolar diameter. The vertical height of the medial and lateral
flaps is measured at 9 cm inferiorly. Depending on the size of
the breast, the width of the pedicle may vary considerably.
Surgical Technique
The surgery is performed under general anesthesia, with the
patient in the supine position. The skin is prepared with 70%
chlorhexidine and alcohol, followed by an iodine-based
solution.
Nerve blocks are used. Skin incisions are made along the
marked lines, and the pedicle is de-epithelialized.

215
Surgical Preparation and Technique
The mesh is attached to the chest wall, using a 3-0 nonabsorb­
able suture on a large needle in the submammary region. It is
then draped along the lateral border of the pedicle to reach
the lateral anchorage point (the periosteum of the fourth rib),
behind the upper free border of the pectoralis major (see Fig.
27.5E). The mesh is draped along the medial edge of the pedicle
from the submammary region to reach the anchorage point at
the second sternochondral junction and attached with the same
stitch to the perichondrium (see Fig. 27.5F). The mesh is then
attached circumferentially around the perimeter of the pedicle
using 3-0 sutures, ensuring that all the breast tissue is supported,
without any creases in the mesh (see Fig. 27.5G).
A cannula for introducing a local anesthetic solution post­
operatively (48 hours) is inserted into the subclavicular operation
field, as well as suction drains in the submammary area. The
medial and lateral flaps are approximated with absorbable
subcutaneous sutures. Lengthening the vertical suture line will
shorten the submammary skin excision and reduce the dog
ears. The areolar circumference is marked, and the skin is
excised to accommodate the NAC, which is attached at the 6,
The medial flap is elevated at a thickness of just under 1 cm
and dissected medially in an oblique direction, down to the
chest wall. The pectoralis major fascia is then exposed from
the submammary fold to the second intercostal space (Fig.
27.5A). This dissection plane will preserve the perforators of
the internal thoracic artery running in the medial vertical liga­
ment attached to the pedicle.7–9
The lateral flap is raised and dissected down to the lateral
chest wall, exposing the upper lateral free border of pectoralis
major (see Fig. 27.5B). During this procedure, the branches of
the lateral thoracic artery may be encountered and are sacrificed
for adequate exposure.
The medial and lateral dissection planes are then joined
superior to the NAC, creating the superior flap. Keeping breast
tissue attached to this flap will enhance upper pole fullness
(see Fig. 27.5C). Elevation of the superior flap is performed
along the pectoralis fascia into the subclavicular area.
The pedicle is mobilized by incising the dermis in the
submammary region and performing blunt dissection to the
chest wall (see Fig. 27.5D). Meticulous hemostasis is obtained.
1
2
3
4
5
6
FIGURE 27.3  The blood supply of the breast. In the posteroinferomedial pedicle the medial vertical ligament is retained with the perforating branches of the internal
thoracic artery. The horizontal septum is retained as well with the branches from the anterior intercostal arteries giving the pedicle a dual blood supply. Branches from the
lateral thoracic artery supplying the NAC must be sacrificed in the technique.
A
C
B
FIGURE 27.4  Preoperative markings for the posteroinferomedial pedicle used in the internal breast support technique.

216
    CHAPTER 27  •  Mastopexy With Mesh for Breast Ptosis
Patients are followed up after 3 months and then annually
thereafter.
Results
Excellent results can be obtained with this technique regarding
breast shape, nipple projection, upper breast fullness, and
9, 12, and 3 o’clock positions with a 4-0 subcutaneous absorbable
sutures, followed by subcuticular continuous 4-0 absorbable
sutures.
Intraoperatively, patients receive a single intravenous
prophylactic antibiotic dose that mainly targets gram-positive
bacteria. The drains are usually removed on day 1 postsurgery,
and the stitches are usually removed 1 week postoperatively.
A
D
E
F
G
B
C
FIGURE 27.5  Surgical technique. (A) Mobilizing the medial flap. (B) Mobilizing the lateral flap. (C) Mobilizing the superior flap. (D) Mobilizing the pedicle by releasing
the dermis at the inferior pole. (E) Anchoring the mesh to the periosteum of the fourth rib behind the upper free border of the pectoralis major muscle. (F) Anchoring the
mesh to the second costochondral perichondrium. (G) The final shape of the pedicle after attachment of the mesh.

217
Conclusion
2.
Kirwan, L., 2002. A classification and algorithm for treatment of breast
ptosis. Aesthet. Surg. J. 22, 355–363.
3.
Wueringer, E., Tschabitscher, M., 2002. New aspects of the topographical
anatomy of the mammary gland regarding its neurovascular supply
along a regular ligamentous suspension. Eur. J. Morphol. 40, 181–189.
4.
Matousek, S.A., Corlett, R.J., Ashton, M.W., 2014. Understanding the
fascial supporting network of the breast: key ligamentous structures
in breast augmentation and proposed system of nomenclature. Plast.
Reconstr. Surg. 133, 273–281.
5.
Cooper, A.P., 1840. On the Anatomy of the Breast, vol. 1. Harrison,
London, pp. 48–52.
6.
Van Deventer, P.V., 2004. The blood supply to the nipple-areola complex
of the human mammary gland. Aesthetic Plast. Surg. 28, 393–398.
7.
Van Deventer, P.V., Graewe, F.R., 2010. Enhancing pedicle safety in
mastopexy and breast reduction procedures: the posteroinferomedial
pedicle, retaining the medial vertical ligament of Wuringer. Plast.
Reconstr. Surg. 126, 786–793.
8.
Van Deventer, P.V., Page, B.J., Graewe, F.R., 2008. The safety of pedicles
in breast reduction and mastopexy procedures. Aesthetic Plast. Surg.
32, 307–312.
9.
Van Deventer, P.V., Graewe, F.R., Wuringer, E., 2012. Improving the
longevity and results of mastopexy and breast reduction procedures:
reconstructing an internal breast support system with biocompatible
mesh to replace the supporting function of the ligamentous suspension.
Aesthetic Plast. Surg. 36, 578–589.
longevity of the mastopexy (Fig. 27.6). The mesh is not palpable
postoperatively. The mesh is radiolucent.
Complications of the Polyester Mesh
Mastopexy
Complications are rare and include hematoma, seroma and
infection, delayed wound healing, and palpable folds.
Conclusion
This technique has been developed according to sound anatomic
principles, with predictable results. Complications can be treated
effectively. However, as with any other surgery, the outcome
of the operation depends on the quality of the surgery, excellent
hemostasis, and insertion of the mesh in a perfect correct
position under strict aseptic conditions.
References
1.
Regnault, P., 1976. Breast ptosis: definition and treatment. Clin. Plast.
Surg. 3, 193–203.
A
C
E
F
D
B
FIGURE 27.6  (A–C) Mastopexy with internal mesh support on a 36-year-old patient (BMI = 36). (D–F) 10-year follow-up result. During this period, she gained body mass
of 5 kg, which she lost again without recurrent breast ptosis.

219
The Clinical Problem
219
28 
Simultaneous Augmentation and Periareolar
Mastopexy: Indications and Limitations
Alberto Rancati MD, PhD
Claudio Angrigiani MD
The Clinical Problem
Hypoplasia and ptosis of the mammary are frequent occur­
rences, especially in multiparous women or in women after
significant weight loss. Decreased breast volume may induce a
negative body image and low self-esteem, affecting a patient’s
quality of life. A mastopexy survey of 487 members of the
American Society for Aesthetic Plastic Surgery, published
in 2006, concluded that the inverted T is the most popular
mastopexy approach (46%) despite the varying nature of
mammary ptosis and its treatment. Short scar mastopexy
techniques were used by 18% of respondents, and the peri­
areolar approach was used by only 6.2% of respondents.1 Breast
augmentation with a simultaneous periareolar mastopexy
has remained a challenging and controversial procedure.2–5
The aesthetic results may be less predictable than those
associated with implant-based augmentation or mastopexy
alone.3
According to Rohrich et al.,1 the periareolar approach is the
preferred breast mastopexy technique for as many as 40% of
the most experienced surgeons, who perform more than 26
mastopexies each year. There is a suggested learning curve
for achieving acceptable aesthetic results.4 Breast surgery has
constituted 60% of all cosmetic liability claims in the United
States in the last decade, and periareolar mastopexy comprised
63% of all mastopexy liability claims.1
Planning simultaneous augmentation and periareolar
mastopexy with shaped implants helps achieve the desired
results, avoids unnecessary scars, and minimizes the fre­
quency of complications in carefully selected cases (Fig.
28.1). Ideal objectives include breast lift, addition of volume,
nipple areolar complex (NAC) lift, reduction of the areolar
diameter and skin envelope, outcome longevity, and minimal
complications.
Synopsis
■ Periareolar breast augmentation and mastopexy is a very
versatile technique.
■ Anatomic implants provide the best possible match in
uplifted breasts.
■ Careful patient selection and planning are necessary.
■ Be conservative in lateral areolar resections.
■ Always consider staging.
■ Extra attention should be paid with large implants (to
avoid bottoming out).
■ Always advise the patient about possible revisions.
Case 28.1
Presentation and Outcome
A multiparous 42-year-old woman presented with bilateral
hypoplasia and grade 2 breast ptosis. She opted for a simultane­
ous augmentation and mastopexy (Fig. 28.2).
Fig. 28.3 shows the markings for a periareolar approach on
the right breast and an anticipated lollipop approach to the
left breast. Fig. 28.4 shows the intraoperative result following
simultaneous periareolar augmentation and mastopexy on the
right breast. Left breast symmetry was achieved by a periareolar
approach of augmentation and mastopexy (Fig. 28. 5). Fig. 28.6
shows the lateral view of the right breast 1 year after simultane­
ous mastopexy and augmentation.
Critical Decisions in Augmentation and Mastopexy
• Which mastopexy technique should be used?
• Should it be one stage or two?
• One-stage approach—first, the augmentation
• Two-stage approach—first, the mastopexy

220
    CHAPTER 28  •  Simultaneous Augmentation and Periareolar Mastopexy: Indications and Limitations
FIGURE 28.1  Different approaches and resulting scars in simultaneous
mastopexy and augmentation.
CLINICAL CASE
Upper pole
fullness
Ascend and
reduce NAC
Ascend
breast volume
Skin
laxity
FIGURE 28.2  Case presentation.
25cm
7cm
8cm
IMF
12,5cm
26cm
FIGURE 28.3  Preoperative breast markings.

221
The Clinical Problem
• How much should the nipple-areolar complex (NAC) be
elevated?
• How much skin should be removed?
DECIDING AUGMENTATION OR SIMULTANEOUS
AUGMENTATION AND MASTOPEXY
■ Is a mastopexy needed?
■ Is an implant needed?
■ Is there uncertainty about the blood supply, previous
scars, long pedicle, and/or tissue cover of the implant?
■ A one-stage approach requires extra attention, but a
two-stage approach is generally safer and allows
revisions.
■ A second stage can always be carried out later.
☛ Tips and Tricks in One-Stage Augmentation
and Mastopexy
Always re-evaluate after the augmentation while the patient
is positioned upright, after closure of the implant pocket.
Tailor-tack over the augmented breast and then perform the
NAC POSITION
FIGURE 28.4  Intraoperative image of the right breast following simultaneous
periareolar augmentation and mastopexy.
C
B
A
FIGURE 28.5  Immediately postoperative and 6-month postoperative results. (A) Preoperative. (B) Postoperative day 7. (C) Postoperative results at 6 months.

222
    CHAPTER 28  •  Simultaneous Augmentation and Periareolar Mastopexy: Indications and Limitations
because over-resection will result in flattened breast projection
and place inordinate stress on the periareolar closure. In addi­
tion, ensuring a skin envelope of at least 8 cm to cover the
lower pole between the IMF and bottom of the areola will
allow creation of a smooth contour.
When the lift of the top of the areola exceeds 4 to 6 cm, the
addition of a vertical segment can prevent flattening of the
nipple projection and reduce stress on the periareolar closure.
It is our preference to use a measurement of 40 to 44 mm for
the areolar diameter. This is measured using a cookie cutter,
with the native areola maximally stretched before the incision
is performed, to ensure that the normal elasticity of the areola
does not become a confounding factor leading to areolar
mastopexy. Anatomic implants enhance results and NAC
positioning. Do not be fixed to an anticipated implant.
Use sizers to assist in implant selection. Carefully consider
the nipple inframammary fold (IMF) distance. Check the areolar
position on the breast. Check skin coverage and tissue quality.
Considering Breast Ptosis
The Regnault classification is commonly used to assess breast
ptosis (Table 28.1).6 However, essential aspects not evaluated
by this classification but vital to consider are breast skin elastic­
ity, striae or scars, breast surface area, breast volume, and
internal consistency and tissue support of the breast.
As a general guideline, a periareolar mastopexy may be
appropriate for patients whose areola has a lower edge level
at or slightly below the IMF (Fig. 28.7).
Periareolar Pattern
The dimensions of the periareolar pattern can be based on
what is resected or what is left behind. Our recommendation
is to limit the amount of skin removed medially and laterally,
5,5cm
A
B
FIGURE 28.6  Lateral view. (A) Preoperative view. (B) Results 1 year postoperatively showing the nipple-areola complex above the inframammary fold.
Table 28.1  Ptosis grade according to the regnault classification
Grade
Degree
Features
1
Minor ptosis
Nipple at the level of the
inframammary fold, above the
lower contour of the gland
2
Moderate ptosis
Nipple below the level of the
inframammary fold, above the
lower contour of the gland
3
Severe ptosis
Nipple below the level of the
inframammary fold, at the
lower contour of the gland
FIGURE 28.7  Breast ptosis classifications 1 and 2, which could be considered for
periareolar augmentation and mastopexy.

223
Complications
widening. Patients with large areolas are ideal candidates for
this technique because a considerable amount of areolar skin
can be resected without any risk of flattening the breast. In
such cases, the NAC can be raised by 3 or 4 cm.
Marking of the periareolar incision must be oval and not
circular, skirting the lateral areolar borders (Fig. 28.8). An
interlocking purse-string polytetrafluoroethylene suture (PTFE;
Gore-Tex, W.L. Gore, Flagstaff, AZ) controls the areolar diameter
and shape (Fig. 28.9).
Pocket Location
A subglandular pocket offers a complementary relationship
between the implant and overlying soft tissue. If the subpectoral
plane is used, it is important to ensure full release of the
inferomedial origin of the muscle so that a muscle-tethering
effect does not prevent the implant from demonstrating a full
measure of projection in the lower pole.
Why Anatomic Implants?
Anatomically shaped implants afford a particular advantage
for patients undergoing simultaneous augmentation and
mastopexy because the volume of the anatomically shaped
device is concentrated in the lower pole and the loose and
redundant skin envelope of the breast are more readily filled
out without creating a rounded fullness in the upper pole.
This could become distracting with the use of a round implant.
Also, in our experience, the lifting effect of the implant on
the position of the NAC is greater with an anatomically shaped
implant than with a round device. As a result, less stress is
placed on the periareolar pattern in lifting the position of the
NAC with the skin resection pattern. The implants used have
maximum projection to maximize the anatomic advantage
afforded by the implant.
Complications
These include the following: areolar malposition, usually too
low; alterations in areolar shape or diameter; scarring; loss of
nipple sensation; breast flatness (avoid lateral NAC resections);
NAC not sufficiently lifted (most common complaint); NAC
necrosis (Figs. 28.10 and 28.11); infection and extrusion; and
asymmetry.
No
Yes
FIGURE 28.8  Periareolar resection.
FIGURE 28.9  The interlocking suture, described by Hammond et al.,6 allows
redraping of the skin around the NAC, distributing tension evenly along the suture.
FIGURE 28.10  Partial nipple necrosis in revision simultaneous periareolar
mastopexy, with a previous inverted T scar with unknown pedicle.

224
    CHAPTER 28  •  Simultaneous Augmentation and Periareolar Mastopexy: Indications and Limitations
Postoperative Care
A support bra is essential for at least 6 weeks to establish the
correct implant position and enhance wound healing and scar
control. The bra is not intended to lift the breast, but rather to
maintain the ideal position of the breast on the implants.
Excessive pressure must be avoided.
References
1.
Rohrich, R.J., Gosman, A.A., Brown, S.A., Reisch, J., 2006. Mastopexy
preferences: a survey of board-certified plastic surgeons. Plast. Reconstr.
Surg. 118, 1631–1638.
2.
Persoff, M.M., 2003. Vertical mastopexy with expansion augmentation.
Aesthetic Plast. Surg. 27, 13–19.
3.
Pontes, R., 1981. Reduction mammaplasty: variations I and II. Ann.
Plast. Surg. 6, 437–447.
4.
Spear, S.L., Pelletiere, C.V., Menon, N., 2004. One-stage augmentation
combined with mastopexy: aesthetic results and patient satisfaction.
Aesthetic Plast. Surg. 28, 259–267.
5.
Regnault, P., 1976. Breast ptosis: definition and treatment. Clin. Plast.
Surg. 3, 193–203.
6.
Hammond, D.C., Hollender, H.A., Bouwense, C.L., 2001. The sit-up
position in breast surgery. Plast. Reconstr. Surg. 107, 572–576.
This technique is not recommended for cases of severe ptosis
in patients with a distance of more than 8 cm between the
inferior areolar border and IMF. In regard to implant rotation,
and to avoid pocket overdissection, the recommendation is
not to dissect more than 1 cm beyond the preoperative marks
to ensure an appropriate match between the pocket and implant.
FIGURE 28.11  Complete nipple necrosis after simultaneous augmentation and
mastopexy.

225
Stepwise Approach
225
29 
Asymmetric Breast
Garrick Georgeu MBChB, MSc, FRCS (Plast)
The Clinical Problem (Fig. 29.1)
A young woman’s perception of normal body form is increas­
ingly influenced by the media to match a somewhat stereotyped
image of beauty. The Internet contains large volumes of graphic
imagery available at the click of the mouse that can make any
vulnerable young women, particularly those with asymmetric
breasts, under even more pressure to conform. Minor asymmetry
of any paired structure in the body is normal, but meeting
patients’ expectations has become increasingly difficult in this
litigious age.
There is no quick fix to correct most women’s breast asym­
metry problems. This is because more than one breast parameter
needs to be addressed.1
Stepwise Approach
Understanding the Patient’s Requests
During two consultations with the patient, discuss what she
perceives to be the issues with her breast asymmetry. I find a
very simple but enlightening experience for the patient is to
ask her to take images of herself in front, side, and three-quarter
views and then compare these to online images of what she
would like to be her final “ideal” result. Often, by the time of
the second consultation, the tough decisions have been made
about what is anatomically and financially possible.
Examination of the Patient
Like most clinicians, using a standardized template is helpful
to record everything methodically so that a true representation
of the preoperative status can be made. This is available when
reviewing the results of surgery (Fig. 29.2).
As a bare minimum, the following should be assessed and
documented2:
• The spine and rib cage vectors
• Projection of the breasts
• Total breast volume, and quality and quantity
• Breast measurements: sternal notch (SN) to
nipple-areola complex (NAC); NAC to inframammary
fold (IMF); NAC to midline; medial edge height, IMF
height, NAC diameter, and skin roll test
Explaining Anatomy to the Patient
This is a crucial step in the consultation process, where I stand
the patient in front of a full-length mirror and explain the
anatomic differences and issues. It is wise to include a close
relative and always a nurse chaperone.
I divide the asymmetry into three distinct anatomically areas:
• The breast tissue, shape, and size—these are the tissues
with which we commonly, which includes the NAC.
• These the areas that we can disguise or partly change,
such as a rib or chest wall deformity.
• These are areas that are beyond my surgical discipline
and cannot change, such as spinal scoliosis.
Formulating the Individualized Operative Plan
A simple chart (Table 29.1) helps me visualize and plan the
aesthetic breast reconstruction, but with breast asymmetry this
is not always possible. Specialized radiologic imaging (e.g.,
computed tomography [CT], magnetic resonance imaging [MRI])
may be required in more severe cases. The IC 360 camera
(oVio360 Imaging System, OVio Technologies, Newport Beach,
CA, USA, ) gives an excellent panoramic
view that highlights the asymmetric features and provides the
patient with a memory stick for private reflection.

226
    CHAPTER 29  •  Asymmetric Breast
RIB CAGE
Where there are significant developmental chest wall
deformities, such as occurs in Poland syndrome or pectus
carinatum or excavatum, a different volume or size of
implant may not be enough to disguise the differences
or the defect (Fig. 29.3). Improved CT and MRI radiologic
scanning, coupled with three-dimensional (3D) computer
modeling and 3D printers permit the manufacture of custom­
ized deformity-correcting silicone implants in select cases.3
Anatomic implants can be used to disguise such deformities
(Fig. 29.4).4
THE BREAST ITSELF
Similar Volumes but Different Positions on
the Chest Wall
Variation in position of the breast on the chest wall is common.
This leads to variation in nipple height and the NAC-IMF
distance. By using the so-called Velcro effect of polyurethane
implants, not only can the breast volume be altered but also
the breast can be lifted and repositioned into a more stable
and symmetric position (Fig. 29.5).
SPINE
Scoliosis is common, and the more you look for it, the more
you will observe it. There can be considerable differences in the
breast footprint, depending on how the breast volumes sit on
the asymmetric, anterior, and costal cartilage configurations.
FIGURE 29.1  The clinical problem.
EXAMINATION
HEIGHT
Scoliosis
Pectoral Muscles
Chest wall vectors
positive
negative
neutral
Lat Dorsi
Pectus Deformity
Scars
WEIGHT
BMI
Breast
Left
Yes/No
Yes/No
Yes/No
Base
SN-N
N-IMF
N-midline
Skin roll
Projection
IMF height
Medial edges
Base
SN-N
N-IMF
N-midline
Skin roll
Projection
IMF height
Medial edges
Nipple inversion
Base
S-N
N-IMF
Pinch
Yes/No
Tuberous breast
Impression:
Breast base: Round/SHWB/THNW
None/pseudo-ptosis/
Regnault grade I/II/
III
None/pseudo-ptosis/
Regnault grade I/II/
III
Right
Cup size (approx.)
Symmetry
Ptosis
FIGURE 29.2  Example of a breast template.
Table 29.1  Preoperative asymmetry guide to operative planning
Parameter
Left
Right
Chest wall shape
• Normal
• Asymmetric
Do nothing.
Do nothing.
Breast implant
alone
Breast implant
alone
or
or
3D custom-made
silicone implant
3D custom-made
silicone implant
Breast volume
• Normal
• Too big
• Too small
Do nothing.
Do nothing.
Reduce.
Reduce.
Volumize with
implant or fat
transfer.
Volumize with
implant or fat
transfer.
Breast shape
• Like the shape
• Ptotic
Do nothing.
Do nothing.
Uplift, reshape
Uplift, reshape
Breast skin amount
• Normal
• Deficient
• Excess
Do nothing.
Do nothing.
Expansion with
tissue expander
or implant
Expansion with
tissue expander
or implant
Reduction
Reduction
Implant
• Volume, shape,
base widths
Round, teardrop,
conical
Round, teardrop,
conical
Nipple-areolar
complex
• Normal
• Puffy
• Inverted nipples
Do nothing.
Do nothing.
Areolar reshaping
Areolar reshaping
Correction
Correction

A
B
FIGURE 29.3  Poland syndrome, before (A) and after treatment (B). (Courtesy Bassem Mossaad.)
Neutral vector
Negative vector
Positive vector
Mixed vectors
B
Round frame
Heart shape frame
Oblong frame
U-shape frame
Triangular frame
A
FIGURE 29.4  Breast frames. (A) Transverse chest
frames. (B) Longitudinal chest vectors. (From
Frame, J., Connolly, C. 2015. Framing the breast.
Aesthetic Surg. J. 35:106–12.)

228
    CHAPTER 29  •  Asymmetric Breast
Base Width of Implant.  Often, the base width or height needs to
be adjusted to attain symmetry and balance. Oval anatomic
implants have a role when the breast is wider than tall, and
the converse is also true.
Projection of Implant.  Careful consideration is needed with
implants used for full projection because this may create a more
artificial-looking breast. However, fuller projecting implants
are more appropriate within a depressed chest wall defect.
Nipple Areolar Complex
Once major volume and shape adjustments have been made,
the NAC must be addressed primarily or secondarily under
local anesthetic. Simple hemiexcisions of periareolar tissue can
often balance nipple positions.
Tissue Quality and Additional Support
Some patients have poor-quality breast tissue, which requires
additional support for a better and more stable long-term result.
In these cases, additional support in the form of acellular dermal
matrix (ADM) such as Surgimend TM (TEI Biosciences, Boston,
MA, USA) or synthetic matrices such as Breform (Triangle
Surgical, Buckinghamshire, England) are becoming more
popular to relocate the breasts.
Complications
Common complications include bleeding, infection, delayed
healing, necrosis, scarring, change or loss of sensation, seroma,
fat necrosis, oil cysts, capsular contracture, difficulty in breast
screening, and difficulty breastfeeding. All patients need to
consider the potential of revision surgery over time. With any
implant-based reconstruction, the patient needs to be made
aware of the potential risk of anaplastic large cell lymphoma.
Volume Reduction and Reshaping
Differential reduction or mastopexy is used to balance breast
volume and shape in larger ptotic breasts. Numerous surgical
techniques have been described; however, I prefer superior
medial pedicle lifts of the NAC complex. Younger patients
may require further surgery, and the superior pedicle approach
keeps all options open.
Volume Replacement
There are a considerable number of surgical decisions to be
made in this volume replacement category. Often, it is a com­
promise between the various options to obtain the final result.
Stages of Reconstruction
In conditions such as breast hypoplasia or tubular breast
deformity, skin expansion is needed, but frequently a deep
soft tissue fascia and radial breast tissue release is required to
allow the breast envelope to expand.
Silicone Implant.  Volume replacement with a silicone implant
is the preferred option in most cases. However, autologous
fat transfer is a reasonable alternative in small-volume or
marginal asymmetry volume replacement. Many experi­
enced surgeons believe that polyurethane-covered silicone
implants have the least complications and a more extended
longevity.5,6
Implant Volumes.  The selection is based on the skin capacity,
comparative size and shape of each breast, and implant fill
volumes required (Fig. 29.6).
Shape of Implant.  With a polyurethane implant, there are three
shapes available—round, anatomic teardrop, and conical.2
Different shapes and volumes of implants may help lift,
volumize, and balance the breasts (Fig. 29.7).
A
B
FIGURE 29.5  (A,B) A 34-year-old mother of two with breast volume asymmetry of position on the asymmetric rib cage (right side projecting more outwardly). She
underwent breast augmentation with 295-mL, low-profile, conical Pure implants (Silimed, Brazil).

229
Complications
A
C
D
B
FIGURE 29.6  (A,B) A 37-year-old with breast volume asymmetry corrected (C,D) using 295- to 350-mL, low-profile, conical Pure implants.

230
    CHAPTER 29  •  Asymmetric Breast
A
D
E
F
B
C
FIGURE 29.7  (A–C) A 31-year-old with significant breast asymmetry. She underwent differential breast augmentation with an anatomically shaped 315-mL, medium-
profile, Pure implant on the left and a 260-mL, low-profile, conical Pure implant on the right. (D–F) Note that the volume and shape have improved, but the outwardly
projecting right breast still remains.
References
1.
Rohrich, R.J., Hartley, W., Brown, S., 2003. Incidence of breast and
chest wall asymmetry in breast augmentation: a retrospective analysis
of 100 patients. Plast. Reconstr. Surg. 111, 1513–1519.
2.
Georgeu, G.A., Frame, J.D., Jr., Frame, J.D., 2013. Conical polyurethane
implants: an uplifting augmentation. Aesthetic Surg. J. 33, 1116–1128.
3.
Majdak-Paredes, E.J., Shafighi, M., Fatah, F., 2015. Integrated algorithm
for reconstruction of complex forms of Poland syndrome: 20-year
outcomes. J. Plast. Reconstr. Aesthet. Surg. 68, 1386–1394.
4.
Frame, J.D., Connolly, C., 2015. Framing the breast. Aesthet Surg. J.
35, 106–112.
5.
Fleming, D., 2012. Polyurethane foam breast implants. In: Peters,
W., Brandon, H., Jerina, K.L., et al. (Eds.), Biomaterials in Plastic
Surgery: Breast Implants. Woodhead Publishing, Cambridge, England,
pp. 96–120.
6.
Dancey, A., Nassimizadeh, A., Levick, P., 2012. Capsular contracture—
what are the risk factors? A 14-year series of 1400 consecutive augmenta­
tions. J. Plast. Reconstr. Aesthet. Surg. 65, 213–218.

231
Surgical Preparation and Technique
231
30 
Transaxillary Excision of
Gynecomastia (Andromastia)
Paul Levick MS, FRCS (Ed), FRCS (Eng)
The Clinical Problem (Fig. 30.1)
Why is Gynecomastia Important?
When my breasts developed as an adolescent male, I was
winning medals for swimming, but I never swam in public
again. The embarrassment felt by the patient may be very large
and may cause unreasonable restrictions in lifestyle, in my
opinion mainly because of joking by other males.
I think gynecomastia should be termed andromastia, because
these are male breasts, not female breasts. All mammals,
both male and female, have breasts, and they all vary
in size.
The average male breast is very small, but genetics causes
some to be above-average size. Some Polynesian Islanders have
a very high percentage of andromastia, suggesting that genetics
is the main factor.
If a man takes female hormones, he will change to a female
shape, and his breast, thigh, and hip fat deposits will enlarge.
This can be intentional or a byproduct of drug therapy (e.g.,
for benign enlargement of the prostate or for prostate cancer),
body-building drugs, or hair growth promoters—often the
same drug is used for an enlarged prostate, but in a different
dose—where levels of female hormones can rise. There is a
very long list of drugs that may cause male breast enlargement
and, unfortunately, if these cause breast growth, the tissue
does not revert to normal when the treatment is finished, and
surgery becomes the only cure.
Very rarely, hormones can be caused by tumors of the
endocrine system, notably the testis and pituitary gland, and
may even be associated with actual milk production, thereby
proving that male and female breasts are the same. These tumors
arise in adulthood so if andromastia appears in a grown man
for no apparent reason, blood tests and testicular ultrasound
scanning need to be carried out.
If you do a good job, you will have lots of very happy
patients who will tell you how much you have improved the
quality of their lives, which is what cosmetic surgery is all
about.
Examples of Andromastia
There is no need for complicated classification. The use of M,
L, XL, and XXL is fine.
■ M—puffy nipple syndrome (<50 g total breast tissue;
Fig. 30.2)
■ L—Large andromastia (50–200 g; Fig. 30.3)
■ XL—very large andromastia (200–400 g; Fig. 30.4)
■ XXL—extra large andromastia (>400 g; Fig. 30.5)
The main objectives for this surgery are as follows: (1) to
keep skin scars to a minimum using a 1-cm anterior axillary
wound; and (2) to remove all the gland, including subareolar
breast tissue, to prevent further excisional surgery.
I have only done one circumareolar skin reduction at the
time of glandular excision, and this was because of the unfavor­
able result, as shown in Fig. 30.6). Since changing to the axillary
miniscar and avulsion technique, there have been no patients
requesting areolar size reduction.
Surgical Preparation and Technique
Preoperative Preparation
First, get the patient to wash his chest and axillae with 2%
chlorhexidine (on ward). Then, take preoperative photos in
the anesthesia suite.
Mark out the extent of the breast tissue, and draw a vertical
line from the anterior axillary fold and position of the incision.

232
    CHAPTER 30  •  Transaxillary Excision of Gynecomastia (Andromastia)
Step 4. Separate the skin from the gland with long Nelson
scissors.
Step 5. Divide the milk ducts from the nipple, excising all
subareolar tissue.
Step 6. Remove the gland with long Kocher or Lane forceps.
Step 7. Use a 3-mm cannula for liposuction to the
periglandular tissue to make the subcutaneous fat layer
even over the upper chest.
Step 8. Spray 2.5 mL thrombin and fibrinogen (Evicel,
Ethicon, Somerville, NJ) into each cavity.
Step 9. Suture with one or two subcutaneous Vicryl sutures
and take a preoperative photograph.
Step 10. Apply a cooling pad (e.g., Hilotherm pad, PROSPOT
d.o.o. Radovljica, Slovenia) and pressure band loosely
(otherwise the cooling water may not circulate properly).
Step 11. Wake the patient up slowly and gently to avoid
hematomas.
The average surgery time is 90 minutes.
Postoperative Care
Undo the pressure band the next morning, remove the Hilotherm
pads, examine the operation site and reapply the pressure band
tightly (Fig. 30.7).
POSTOPERATIVE INSTRUCTIONS
1. Keep the pulse and blood pressure down for at least
1 week—that is, no exercise, stress, or hot showers, and
wear the pressure band continuously for 7 days.
Retighten and adjust as necessary.
Arrange the patient square on the table, with his arms at his
side, held by angle restraints.
Procedure (Video 30.1)
Step 1. Puncture the skin of the anterior axilla and stretch to
2 cm to achieve minimal scarring.
Step 2. Inject 750 mL of liposuction fluid on each side, and
wait 7 to 10 minutes.
Step 3. Tunnel in the subcutaneous and subglandular planes
with a 3-mm cannula.
FIGURE 30.1  The clinical problem in a 31-year-old male patient.
A
B
C
FIGURE 30.2  (A) 20-year-old male patient. (B) Gland—L, 22 g; R, 17 g. (C) 16 months postoperatively.
A
B
C
FIGURE 30.3  (A) 31-year-old male patient. (B) Gland—L, 87; R, 91 g. (C) 7 months postoperatively.

233
Complications
surgeon can then assess whether a hematoma or seroma
is present.
3. The patient should start simple pain-free massage and
stretching at week 3 and beyond, provided no pain or
fluid collection is present. This should be done only for a
few minutes; a professional masseur or expensive oils is
not needed.
4. If there is a fluid collection, the patient should confirm
with a selfie and apply firm constant pressure. If no
improvement is seen in 1 week, the patient should repeat
the selfie and return for aspiration or see the clinician or
a local seroma nurse.
Note that small or moderate amounts of normal swelling
are often confused with a fluid collection.
Complications
In 450 patients since 2010, I have observed the following
complications: bleeding in 15 patients (3.3%; but in none of
100 patients since 2014); infection, 0%; nerve damage, 100%
(none to motor nerves); keloid or hypertrophic scars, 0%;
regrowth of gland in one patient (pseudoangiomatous stromal
hyperplasia patient); and triamcinolone injection to the internal
scar, about 5%.
Management of Complications
TENSE, EXPANDED, PAINFUL HEMATOMA
Return to the operating room, aspirate and wash out, and
enlarge the incision (in a posterior direction) to 5 cm. Use breast
At 7 days postoperatively, the patient should remove
the binder, shower, send a selfie and update, put on the
pressure vest garment, and wear this continuously
(except for showering) for 2 weeks. Put the pressure band
on top of the vest, if necessary. At 3 weeks
postoperatively, leave the pressure garment off during
day but replace it at night for 2 more weeks.
2. Avoid aspirin and alcohol for 2 weeks. Avoid gym and
heavy exercise for 1 month (longer for heavy weights and
contact sports).
The patient should send an update and selfie at any
time but especially at the 1-week postoperative stage. The
A
B
C
FIGURE 30.4  (A) Preoperative view. (B) Gland, 245 g. (C) 17 months postoperatively. Note skin retraction and nipple reduction without skin excision.
A
B
C
FIGURE 30.5  (A) 21-year-old male patient. (B) Weight loss, 110 kg. The skin and the gland weighed 869 g. (C) 4 years postoperatively; requires skin reduction. The blue
line shows the skin excision.
FIGURE 30.6  The unfavorable result, poor (and unnecessary) scars and residual
gland.

234
    CHAPTER 30  •  Transaxillary Excision of Gynecomastia (Andromastia)
of serum or blood. The pressure band applies the firmest
pressure and should be worn constantly for the first
7 days.
Hot showers can cause bleeding in the first week. Fluid
buildup is made worse by an increase of pulse and blood
pressure, so the patient should avoid exercise and stress.
Recovery of the Lymphatic Vessels
The lymphatic system removes the serum that naturally leaks
from the capillaries and is always damaged by surgery. The
lymphatics take many weeks or months to recover; swelling
of the surgical area occurs more frequently until the lymphatics
are naturally repaired.
Formation and Maturation of Scar Tissue
Scarring is a normal part of the healing process and starts
to build up to its maximum at the 3- to 6-month stage. New
scar is soft, spongy, and thickened and then becomes firmer,
flatter, and more even. Sometimes hard lumps of scar can
form, which take a long time to soften and flatten. These can
form adhesions between the tissue layers and cause distor­
tions of the overlying skin. I call these abnormal scars and
sometimes inject them with steroid or divide obvious strands
with a needle, usually at 6 months or more postoperatively
(Fig. 30.8).
Recovery of the Nipple-Areola Complex
The NAC skin contains muscle, which loses its nerve supply
during surgery. The muscle tone and skin shape slowly recover
as the nerves recover.
Revision Surgery
The revision rate is low if a good operation is carried out.
Some patients are very picky and demand perfection, so try
to give it to them; otherwise, they may become very unhappy
with you. Patients are named thus but are often impatient;
they may get reassurance from other patients of yours on the
internet forums, provided you have produced good results.
augmentation fiberoptics to inspect the cavity; however, the
artery responsible is often not seen. Use diathermy, if required,
and spray 5 mL Evicel. Resuture and apply Hilotherm pads
and a pressure band.
LOCALIZED SOFT HEMATOMA
This can be aspirated with the patient in bed the next morning,
with lidocaine injected into the incision using a 3-mm cannula
(or syringe) and a gentle saline washout.
DEHISCENCE OF WOUND
This can be resutured or a Steri-Strip can be used.
Four Main Stages of Normal Healing
1. Closure of the cavity left by removal of the breast tissue
2. Recovery of the lymphatic vessels
3. Formation and maturation of scar
4. Recovery of the nipple-areola complex (NAC)
Closure of the Subcutaneous Cavity
Small amounts of fluid are present from day 1, and constant
firm pressure will disperse them and prevent further buildup
A
B
FIGURE 30.7  Remove the Hilotherm pads and inspect. Replace the pressure band tightly.
FIGURE 30.8  Typical axillary scars, 1 year postoperatively.

235
Some Frequently Asked Questions
Some Frequently Asked Questions
■ Have I got fluid building up?
■ Is the gland growing back?
■ How long should I wear the pressure garment?
■ When should I start massage?
■ Why is my nipple distorted and dented?
■ Have I got bad scar building up (and do I need steroids)?
■ When can I start exercising?
■ Why am I taking longer to settle?
☛ Tips
■ Be readily accessible by email.
■ This is major surgery, and some patients worry a lot. If
you don’t answer their queries they will go online and
may be given inaccurate or even false information.
■ Make sure the frequently asked questions are well
covered in consultation, and give the patient a clearly
written fact sheet to refer to.

239
Surgical Technique
239
31 
Improving the Waistline With the Modified
Brazilian Abdominoplasty
Bassem M. Mossaad MRCS, MSc (Aesth Plast), FEBOPRAS, MD
The Clinical Problem (Fig. 31.1)
Abdominoplasty is a surgical procedure designed to rejuvenate
truncal aesthetics, in which flattening a protuberant abdomen,
removing redundant tissue, and restoring normal waistline
definition is a surgical challenge. Advancement in surgical
techniques should reduce surgical risk and improve aesthetic
outcomes. The term modified Brazilian abdominoplasty (MBA)
originated after a presentation by the Brazilian plastic surgeon,
Joao Erfon Ramos, at the International Society of Plastic Surgeons
Meeting in Australia in 2008. Results are at least as good, but
the complications are significantly lower than with a traditional
abdominoplasty, where there is wide undermining and excision
of Scarpa’s fascia in the lower abdomen. The proven lower
complication rates are achieved through minimizing dissection
and dead space. Waist definition is improved by a combination
of medially advancing lower abdominal Scarpa’s fascia and
repairing any divarication of the rectus abdominis muscles.
Scarpa’s fascia is an important part of the superficial fascial
system (SFS), which helps define waist contour and may also
have a role in urogenital dynamics.
Abdominoplasty is a plastic surgery procedure that has
been evolving over time. Significant refinements have been
introduced in abdominoplasty techniques to meet the growing
perception of aesthetics among the general population, as well
as dealing with the new challenges that were recognized by
surgeons. Eventually, a new concept has evolved—truncal
rejuvenation. This truncal rejuvenation, as described by
Lockwood in 2004, envisages the trunk and thighs as a
circumferential aesthetic unit, extending from the breasts to
the knees.1
One of the challenging elements of truncal rejuvenation is
restoring a normal waistline definition. The combined effects
of pregnancy, aging, and fluctuations of obesity on the abdomi­
nal wall are characterized by redundant skin, with associated
striae, excess subcutaneous fat, and musculoaponeurotic
flaccidity. When performing a traditional abdominoplasty, these
three fundamental defects of the abdominal wall must always
be addressed by the plastic surgeon.2 The waist, as part of the
trunk circumferential aesthetic unit, must also be addressed
in the same manner.
Musculoaponeurotic laxity is corrected by midline plication
of the rectus sheath from the xiphoid to the pubis3; however,
this technique alone is not sufficient to improve the contour
deformity of the whole musculofascial layer, especially in the
waist area.4 Skin excess or lipodystrophy encircling the truncal
region, especially involving the flank areas, can be extremely
problematic for the plastic surgeon. Unfortunately, this cannot
be corrected solely by a traditional abdominoplasty operation
or liposuction in most cases. In addition, abdominal wall
flaccidity and ptosis inevitably cause unwanted bulging of the
mons pubis.
The MBA technique was adopted over 8 years ago as a
means to excise lower abdominal wall apron, tighten the rectus
sheath, provide a more aesthetic waistline, and reduce the
prominent bulge of the mons pubis, thus returning the ptotic,
bulging, U-shaped mons back to its more youthful V shape.5
This discussion focuses on the surgical technique whereby
flank tightening using medial advancement of Scarpa’s fascia
improves waist definition, and mons elevation is achieved
using lipocutaneous mobilization and elevation of Scarpa’s
fascia in the lower abdomen. It is always combined with the
MBA technique.
Surgical Technique
Incisions
The lower elliptic linear incision line is marked at the upper
limit of the pubic hair in the natural crease line, where possible.
The upper incision line is marked to include the umbilicus.

240
    CHAPTER 31  •  Improving the Waistline With the Modified Brazilian Abdominoplasty
The lateral limit to the scar was determined by assessing the
skin redundancy with the patient in the sitting position.
EXCESS TISSUE EXCISION
Tissue excision is full thickness down to the rectus sheath,
only within a subumbilical midline strip 4 cm lateral to the
midline on both sides using the harmonic scalpel (Ethicon,
Somerville, NJ; Figs. 31.2A,B and 31.3). The lateral tissue is
excised using a harmonic scalpel down the plane superficial
to Scarpa’s fascia using a controlled traction technique. Scarpa’s
fascia is preserved together with the underlying fat and left
FIGURE 31.1  The clinical problem.
A
B
C
D
FIGURE 31.2  Diagram of operative steps. (A) Preoperative markings. The red line
represents the incision, blue infraumbilical rectangle represents the area of
full-thickness excision, green lateral triangles represent areas of a supra–Scarpa’s
fascia excision, indigo supraumbilical triangle represents area of dissection to
enable midline plication, yellow small triangles represent areas of Scarpa’s fascia
excision, and the violet area represents area of liposuction. (B) Infraumbilical
midline full-thickness excision. (C) Lateral supra–Scarpa’s excision. (D) Scarpa’s
fascia pulled medially and sutured in the midline, causing traction on Scarpa’s
fascia in the waist area and leading to improved waistline definition.
A
B
FIGURE 31.3  Modified Brazilian abdominoplasty approach and excision of skin and fat down to Scarpa’s fascia laterally.

241
Postoperative Course and Results
attached to the abdominal wall (see Figs. 31.2C and 31.3B).
There is less damage to the neurovascular and lymphatic
channels.
Mobilizing
UPPER ABDOMINAL FLAP
Unlike the traditional techniques, which require wide undermin­
ing of the abdominal flap extending superiorly to the xiphi­
sternum and laterally to the costal margins, the Brazilian
abdominoplasty largely involves tissue advancement after
lipomobilization, using a standard tumescent liposuction
technique. In nonobese patients, the cannulae are not used to
remove fat but only to create channels. The dissection is limited
to a central tunnel in the midline to allow midline plication
of the medial rectus sheath and repositioning of the umbilicus
(Fig. 31.4). This technique is similar to that demonstrated by
Saldanha et al. in 2003.6
MONS PUBIS
The mons pubis is also lipomobilized, debulked if necessary,
elevated, and fixed by suturing Scarpa’s fascia to the anterior
rectus sheath. This changes the ptotic, often bulky, U-shaped
mons to a more youthful V shape.
UMBILICUS
The umbilicus is then positioned using a single suture through
the anterior abdominal wall for later re-siting once the exact
position has been determined (usually 9 cm above the pubic
hairline).
Improving the Waistline Definition
The preserved Scarpa’s fascia on both sides of the midline of
the lower abdomen are then pulled medially, thinning and
sliding over the underlying fat before suturing together in the
midline and onto the centrally plicated rectus sheath. This pull
places medial traction of the whole superficial fascial system
A
B
FIGURE 31.4  (A) Central tunneling is limited to provide only enough access to correct any epigastric divarication. (B) The excision specimens show three segments; the
central is skin plus all layers down to the aponeurosis. The excised Burov’s triangle tissue, marked within the yellow triangles, is usually necessary after medial plication of
the scarpas fascia. This prevents paraumbilical bulging and permits an even redistribution of skin during closure.
of the lower abdomen, causing a tightening effect on the flanks
(Figs. 31.5 and 31.6; see Fig. 31.2D), and also obliterates the
lower midline deadspace.
Closure
The abdominal adipocutaneous tissue that remains is then
pulled downward for closure. A small triangular excision of
Scarpa’s fascia is done at its junction with the abdominal flap
(Burow’s triangle; see Fig. 31.4). The latter step helps avoid
unwanted bulging of the central part of the abdominal flap
after medial advancement of Scarpa’s fascia. The remaining
lower abdominal wall is closed in three layers, and the umbilicus
is retrieved and sutured into a heart-shaped opening created
by a V-shaped cutaneous incision. The lower abdominal wound
is closed in three layers using absorbable sutures, and the
wounds are then covered with Prineo (Ethicon) and Dermabond
(Ethicon). Drains are not used because there is no surgical
dead space.
Postoperative Course and Results
Lower Complication Rate
The complication rates with the MBA technique are extremely
low. This is due to the limited undermining, thus avoiding the
creation of any surgical dead space. Such surgical dead space
is common to all the other procedures, leading to high morbidity,
especially with hematomas and seromas. As the technique has
developed, the early complication rate is extremely low, and
less than 2% of all cases in a large series have required revisional
surgery, consisting mainly of liposuction centrally to the lower
abdomen. Seromas and hematomas are extremely unlikely in
all groups except perhaps massive weight loss patients, and
more care must be taken with these patients. With further
refinement to technique, paying attention to Burow’s triangles
and a more lateral vector pull to the abdominal flap, the
incidence of this complication can be reduced. The complication
rate from the MBA compares favorably with all other techniques.

242
    CHAPTER 31  •  Improving the Waistline With the Modified Brazilian Abdominoplasty
A
C
B
FIGURE 31.5  Scarpa’s fascia is advanced medially, showing the waistline
definition improvement.
X
X
Y
Y
Scarpa’s fascia
Linea
alba
FIGURE 31.6  Effect of subcutaneous thinning as the Scarpa’s fascia and
sub–Scarpa’s fat are advanced medially and sutured at the linea alba.
In a large series of traditional abdominoplasty techniques, the
authors reported early complications in as many as 18% of
patients, the most common of which were seroma, hematoma,
infection, skin or fat necrosis, and delayed healing. Of these
patients, 25% had late complications, and 24% underwent
revision surgery.7 These complication rates are not recognized
with use of the MBA.
High Patient Satisfaction
Patients have reported high satisfaction, with postoperative
improvement in the waistline definition. Preoperative and
postoperative photographs demonstrate significant improve­
ment of waist definition (see Figs. 31.7–31.12).
Conclusion
It appears that it is not absolute levels of body fat but the
distribution of body fat that is most important in determining
female attractiveness. Two different women can weigh the same
amount, yet the shape of their bodies can vary enormously.
This explains the importance of restoring waist definition.8

243
Conclusion
In the MBA technique, the role of Scarpa’s fascia as an
important part of the SFS is demonstrated by lifting and contour­
ing the waist area, without the need of extra incisions and
subsequent scarring. This valuable modification was added to
the combined techniques of lipomobilization with limited
dissection, midline musculoaponeurotic plication, and skin
excess excision. The technique represents a balance between
lowering complication rates through minimizing dissection
and dead spaces and achieving adequate contouring, with
better waist definition and mons shape.
The primary function of the SFS is to encase, support, and
shape the fat of the trunk and extremities and hold the skin
onto the underlying tissue. With aging, parity, and weight
changes, the entire skin-fat-SFS unit relaxes and stretches and
often results in ptotic soft tissues and cellulite. SFS suspension
is an important adjunct to body contour surgery of the trunk
and extremities. Similar to the superficial musculoaponeurotic
system role in face lift procedures, the SFS diffuses the tension
on skin flaps, more effectively lifts areas of soft tissue ptosis,
and provides longer lasting support.9
A
B
FIGURE 31.7  Preoperative (A) and postoperative (B) views showing better waistline definition using the medial advancement technique. There is poor-quality lower
abdominal skin, but this patient is a very good candidate because this is the skin to be excised.
A
B
FIGURE 31.8  Preoperative (A) and postoperative (B) views showing improved waistline definition using the Scarpa advancement technique. There is mainly a lower
abdominal apron.

244
    CHAPTER 31  •  Improving the Waistline With the Modified Brazilian Abdominoplasty
A
B
FIGURE 31.9  Preoperative (A) and postoperative (B) views after modified Brazilian abdominoplasty, again showing improved waistline definition. There is poor skin
elasticity.
A
B
FIGURE 31.10  Preoperative (A) and postoperative (B) views after a Brazilian abdominoplasty in a patient with good skin and central fullness.

245
Conclusion
A
B
FIGURE 31.11  Brazilian abdominoplasty in a patient with poor abdominal wall skin and hypochondrial fat pads. The waistline definition has improved.
A
B
FIGURE 31.12  Preoperative (A) and 1 year postoperative (B) results after a Brazilian abdominoplasty in a young woman with resultant lower abdominal scars and tissue
overhang after a cesarean section.

246
    CHAPTER 31  •  Improving the Waistline With the Modified Brazilian Abdominoplasty
References
1.
Lockwood, T.E., 2004. Maximizing aesthetics in lateral-tension
abdominoplasty and body lifts. Clin. Plastic. Surg. 31, 523–537.
2.
Seung-Jun, O., Thaller, S.R., 2002. Refinements in abdominoplasty.
Clin. Plast. Surg. 29, 95–109.
3.
Grazer, F., 1973. Abdominoplasty. Plast. Reconstr. Surg. 51, 617–623.
4.
Brauman, D., 2008. Diastasis recti: clinical anatomy. Plast. Reconstr.
Surg. 122, 1564–1569.
5.
Mossaad, B.M., Frame, J.D., 2013. Medial advancement of infraumbilical
Scarpa’s fascia improves waistline definition in “Brazilian” abdomi­
noplasty. Aesthet. Plast. Surg. 37, 3–10.
6.
Saldanha, O.R., De Souza Pinto, E.B., Mattos, W.N., Jr., et al., 2003.
Lipoabdominoplasty with selective and safe undermining. Aesthetic
Plast. Surg. 22, 322–327.
7.
Stewart, K.J., Stewart, D.A., Coghlan, B., et al., 2006. Complications
of 278 consecutive abdominoplasties. J. Plast. Reconstr. Aesthet. Surg.
59, 1152–1155.
8.
Singh, D., Bronstad, P.M., 1997. Sex differences in the anatomical
locations of human body scarification and tattooing as a function of
pathogen prevalence. Evolution Hum. Behav. 18, 403–416.
9.
Lockwood, T.E., 1991. Superficial fascial system (SFS) of the trunk
and extremities: a new concept. Plast. Reconstr. Surg. 87, 1009–1018.
Further Reading
Mossaad, B.M., Frame, J.D., 2015. Medial advancement of infraumbilical
Scarpa’s fascia improves waistline definition in “Brazilian” abdomi­
noplasty. In: Di Giuseppe, A., Schiffman, M.A., (Eds.), Aesthetic Plastic
Surgery of the Abdomen. Springer, New York, pp. 75–86.

247
Surgical Preparation and Technique
247
32 
Postbariatric Abdominoplasty
Anne Dancey MBChB (Hons), MMedSci (Hons), FRCS (Plast)
The Clinical Problem
Contour deformities after post–bariatric surgery weight
loss are varied and often complex. The Pittsburgh Rating Scale1
is a useful classification system that allows grading of 10
areas of the body following massive weight loss. Each area
is scored on a scale of 0 to 3 and considered as part of the
overall picture. Mild abdominal deformities call for standard
measures, and increasing levels of deformity require more
complex surgery and modifications to achieve adequate
correction.
The grades of abdominal deformity are shown in
Fig. 32.1.
Synopsis
There has been an exponential increase in obese and overweight
patients throughout the world, with rates in Europe and North
America estimated to be approximately 20% to 30% of the
adult population.2 One of the few means to achieve significant
and maintained weight loss consistently is bariatric surgery.3,4
Evidence has shown that this brings a reduction in health-
related complications, such as diabetes, psychosocial function­
ing, personal health perceptions, and health-related quality
of life.
An inevitable consequence of significant weight loss is
the persistence of large quantities of excess and inelastic skin
and subcutaneous tissue. Body contouring surgery involves
many areas and even more techniques. The best results are
obtained by tailoring surgery to create individual packages
for each patient. The abdomen is normally the first priority.
Depending on the deformity, it can be treated in isolation
or with a circumferential technique to address the buttocks
and back.
The Aesthetic Problem
PATIENT PERSPECTIVE
After massive weight loss, large areas of redundant skin and
fat cause significant distress to patients. They often experience
skin irritation, mycotic infection, and secondary self-image
problems.1 The excess skin also affects activities of daily living
and often leaves patients more embarrassed and self-conscious
than the obesity itself.5,6
SURGICAL PERSPECTIVE
It is essential to ensure that patients are optimized before surgery
and, in many cases, it is appropriate to liaise with their bariatric
team. They need to have achieved weight stability for at least
1 year. A body mass index (BMI) of 30 or less is optimal. Folate,
vitamin B12, and iron deficiencies must all be corrected. Patients
need to be counseled that multiple, often staged procedures
may be necessary to meet their goals, and their expectations
have to be realistic. Each stage encompasses further risk,
recovery time, and often expense.
Surgical Preparation and Technique
Surgical Options
The key deciding factors used in choosing the abdominoplasty
technique are as follows:
■ The amount of abdominal laxity
■ Patient preference regarding the extent and location of
scars
■ Risk factors, such as previous abdominal incisions (e.g.,
Kocher’s incision) and keloid or hypertrophic scar
■ Resistant fat pads—their quantity and location

248
    CHAPTER 32  •  Postbariatric Abdominoplasty
TWO-STAGE PROCEDURE
A standard abdominoplasty alone will not address laxity and
fat deposits above the rib cage. For some patients, a standard
abdominoplasty followed by a reverse abdominoplasty at a
second stage will allow the abdomen to be tightened without
the need for a midline scar.
CORSET BODY LIFT
This incorporates incisions from the fleur de lis and reverse
abdominoplasty without undermining. It addresses laxity in
the vertical and horizontal directions and the posterior waistline,
as well as excising the folds of skin and fat above the rib cage.
A corset body lift is performed with the patient in the supine
position, without the need to turn the patient. It is therefore
results in a 360-degree improvement of the trunk, with a low
risk of skin complications. The technique is suitable for most
massive weight loss patients but should be carried out in
specialist unit.
Preoperative Markings (Fig. 32.2)
The patient is marked in the standing position. The following
reference lines are drawn:
■ IMF
■ Midline
■ Lower abdominal incision at the pubic hairline
Resection and Plication
VERTICAL RESECTION (FIG. 32.3)
The extent of the vertical resection is best marked with the
patient in the supine position on the operating table. The
maximum resection is marked on each side by pinching the
flank skin into the midline. The skin is tailor-tacked with staples
in the correct position. A vertical line is drawn from the IMF
to the pubis on each side of the staple line. When the staples
are removed, the amount of skin resection can be seen. There
should be the same amount of skin resection on each side,
which can be checked with a ruler.
The skin markings are incised with a No. 10 blade, and
dissection is commenced vertically down to the rectus fascia
using the hand-held diathermy. The umbilicus is circumscribed
Abdominoplasty Techniques
TRADITIONAL ABDOMINOPLASTY
The traditional abdominoplasty involves elevation of skin to
the xiphisternum and costal margin laterally. The skin is then
pulled taught by flexing the patient at the waist to reduce the
tension, and a new opening is created for the umbilicus. This
technique has several limitations, which restricts its use.
Large areas of undermining limit the blood supply to the
skin and divide the retaining ligaments. This opens a large
cavity with the potential for seroma and hematoma formation,
both of which have a higher incidence in weight loss patients.
Tensing the skin and dividing the retaining ligaments to enable
closure gives a barrel-shaped abdomen, with loss of the defini­
tion of the rectus muscle and waist. The undermining inevitably
compromises blood supply and prevents liposuction in zones
1 and 2.
Most weight loss patients will retain significant fat pads
and laxity under the inframammary fold (IMF). Given
the degree of skin laxity in these patients, most patents will
have significant dog-ears laterally, which need a second
stage for removal. In addition, the vertical laxity cannot be
addressed.
LIPOABDOMINOPLASTY
This technique does not usually allow for tightening of the
skin in the vertical dimension.
FLEUR DE LIS ABDOMINOPLASTY
This results in a vertical scar from the xiphisternum to the
pubis, with a horizontal scar in the lower abdomen. Unfortu­
nately, the patient is commonly left with a bulge in the
xiphisternum as a result of a dog-ear created in this area.
CIRCUMFERENTIAL ABDOMINOPLASTY
(BELT LIPECTOMY)
A standard abdominoplasty is extended round the lower
torso to address laxity in the flanks, buttocks, and thighs. This
allows resuspension of the lateral and anterior thighs, along
with the traditional abdominoplasty improvements. It is an
extensive procedure with a high risk of wound breakdown
and seroma.
0
1
2
3
FIGURE 32.1  Grades of abdominal deformity.

249
Surgical Preparation and Technique
on the skin edges during closure. The umbilical stalk is trimmed
and defatted. It is then inset into a circular opening in the skin
and secured with 5-0 Vicryl Rapide sutures. The repair is stopped
short of the superior and inferior dog-ear. The sutures are left
temporarily and protected.
INFRAMAMMARY FOLD RESECTION (FIG. 32.4)
The upper abdominal resection removes the dog-ear created
by the midline closure and allows the lateral excess skin at the
level of the IMF to be resected. It can be continued as far laterally
as necessary. Tailor tacking is used to establish the amount of
tissue resected. The length of the inferior resection margin
should correspond to the length of the upper abdominal
incision.
and dissected free from the abdominal flap. The vertical skin
flap is resected off the abdominal wall. Hemostasis is secured.
ABDOMINAL WALL PLICATION AND VERTICAL CLOSURE
The abdominal wall is plicated in the midline using a barbed
suture. The plication commences at the level of the umbilicus
and proceeds proximally and distally. A second row of inter­
rupted sutures supports the closure. This reduces the abdominal
defect, thereby facilitating a tension-free closure.7 In addition,
it allows the waist to be narrowed and the body contour
improved.
Attention is then turned to closing the wound itself. A barbed
suture is used to close Scarpa’s fascia and the dermal layer.
Several interrupted deep dermal sutures reduce the tension
A
B
C
D
FIGURE 32.2  Preoperative markings.

250
    CHAPTER 32  •  Postbariatric Abdominoplasty
GROIN RESECTION (FIG. 32.5A,B)
The groin resection removes the inferior dog-ear created in
the groin, as well as removing excess lower waistline skin from
the trunk around to the back. It can be extended laterally as
far as necessary to achieve the desired result. If there is excess
adipose tissue in the suprapubic mound, this is reduced with
targeted liposuction, and the excess skin is excised. Deep 2-0
PDS sutures are used to elevate the skin and prevent recurrent
The incision in the IMF should be vertically down to the
chest wall to avoid undermining or distortion of the IMF. The
excess skin and soft tissue should be excised and the abdominal
flap secured to the IMF with 2-0 PDS sutures at four key points
to avoid migration of the flap and distortion of the IMF. The
key sutures are placed medially, laterally, and centrally into
the periosteum of the corresponding rib. The remaining skin
is closed with interrupted 3.0 Vicryl sutures to Scarpa’s fascia
and a subcuticular barbed suture.
FIGURE 32.3  Vertical resection.
FIGURE 32.4  Midline plication of abdominal wall with resection of a right dog-ear
along the inframammary fold.
A
B
FIGURE 32.5  (A) Lower abdominal dog-ear resection. (B) Completion of closure.

251
Postoperative Care
Postoperative Result at 6 Months (Fig. 32.7A–D)
A two-stage abdominoplasty—standard abdominoplasty fol­
lowed by reverse abdominoplasty—using excess skin in the
hypochondrium to augment the breasts was performed. The
upper abdominal skin flaps were rotated laterally to avoid a
midline scar and a dog-ear in the epigastrium.
Case 32.2: Corset Abdominoplasty With
Bilateral Breast Reduction (Fig. 32.8A,B)
Postoperative Result at 8 Weeks
See Fig. 32.9.
Complications
The risks for a corset abdominoplasty are as for any abdomi­
noplasty procedure. Those complications that are specific or
most relevant to this technique are described as follows.
ptosis of the mons pubis. The patient is flexed to maximize
removal of the lower abdominal skin. Closure is with barbed
sutures, as previously described. Drains are not used. The
wounds are dressed with a skin glue and a binder applied.
Postoperative Care
The patient is put in an abdominal binder in theatre and this
should be worn day and night for 4 weeks. The patient can
drive and return to work after 2 to 3 weeks depending on
comfort and intensity of their occupation. Gentle exercises can
be started at 4 weeks building up gradually to full excercises.
Case 32.1
Preoperative Photographs
See Fig. 32.6. A weight loss of 10 pounds was attained through
diet and exercise. The patient wished to avoid a midline scar.
A
B
C
FIGURE 32.6  Preoperative photographs.

252
    CHAPTER 32  •  Postbariatric Abdominoplasty
A
B
C
FIGURE 32.7  Postoperative results at 6 months.
A
B
FIGURE 32.8  Corset abdominoplasty with bilateral breast reduction.

253
Postoperative Care
A
B
C
FIGURE 32.9  Postoperative view at 8 weeks, patient 2.
INFRAMAMMARY FOLD DISTORTION
It is essential to suture the superior abdominal incision into
the periosteum at the IMF to prevent tension on the IMF, with
subsequent migration and visible scarring. Three key periosteal
sutures are used in the medial, middle, and lateral IMF crease
to anchor the skin flap to the ribs. Thereafter, sutures are used
to attach the abdominal flap to the IMF fascia.
SEROMA AND HEMATOMA
The risk of seroma and hematoma is higher in massive weight
loss patients. The lack of undermining in this technique should
minimize these risks as much as possible by avoiding a dead
space.
KELOID OR HYPERTROPHIC SCARRING
The use of rectus plication and Scarpa’s fascia sutures should
avoid tension on the skin incisions, thereby reducing the risk
of abnormal scarring.
WOUND-HEALING PROBLEMS
There is also an increased risk of wound-healing problems in
massive weight loss patients, particularly those with a BMI
more than 30. This is minimized by avoiding undermining
and tension on the wound edges, thereby maximizing the blood
supply.
References
1.
Song, A.Y., Jean, R.D., Hurwitz, D.J., et al., 2005. A Classification of
contour deformities after massive weight loss: application of the
Pittsburgh rating scale. Plast. Reconstr. Surg. 116, 1535–1544.
2.
Vico, P.G., De Vooght, A., Nokerman, B., 2010. Circumferential body
contouring in bariatric and non-bariatric patient. J. Plast. Reconstr.
Aesthet. Surg. 63, 814–819.
3.
Maggard, M.A., Shugarman, L.R., Suttorp, M., et al., 2005. Meta-analysis:
surgical treatment of obesity. Ann. Intern. Med. 142, 547–559.
4.
Buchwald, H., Avidor, Y., Braunwald, E., et al., 2004. Bariatric surgery:
a systematic review and meta-analysis. JAMA 292, 1724–1737.
5.
Song, A.Y., Rubin, J.P., Thomas, V., et al., 2006. Body image and quality
of life in post massive weight loss body contouring patients. Obesity
(Silver Spring) 14, 1626–1636.
6.
Larsen, M., Polat, F., Stook, F.P., et al., 2007. Satisfaction and complica­
tions in post-bariatric surgery abdominoplasty patients. Acta Chir.
Plast. 49, 95–98.
7.
Moya, A.P., 2013. Barbed sutures in body surgery. Aesthet Surg J. 33
(Suppl.), 57S–71S.

255
Surgical Preparation and Technique
255
33 
Nonexcisional Management of the Anterior
Abdominal Wall
Riccardo Frati MD, PhD
Grant Hamlet MBChB
The Clinical Problem
See Fig. 33.1.
The Aesthetic Problem
A patient will present at surgery with a number of perceived
concerns about their abdominal area. Often, this is a surplus
of unwanted subcutaneous fat, visceral fat, loose skin, lack of
definition, a so-called muffin top overhang in clothing, and a
general dislike of the midsection. It is usual for more than one
issue to present itself, especially if the patient is female and
postchildbirth. where separation of muscle and stretch marks
can also contribute to the general paunch in this area.
The aesthetic concern is that the patient is fed up with how
the midsection looks. She or he dresses to hide the perceived
figure flaw, wearing loose clothing or avoiding some styles of
clothing altogether (e.g., bikini, swimwear) for fear of exposing
the problem area to others. Patients explain that they cannot
buy clothes that fit properly because the midsection area is
proportionally larger than the rest of them, so they take to
dressing to disguise the area. Behavioral changes such as these
are a sign that this is affecting them psychologically and that
their concerns are genuine and warrant assessment and possible
action.
During a consultation, a physical assessment of the patient
will take place so that the area can be assessed and treatment
options given. It is important to understand that the patient
may struggle to verbalize the concerns and, instead, prefer to
grab at the midsection to highlight what they do not like.
Understanding their concerns and what they see as aesthetically
pleasing for this area is vital at the consultation stage to ensure
that their expectations are managed and to give a realistic
visual of any expected outcome following treatment. The
midsection will show loss of definition, with a layer of unwanted
subcutaneous fat covering the abdominal wall and causing a
swollen look. There may or may not be loose sagging skin
and, in some cases, a combination of both these factors causes
an apron or overhang effect. The patient will be able to grab
fat and will talk of wanting a flatter, smoother silhouette. The
consultation will take into consideration the patient’s anatomy,
what they present with, and an outcome of fat reduction and
skin tightening that is realistic and achievable.
Surgical Preparation and Technique
Management and Treatment Options
It may be that you can offer surgical and nonsurgical treatments
to give the patient the outcome they desire. Explaining the
risks and benefits of both types of treatment is key at this stage.
A better outcome may be possible surgically for some patients,
but they may not wish to risk the complications that can
accompany surgery, such as the risk of being anesthetized,
downtime, long recovery period with the necessary time off
work, and even the cost of the procedure. Sometimes, the patient
may believe that aesthetic surgery carries a stigma and is
frowned on by friends and family.
At this stage, discussions about more discrete noninvasive
treatments can take place, along with discussing any risks associ­
ated with these treatments and any limitations that they may have.
There are systems that use ultrasound for noninvasive fat loss,
but downtime may be increased with such treatments. Studies
have shown that the use of multipolar radiofrequency (RF) can
cause apoptosis of fat cells without damaging surrounding tissue,
with no downtime. A course of treatments using BTL Vanquish
ME (BTL Industries, Framingham, MA), which is a system that
uses noncontact multipolar RF to treat subcutaneous fat, may
be better suited to these clients. Once again, managing patient
expectations and ensuring that they are aware of the type of
end result they can expect is a priority.

256
    CHAPTER 33  •  Nonexcisional Management of the Anterior Abdominal Wall
to moderate adipose tissue in the core area. The patient has
realistic expectations.
TECHNIQUE
Patients should hydrate before, during, and 2 days after treat­
ment. Measurements and photographs should be taken at the
beginning and end of the course of treatment.
Position the patient with the midsection exposed under the
BTL Vanquish ME CORE applicator, and lower it so it is
approximately 10 mm above the dermis. The applicator
does not touch the patient. Set the timer on the device for 30
to 45 minutes. Every 10 minutes, the device will time out
to allow the clinician to check for a buildup of sweat on
the surface or hot spots. Wipe down the skin and resume
treatment.
Postoperative Considerations
Measure and photograph the patient immediately after the
final treatment and again 1 month after the final treatment for
end results. A 60% reduction of fat cells in the treated area can
be expected (Fig. 33.3), with measurable circumference loss
shown. The average change in circumference is 4.47 cm,
although this will vary depending on the size of the patient.
After the procedure, the patient will have a more uniform
smaller midsection, with a measurable reduction and a more
streamlined figure.
For Case 33.1, see Fig. 33.4, for Case 33.2, see Fig. 33.5, and
for Case 33.3, see Fig. 33.6.
Complications
The BTL Vanquish ME system has been proven to be safe and
effective. However, as with all noninvasive treatments, some
complications may present, but they are rare.
Redness and Radiating Heat
This will dissipate within a couple of hours, but if any patient
discomfort is reported, cool the area with a cold compress or
aloe vera.
With noninvasive fat reduction, we are trying to reduce the
amount of subcutaneous fat without causing any damage to
surrounding tissue, such as nerve endings, blood vessels, and
skin. Devices that freeze fat will often cause necrosis of not
only fat cells, but blood vessels and nerve endings in the treated
area, causing possible side effects. These may include swelling,
bruising, numbness, tingling, or burns, and an approximate
wait time of 3 months before final results are seen. For some,
this downtime is suboptimal, despite the fact that fat cell death
is permanent in the treated areas. Using multipolar RF reduces
the risk of side effects because a device such as BTL Vanquish
ME is tuned to the subcutaneous fat. Only fat cells are targeted;
there is no damage to surrounding tissue, blood vessels, or
nerve endings, so there is no downtime, swelling, pain, or
bruising. A simplified operator protocol with zero consumables
ensures that results are consistent and deliverable; therefore,
a successful outcome with 60% of fat cell death in the treated
area is achievable.
Treatment and Operative Technique
The ideal patient for applying the BTL Vanquish ME system
has mid to moderate adipose tissue and is within 20 pounds
of the ideal weight. Treatments last between 30 and 45 minutes,
and a course of four to six treatments is advised for optimal
results, spaced 7 to 10 days apart. Sometimes results can be
seen as soon as after the first treatment, but the final result is
seen 2 to 4 weeks after the last treatment.
In regard to the depth of penetration, the focal point is
approximately 10 mm below the surface. It uniformly heats
approximately 5 to 15 mm to 43°C to 45°C (109.4°F to 113°F),
causing the apoptosis of fat cells (Fig. 33.2).
PATIENT SELECTION
The ideal candidate is from 21 to 65 years old, within 20 pounds
of their ideal weight, and with a stable weight. There is mild
FIGURE 33.1  The clinical problem.
5mm
10mm
Focal point
15mm
43-45ºC
FIGURE 33.2  Depth of penetration. The focal point is approximately 10 mm below
the dermis.

257
Complications
Volume of the fat
layer-treated area
Volume of the fat
layer-untreated area
FIGURE 33.3  Histologic evaluation revealed that the epidermis, dermis, and adnexal structures, such as hair follicles, were unaffected by the treatment, whereas adipocytes
were significantly affected. (From Weiss. R., Weiss, M., Beasley, K., Vrba, J., Bernardy, J., 2013. Operator independent focused high frequency ISM band for fat reduction:
porcine model. Lasers Surg. Med. 45, 235–239.)
Treatment
After 4th treatment
Before 1st treatment
77
25.43
96
79
26.09
109
Weight (kg)
BMI
Circumference (cm)
A
B
FIGURE 33.4  Results after weekly sessions, four times/week, of BTL Vanquish,13-cm circumference loss.

258
    CHAPTER 33  •  Nonexcisional Management of the Anterior Abdominal Wall
A
B
Treatment
After 4th treatment
Before 1st treatment
67
24.61
77
67.7
24.86
84
Weight (kg)
BMI
Circumference (cm)
FIGURE 33.5  Results after weekly sessions, four times/week, of BTL Vanquish, 7-cm circumference loss,
A
B
Treatment
After 4th treatment
Before 1st treatment
89.2
28.79
106
91
29.37
113
Weight (kg)
BMI
Circumference (cm)
FIGURE 33.6  Results after weekly sessions, four times/week, of BTL Vanquish, 7-cm circumference loss.

259
Complications
Further Reading
Fajko, R., Machovcov, K., Onder, M., Fritz, K., 2014. Selective radiofrequency
therapy as a non-invasive approach for contactless body contouring
and circumferential reduction. J. Drugs Dermatol. 13, 291–296.
Rho, N.K., 2012. Reducing subcutaneous fat in abdomen by non-contact
high frequency wave: treatment principles and results of preceding
research. Presented at the Leaders Clinic, Seoul, Republic of Korea.
Stoilova, I., Lozanova, P., 2013. Selective high-frequency (HF) device for
non-invasive contactless reduction in size of abdomen of the body.
Unpublished clinical study, conducted August–December 2013, available
from BTL Aesthetics & CCF Media.
Weiss, R., Weiss, M., Beasley, K., et al., 2013. Operator independent focused
high-frequency ISM band for fat reduction: porcine model. Lasers
Surg. Med. 45, 235–239.
Panniculitis
Some cases have been reported; the condition will improve
with time. However, it can be treated with acoustic wave or
massage to help break down the nodules.
Skin Blisters
These are caused by a buildup of sweat during the treat­
ment. They can be avoided by checking the surface of the
skin every 10 minutes and wiping away any buildup of
sweat.

261
Surgical Preparation and Technique
261
34 
Body Contouring Following Massive Weight Loss
Shailesh Vadodaria MBBS, MS, MCh, FRCS (Plast)
Dharmadev Trivedi MBBS, MS, MRCS, FHEA (UK)
The Clinical Problem (Fig. 34.1)
Truncal body-contouring surgery aimed at excising large
quantities of redundant skin and subcutaneous tissue, especially
after massive weight loss, with or without bariatric surgery,
is not without risk, but can be made safer and more rewarding
for many patients. Liposuction-assisted pseudo-undermining
technique helps preserve the lymphatics around intact Scarpa’s
fascia and reduces the problems with seroma formation, wound
healing and flap necrosis. It also allows enhanced sculpturing
of the flanks (love handles), as well as epigastric fullness.
Liposuction-assisted pseudoundermining is time-efficient and
causes less blood loss, and suction drains may not be required.
This facilitates early mobilization and reduces hospital stay.
Postoperative use of compression garments for at least 6 weeks
is advised.
Surgical Preparation and Technique
Body-Contouring Surgery
Body-contouring surgery has become increasingly popular over
recent years, owing to increasing number of weight loss surgery
procedures being performed as a definitive treatment for morbid
obesity.1,2 It is now recognized as a subspecialty of plastic
surgery. These procedures are rewarding, with very good patient
satisfaction.
Detailed preoperative counseling, selection of safe procedure,
meticulous planning, attention to minute aesthetic details,
adequate investment of time, and personalized postopera­
tive care are essential for the best outcome to be attained. A
liposuction-assisted pseudoundermining technique is preferred
for surgical undermining for all skin reduction procedures. This
technique preserves perforators and lymphatics, minimizing the
incidence of flap necrosis and seroma. Adjunctive liposuction
debulks the skin flaps, improves flap mobility, and facilitates
sculpturing.
Conventional procedures carry a higher risk to skin flap
vascularity and of wound dehiscence. Pseudoundermining
using a power-assisted liposuction device mostly preserves
the integrity of Scarpa’s fascia.
This chapter focuses on truncal body contouring procedures
following massive weight loss, emphasizing key technical
features and perioperative care.
Patient Selection
Patients with a stable weight for at least 12 months following
massive weight loss, absence of major comorbidities, and
abstinence from smoking are the main criteria for selection. It
is advisable to defer patients who are younger than 16 years,
are active smokers, and have psychosocial conditions until
they are no longer smoking and are clearly motivated. Patients
who are young and fit can be considered for longer duration
combined procedures.
A multidisciplinary approach for an individualized manage­
ment plan is essential.3,4
Preoperative Planning
There should be at least two preoperative consultations with
time to reflect on the benefits and risks, with preoperative
patient photographs and detailed documentation, including
measurements. A thorough clinical examination is necessary,
particularly examining the divarication of recti, hernial sites,
and muscle tone. There should be an assessment of redundant
excessive skin and residual fat to determine the type of pro­
cedure required.
Counseling of the patient about the procedure includes
providing the patient with an information leaflet. The patient
should sign a consent form and given the opportunity to speak
to a patient who has previously undergone a similar procedure.

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    CHAPTER 34  •  Body Contouring Following Massive Weight Loss
• Marking the proposed site of skin excision and
extended zone of liposuction
• Application of compressive stocking
• General anesthesia
• Intravenous broad spectrum antibiotic on induction,
continued orally for 5 days postoperatively
• Aqueous povidone-iodine (10%) for skin preparation
Operative Steps (Table 34.1)
LOWER BODY LIFT (VIDEO 34.1; FIGS. 34.2 TO 34.4)
Begin with the patient in the prone position, using tumescent
infiltration, power-assisted liposuction, with no. 4 and 5 can­
nulae. The ratio of tumescent versus aspirate is 1 : 1.
A so-called flying bird incision is made within the bikini
line (Video 34.2). The incision and flap are created with pseu­
doundermining (Videos 34.3 and 34.4). Only flaps of the
proposed zone of skin excision are harvested. The staple test
is carried out—stapling future skin edges before excision of
excess skin to confirm a tension-free apposition. These tem­
porary staples are then removed before skin excision.
Skin excision (Video 34.5)—uses meticulous hemostasis for
skin closure using the halving technique, planned at the time
of marking, with 2-0 Monocryl sutures (Ethicon, Somerville,
NJ), deep dermal sutures, and 3-0 Monocryl subcuticular sutures
(Video 34.6).
Tumescent infiltration is done with bupivacaine with epi­
nephrine for long-term analgesia. Tincture of benzoin Steri-Strips
and a padded Opsite dressing (Smith & Nephew, Fort Worth,
TX; Video 34.7) are applied.
The patient is then turned to the supine position. Skin
preparation and tumescent infiltration are carried out as
described above (Video 34.8). Exteriorization of the umbilicus
is done with power-assisted liposuction (Video 34.9). A supra­
pubic incision is made (Video 34.10).
The flap is harvested adhering to the principle of Saldanha5
(Video 34.11). A full-thickness, skin-only flap is harvested up
FIGURE 34.1  The clinical problem.
Table 34.1  Indications for and key features of post–massive weight loss reconstructive procedures
Procedure
Indication
Key features
Lower body lift
Circumferential panniculus of loose
redundant skin over lower abdomen
Umbilicoplasty; correction of divarication of recti
Upper body lift
Saggy skin forming so-called banana roll
on posterolateral aspect of upper back
Precise placement of scar under horizontal strap
of the bra
Post–massive weight
loss gynecomastia
Loose saggy skin, with severe ptosis of the
nipple-areola complex
Liposuction-assisted skin excision, free nipple-
areola composite graft
Mastopexy
Severe ptosis of the breasts
No liposuction
Brachioplasty
Loose redundant skin over the upper arms,
forming bingo wings
No undermining of adjoining flap, extensive
liposuction underneath proposed skin excision
Thigh reduction
Loose redundant skin, with extensive
sagginess over inner thighs
Absolute attention to tension-free closure, no
undermining of adjoining flaps
Liposuction
Residual saddle bag deformity of outer
thighs
Improves the sculpturing and assists in thigh lift
in conjunction with a lower body lift
Power-assisted
liposuction
For pseudoundermining, volume reduction,
and body sculpturing
Extensive liposuction with 4- and 5-mm cannulae
There should be a preoperative anesthetic assessment. The
standard preoperative investigation should include the use of
methicillin-resistant Staphylococcus aureus swabs.
This is a summary of the suggested preoperative routine:
• Completion of consent form
• Preoperative photography
• Marking for procedure in standing position
• Pinch test and use of multicolor permanent marker

263
Surgical Preparation and Technique
Before
After
A
B
FIGURE 34.2  Lower body lift and thigh reduction. (A) Preoperative. (B) Three months postoperative, anterior view.
Before
After
A
B
FIGURE 34.3  Lower body lift. (A) Preoperative. (B) Three months postoperative, right lateral view. There was a significant buttock lift and thigh lift.

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    CHAPTER 34  •  Body Contouring Following Massive Weight Loss
tension. The skin excision is completed, with skin closure and
wound dressing as described above (Videos 34.17 to 34.23). A
circumferential Gamgee dressing is used to cover the suture
lines, and a pressure garment is applied.
Early Postoperative Care
This includes the patient keeping the hips and knees flexed to
avoid tension on the suture lines. Mechanical deep vein
thrombosis prophylaxis is carried out in the hospital, with
early mobilization. The patient is discharged within 2 days
postoperatively.
UPPER BODY LIFT (FIGS. 34.6 TO 34.8)
The borders of the patient’s bra are drawn preoperatively to
guide placement of the final horizontal scar on the back, as
shown in Fig. 34.5. The procedure is performed with the patient
in a prone position under general anesthesia.
Tumescent infiltration and extensive liposuction are carried
out over a wide area, within and beyond the markings. The
staple test is done and then remarking of the proposed skin
excision within the horizontal strap of the bra. A full-thickness
skin excision is performed, with skin closure, dressings, and
compression garments as described above.
POST–MASSIVE WEIGHT LOSS GYNECOMASTIA
CORRECTION (Fig. 34.9)
The patient is marked in the standing position. The inframam­
mary crease, midline and bilateral midclavicular lines, infero­
lateral border of the pectoralis major for placement of the
to the proposed site of excision, with preservation of Scarpa’s
fascia (Fig. 34.5).
Limited undermining of the abdominal flap is done up to
the xiphisternum (Videos 34.12 to 34.14). The lateral perforators
of abdominal flap are preserved. Pseudoundermining and
deflation of the flap are achieved by liposuction with meticulous
hemostasis.
Following this is plication of the anterior rectus sheath with
loop PDS 1-0 sutures II (Johnson & Johnson Medical) using
round-bodied, blunt-tipped needle (Videos 34.15 and 34.16).
The staple test is done to ensure skin closure without undue
Before
After
A
B
FIGURE 34.4  Lower body lift and thigh reduction. (A) Preoperative. (B) Postoperative, posterior view. Note the significant buttock lift.
FIGURE 34.5  Extensive liposuction for pseudoundermining and skin-only excision,
preserving Scarpa’s fascia.

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Surgical Preparation and Technique
A
B
C
FIGURE 34.6  Upper body lift, revision lower body lift, mastopexy, liposuction-assisted thigh reduction, and liposuction of outer thigh. (A,B) Preoperative. (C) Six weeks
postoperative, posterior view. Note the precise position of incision within the margins of the horizontal strap of the bra.
Before
After
A
B
FIGURE 34.7  Upper body lift, revision lower body lift, mastopexy, liposuction-assisted thigh reduction, and liposuction of outer thigh. (A) Preoperative. (B) Six weeks
postoperative, right lateral view. Note the pseudoelongation of the thigh and correction of the saddlebag deformity.