Bilateral Scarpa`s Fascia Advancement Flaps to Improve

Egypt, J. Plast. Reconstr. Surg., Vol. 35, No. 1, January: 133-140, 2011
Bilateral Scarpa’s Fascia Advancement Flaps to Improve the
Waistline in Abdominoplasty
WAEL M. ELSHAER, M.D.*; SAMEH ELNOAMANI, M.D.** and HOSSAM HOSNI, M.D.**
The Department of Plastic and General surgery, Faculty of Medicine, Bani-Suef * and Cairo** Universities.
better sculpting or to hide the abdominal scar [1].
With the advent and popularity of the liposuction
procedure and with a better understanding of skin
retraction post-liposuction surgery, many of the
previously abdominoplasty procedures are now
treated by the less invasive and more rapid recovery
procedure of liposuction surgery. Nevertheless,
abdominoplasty still holds a very intricate and selfsatisfying place in the world of cosmetic surgery
[2]. The goal of most abdominoplasty procedures
is not only to improve the contour and shape of
the abdomen, but to achieve a smooth, flowing,
harmonious contour by improving the overall silhouette and appearance of the region [3]. The waist
is an area of paramount importance for the feminine
figure, which begins at the level of the lower ribs
and ends at the level of the iliac crest; its narrowest
point is approximately 4cm above the navel [4].
Although aponeurotic suturing in the midline was
noted to be able to reduce anterior projection of
the abdominal wall, it did little to reduce the
diameter of the waist. Many authors have proposed
different techniques to treat the deformity caused
by the laxity of the muscular frame of the abdominal
wall [2] , but the plication of the anterior rectus
sheath is the most popular way to deal with this
muscular deformity. This procedure was emphasized by Avelar [5] and Bozola and Psillakis [6].
Rectus plication and its modifications have become
an integral part of the abdominoplasty operation
in order to narrow the waistline [7]. A row of oblique
transverse plication [8] and vertically longitudinal
plication [9] in the external oblique fascia have
been proposed to reduce the waistline. External
oblique muscle flaps for reinforcement of the
umbilical area have been reported [10] . Dermal
flaps have also been associated with vertical fascial
plication to improve the waistline [11]. H-shaped
and fusiform plications were reported to improve
the waistline and to reinforce the musculoapo-
ABSTRACT
The goal of most abdominoplasty procedures is not only
to improve the contour and shape of the abdomen, but to
achieve a smooth, flowing, harmonious contour by improving
the overall silhouette and appearance of the region. The waist
is an area of paramount importance for the feminine figure,
which begins at the level of the lower ribs and ends at the
level of the iliac crest; its narrowest point is approximately
4cm above the navel. The purpose of this study was to report
our results on 30 patients who underwent abdominoplasty
and improvement of the waistline utilizing Scarpa’s fascial
advancement flaps and plication in the midline.
Patients and Technique: During a 13-month period from
January 2009 to February 2010 we operated on 30 patients.
All patients presented for improvement of the abdominal
contour. On examination there was rectus diastasis, excess
skin and ill-defined waistline. Patients who were smoker, with
uncontrolled diabetes, upper abdominal scars, ventral hernia,
or previous abdominoplasty were excluded from the study.
Results: 30 female patients from 17 to 37 years of age
(mean 29.6 years), followed-up from 6 to 13 months (mean
9.6 months) postoperatively. No cases of major complications
were reported, while minor complications occurred in four
cases. The aesthetic outcome as evaluated by the patients was
good in 27 cases (90%) (Figs. 3,4,5) and fair in 3 patients
(10%), and no bad results.
Conclusion: The procedure proved to be safe, with only
a few minor complications and no major complications. This
technique provides a good option for the treatment of abdominal contour deformities, in which waistline improvement is
desired. Further comparative studies between this technique
and other traditional abdominoplasty techniques are necessary
to evaluate different objective outcomes.
INTRODUCTION
Numerous papers and articles have been written
about different techniques of the abdominoplasty
procedure and date back from over a century ago.
Body sculpting and contouring has been a fascination of many cosmetic surgeons. Throughout the
past century there have been many surgeons who
have described different procedures to achieve
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neurotic system in the upper and lower abdomen
[12] and triple plication in mini-abdominoplasty
[13]. However, while this effect on the waistline is
clearly visible in the operating room when tying
down the plicating suture, it causes intra-abdominal
hypertension known to effect venous return with
a 1.1% risk of deep venous thrombosis [14]. Also
this may cause a respiratory distress in the postoperative period [15]. In addition the results of some
studies indicate that stretching of linea alba is
limited to 2 inches in the majority of cases (82%)
and that stretching beyond 2.5 inches occurs only
in a small number of cases (2%). Therefore the
reliance on linea alba stretching as an indicator of
abdominal wall stretching is erroneous and the
presence of abdominal laxity and protrusion is not
synonymous with the presence of a diastases of
the recti muscles; conversely flat abdomen may
exhibit significant diastases and may not correlate
with the site of the maximal abdominal protrusion
[16]. A very important concept in body contouring
was set forth by Lockwood, with his emphasis on
the superficial fascial system (SFS) [17]. He further
described a high-lateral tension abdominoplasty
which was designed to improve the waistline, while
the wound closure by maximum tension at the level
of the superficial fascia allowed the skin closure
to be performed under minimal tension, which
helps to achieve a fine-line high-quality scar [18].
The superficial fascial system is the connective
tissue network that resides below the dermis and
provides the major structural support for the skin
and fat of the body and repair of the SFS would
be expected to diffuse the tension on the skin flap,
lift areas of soft tissue ptosis, and provide longlasting support [19].
The purpose of this study was to report our
results on 30 patients who underwent abdominoplasty and improvement of the waistline utilizing
Scarpa’s fascial advancement flaps and plication
in the midline.
PATIENTS AND TECHNIQUE
During a 13-month period from January 2009
to February 2010 we operated on 30 patients in
Bani-Suef University Hospital, Kasr Al-Aini Hospital (Cairo University), and author’s private clinic.
All patients presented for improvement of the
abdominal contour. On examination there was
rectus diastasis, excess skin and ill-defined waistline. Patients who were smoker, with uncontrolled
diabetes, upper abdominal scars, ventral hernia,
or previous abdominoplasty were excluded from
the study. The details of the operation were explained, and the patients were shown before and
after pictures to ensure that they clearly understand
the magnitude of the procedure and the location
of the scars. All patients were followed-up for at
least six months after the operation. Anterior and
lateral preoperative and postoperative photographs
were taken, with particular attention paid to the
waistline in the anterior view and the contour of
the abdomen in the lateral view. Outcome variables
of interest included complications and subjective
evaluation of aesthetic outcomes.
Surgical Technique:
• Preoperative markings: Preoperative markings
are crucial to successful surgery and to achieve
desired symmetrical results. Patients were marked
preoperatively in the standing position, and a
transverse line was made just above the pubic
hair extending laterally 7 to 9 cm in each direction
towards and medially to the anterior superior
iliac spine. The amount of hypogastric skin flap
excess was estimated by the tension pulling required to approximate it to the inferior margin
of the incision. Another line is traced in the form
of bicycle handlebars to give high lateral tension;
this second line begins and ends at the anterior
superior iliac spine.
• Upper abdomen liposuction: In all cases, a deep
and superficial liposuction of the upper abdomen
from the inframammary fold to the umbilicus
through an umbilical incision was performed.
The goals were to reduce the volume and to
mobilize the tissues downwards. However, to
preserve vascularization of the flap, wide continuous undermining to the costal margin was not
done, but rather discontinuous tunneling was
performed. Liposuction was performed following
the traditional tumescent method, using cannula
3 and 4mm in size.
• Dermolipectomy: Dermolipectomy incision was
made after the prior markings down to the suprapubic abdominal fascia. Once the Scarpa’s fascia
was exposed centrally, the incision was extended
laterally above the fascia. Suprafascial sharp
dissection was then carried out in a cephalic
direction to the region of the umbilicus (Fig. 1a).
The umbilicus was circumscribed and left insitu. Above this level central dissection was
deepened to the aponeurosis of the rectus muscle
creating a tunnel approximately 10cm wide as
far as the xyphoid process (Fig. 1b). The rectus
muscle diastasis was repaired with continuous
non-absorbable suture from above downwards.
• Scarpa’s fascia flaps: Lateral flaps from the
Scarpa’s fascia were created by incising the lower
border of the fascia at the skin incision level after
Egypt, J. Plast. Reconstr. Surg., January 2011
separating the fascia from the underlying loose
tissues, cutting only the fascial layer to preserve
underlying lymphatic channels. With minimal
undermining of the medial borders of the fascia,
medial advancement of the flaps greatly enhanced
the waistline (Fig. 2a). The Scarpa’s fascia flaps
were sutured to the underlying rectus sheath with
(A)
135
continuous non-absorbable sutures. Overlapping
of the fascial flaps was avoided in order not to
create supra-pubic bulge (Fig. 2b). After positioning of the umbilicus and excision of the excess
skin, closure of the incision was done in two
layers. Two closed-system suction drains were
left under the abdominal flaps.
(B)
Fig. (1): Intraoperative view. (1-A) Suprafascial sharp dissection carried out in a cephalic direction to the region of the umbilicus.
(1-B) Central dissection above the umbilicus deepened to the aponeurosis of the rectus muscle creating a tunnel.
(A)
(B)
Fig. (2): Intraoperative view. (2-A) Lateral flaps from the Scarpa’s fascia created. (2-B) The Scarpa’s fascia flaps sutured to
the underlying rectus sheath without overlap.
RESULTS
Lipo-abdominoplasty with bilateral Scarpa’s
fascia advancement flaps to improve the waistline
were performed on 30 female patients from 17 to
37 years of age (mean 29.6 years), followed-up
from 6 to 13 months (mean 9.6 months) postoperatively (Table 1). The etiology of the abdominal
deformity was as the following: 15 patients due to
repeated multiple pregnancy; 9 cases due to weight
gain; 2 cases due to weight loss; and 4 cases postbariatric surgery (two cases post laparoscopic
sleeve gastrectomy and two cases post laparoscopic
adjustable gastric banding). The operations were
done under general anaesthesia. The results were
evaluated according to the achievement of a nice
abdominal contour presenting narrowing of the
waistline on a scale of good-fair-bad according to
patient's evaluation. No cases of major complications were reported, while minor complications
occurred in four cases. We had two cases of seroma
collection after removal of suction drains, both
cases were treated conservatively by repeated
aspiration and compression. The other two cases
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required scar revision and symmetrization under
local anaesthesia due to scar widening; one of them
had a small dog-ear at the end of the scar. All
patients gained improvements in their posture and
how their clothing fit, and they all expressed satisfaction with the results. The aesthetic outcome
as evaluated by the patients was good in 27 cases
(90%) (Figs. 3,4,5) and fair in 3 patients (10%),
with no bad results. The patients with fair results,
two of them were post sleeve gastrectomy and they
experienced rapid weight loss, preoperatively they
were advised for lower body lift operation but they
refused long circumferential scars and asked for
only abdominoplasty. The third case complained
of the widening of the scar and a small dog-ear at
the lateral end of the wound and was treated by
scar revision and repair of the dog-ear under local
anaesthesia.
Table (1): Patient data and outcome.
No of
patient
Age
Sex
1
33
Female
2
37
3
FU period
Aesthetic
outcome
Complications
Multiple preg.
12
Good
no
Female
Multiple preg.
13
Good
no
35
Female
Weight loss
12
Good
no
4
27
Female
Weight gain
12
Good
no
5
34
Female
Multiple preg.
12
Good
Seroma
6
33
Female
Post bariatric surg.
11
Good
no
7
27
Female
Post bariatric surg.
11
Good
no
8
30
Female
Multiple preg.
8
Good
no
9
18
Female
Weight gain
6
Good
no
10
17
Female
Weight gain
7
Good
Seroma
11
29
Female
Multiple preg.
8
Good
no
12
28
Female
Weight gain
6
Good
no
13
32
Female
Multiple preg.
6
Good
no
14
18
Female
Weight gain
12
Good
no
15
29
Female
Multiple preg.
13
Fair
16
27
Female
Multiple preg.
10
Good
no
17
31
Female
Multiple preg.
7
Good
no
18
33
Female
Multiple preg.
12
Good
no
19
37
Female
Multiple preg.
13
Good
no
20
35
Female
Weight loss
12
Good
no
21
17
Female
Weight gain
12
Good
no
22
34
Female
Multiple preg.
12
Good
no
23
28
Female
Post bariatric surg.
11
Fair
no
24
34
Female
Post bariatric surg.
11
Fair
no
25
30
Female
Multiple preg.
8
Good
no
26
33
Female
Weight gain
6
Good
no
27
34
Female
Weight gain
7
Good
Scar widening
28
32
Female
Multiple preg.
8
Good
no
29
28
Female
Weight gain
6
Good
no
30
29
Female
Multiple preg
6
Good
no
Aetiology
Scar widening
& dog-ear
Egypt, J. Plast. Reconstr. Surg., January 2011
(A)
137
(B)
Fig. (3): Twenty eight year female, with weight gain. Postoperative anterior view show good results with improved waistline.
(A)
(B)
Fig. (4): Thirty seven year old female, with multiple pregnancies. Postoperative anterior view showing marked improvement
of waistline.
(A)
(B)
Fig. (5): Thirty three year old female, with weight gain. Postoperative anterior view showing good results.
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(A)
(B)
Fig. (6): Twenty seven year female, with Post-bariatric weight loss. Postoperative anterior view show good results with improved
waistline.
(A)
(B)
Fig. (7): Thirty one year female, with multiple pregnancies. Postoperative anterior view show good results.
(A)
(B)
Fig. (8): Thirty five year female, with weight loss and previous caesarean section scar with asymmetrical deformity. Postoperative
anterior view show good symmetrical results.
Egypt, J. Plast. Reconstr. Surg., January 2011
DISCUSSION
Improvement of the waistline is one of the goals
of abdominoplasty. However, its shape depends
on several factors such as, fat deposits, individual
abdominal contour, and degree of muscular tension.
The latter is usually affected by pregnancy and is
a very common concern [3]. Several techniques of
muscular reinforcement to achieve a more harmonious contour of the anterior abdominal wall have
been described [4,20-24] . These procedures are
basically focused on the tension of the abdominal
wall; consequently, they may result in some improvement of the waistline [3] . A survey of the
literature revealed that little effort has been made
to achieve a better waistline with only few aponeurotic procedures focusing on this specific point
were described. Correction of rectus diastasis is a
fundamental maneuver to achieve good tension of
the abdominal wall and is responsible for part of
the waist reduction obtained by the technique
described in this study. Furthermore, there was no
need for wide plication or plication under tension
to avoid increased intra-abdominal pressure, disruption of plicating sutures, postoperative pain, or
respiratory complications. Appiani [10] and Psillakis
[25] understood the importance of the external oblique muscle for the cosmetic improvement of the
waist, and some researchers studied the technique
of advancing the external oblique muscles in cadavers. However, no objective studies have been
made to clarify the real effectiveness of this technically demanding maneuver which leads to weakness of the abdominal wall close to the groin region
and undermine the correction of rectus diastasis
[3]. While the Scarpa’s fascia flaps technique adds
to the correction of rectus diastasis, improving
both the muscle and fascial components of the
abdominal wall without the need of wide dissection
or disturbing the musculoaponeurotic system of
the abdominal wall. Functionally the Scarpa’s
fascia plays an important role in the integrity of
the skin and support for subcutaneous structure
[26] and preservation of Scarpa’s fascia during
abdominoplasty proved to lower the complications
associated with conventional abdominoplasty [27].
Reduction of total drain output, reduction of hospital stay, decrease postoperative cutaneous parasthesia, preservation of the ilioinguinal nerve, and
decrease incidence of seroma from damaged lymphatics are known beneficial effects of preservation
of Scarpa’s fascia during abdominoplasty [24]. In
this study, major complications such as deep venous
thrombosis, pulmonary embolism, respiratory complications, and skin loss were not observed. Mostly,
because we did not need to do wide or tight plica-
139
tions for the rectus muscle to improve the waistline
depending on the Scarpa’s fascia flap in creation
of the waistline. The liposuction in the upper
abdomen was discontinuous to preserve the vascularity of the abdominal flap, while the tunnel in
the midline was made wide enough to allow for
plication of the rectus diastasis. There was two
cases of seroma occurred in early cases mostly due
to early postoperative removal of the suction drains.
These cases were treated conservatively by aspiration and compression and none required surgical
drainage. There are many factors affecting the end
scar results, as positioning of the patient, symmetry
of the abdominal deformity, symmetry of dissection
and excision. It should be noted that a scar that is
perfectly symmetrical in the immediate postoperative period may become asymmetrical later on
[21]. Therefore, all our patients were warned that
it may be necessary to perform scar revision after
six months. In two cases we had widening of the
scar requiring scar revision under local anaesthesia.
These occurred because we ignored to reattach the
Scarpa’s fascia layer during wound closure. Subsequently, we closed the Scarpa’s fascia as a separate layer in all other cases. In 2008, a study done
on 92 consecutive abdominoplasty patients demonstrated that the stretching of the linea alba is
usually limited to a fairly narrow range of 2 to 3
inches compared with the much wide range of
people’s waist sizes. They concluded that contrary
to current theory, the protrusion and stretching of
the abdominal wall are caused by the stretching of
the entire musculofascial abdominal wall and not
only the linea alba [16]. The high satisfaction rate
we have obtained in this study is mostly because
by the adoption of this technique both component
of the abdominal wall were repaired (Figs. 6,7,8).
The procedure described was designed to correct
the lax abdominal wall musculature, and to tighten
the superficial fascial system to efficiently improve
the waistline without disrupting the abdominal
wall integrity, weakening it, or increasing the risk
of major complications while effectively reducing
the rate of minor complications.
Conclusion:
Use of Scarpa’s fascia flaps during abdominoplasty resulted in improved tension of the entire
abdominal wall, enhancement of the waistline, and
improved uniformity in the contour of the abdomen.
These results were maintained during follow up
period. The procedure proved to be safe, with only
a few minor complications and no major complications. This technique provides a good option for
the treatment of abdominal contour deformities,
in which waistline improvement is desired. Further
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Vol. 35, No. 1 / Bilateral Scarpa’s Fascia Advancement
comparative studies between this technique and
other traditional abdominoplasty techniques are
necessary to evaluate different objective outcomes.
REFERENCES
1- Giovanni D.B. and William F.: History of abdominoplasty.
In: Shiffman M.A. and Di Giuseppe A. (eds): Body Contouring. Springer-Verlag Berlin Heidelberg, p. 207, 2010.
2- Mentz H.A., Gilliland M.D. and Patronella C.K.: Abdominal etching: Differential liposuction to detail abdominal
muscular tone. Aesth. Plast. Surg., 17: 287, 1993.
3- Nahas, F.X.: Advancement of the External Oblique Muscle
Flap to Improve the Waistline: A study in Cadavers. Plast.
Reconstr. Surg., 108 (2): 550-555, 2001.
4- Santos E. and Muraira J.: The Waist and Abdominoplasty.
Aesth. Plast. Surg., 22: 225-227, 1998.
5-
Avelar J.: Fat suction versus Abdominoplasty. Aesth.
Plast. Surg., 9: 265-275, 1985.
6- Bozola A.R. and Psillakis J.M.: Abdominoplasty. A new
concept and classification treatment. Plast. Reconstr.
Surg., 82: 983-993, 1988.
Delineation of risk factors. Plast. Reconstr. Surg., 119
(4): 1319-1325, 2007.
15- Al-Shaham A.A.: Determination of a safe musculofascial
plication in abdominoplasty. Med. J. Malaysia., 62 (5):
380-382, 2007.
16- Brauman D.: Diastasis Recti: Clinical anatomy. Plast.
Reconstr. Surg., 122 (5): 1564-1569, 2008.
17- Lockwood T.E.: Superficial fascial system (SFS) of the
trunk and extremities: A new concept. Plast. Reconstr.
Surg., 87: 1009-1018, 1991.
18- Lockwood T.E.: High-tension abdominoplasty with superficial fascial system suspension. Plast. Reconstr. Surg.,
96 (3): 603-615, 1995.
19- Sammy A., Yazan A. and Tzakas E.: Superficial fascial
system repair: An abdominoplasty technique to reduce
local complications after caesarean delivery. Arch. Gynecol. Obstet., 279: 673-675, 2009.
20- Marques A., Brenda E., Pereira M.D., Myrian D. et al.:
Abdominoplasty with two fusiform plications. Aesth.
Plast. Surg., 20: 249-251, 1996.
21- Claude L. and Pascal J.F.: High superior tension abdominoplasty. Aesth. Plast. Surg., 24: 375-381, 2000.
7- Netscher D.T., Wigoda P., Spira M. and Peltier M.: Musculoaponeurotic plication in abdominoplasty: How durable
are its effects? Aesth. Plast. Surg., 19: 531-534, 1995.
22- Ramirez O.M.: Abdominoplasty and abdominal wall
rehabilitation: A comprehensive approach. Plast. Reconstr.
Surg., 105 (1): 425-435, 2000.
8- Jackson I.T. and Downie P.A.: Abdominoplasty: The
waistline stitch and other refinements. Plast. Reconstr.
Surg., 61: 180, 1978.
23- Restrepo J.C.C. and Ahmed J.A.M.: New technique of
plication for miniabdominoplasty. Plast. Reconstr. Surg.,
109 (3): 1170-1177, 2002.
9- Abramo A.C., Casas S.G., Oliveira V.R. and Marques A.:
H-Shaped, double-contour plication in abdominoplasty.
Aesth. Plast. Surg., 23: 260-266, 1999.
24- Claude L. and Pascal J.F.: The high-superior-tension
technique: Evolution of lipoabdominoplasty. Aesth. Plast.
Surg., Published online: 08 October, DOI 10.1007/s00266010-9551-5, 2010.
10- Appiani E.: Muscular plasty for aesthetic conformation
of the abdominal girdle. Ann. Plast. Surg., 13: 97, 1984.
11- Gonzalez M. and Guerrerosantos J.: Deep planed torsoabdominoplasty combined with buttocks pexy. Aesth.
Plast. Surg., 21: 245, 1997.
12- Abramo A.C., Viola J.C. and Marques A.: The H approach
to abdominal muscle aponeurosis for the improvement of
body contour. Plast. Reconstr. Surg., 86: 1008, 1990.
13- Sozer S.O. and Agullo F.J.: Triple plication in abdominoplasty. Aesth. Plast. Surg. 30: 263-268, 2006.
14- Huang G.J., Bajaj A.K., Gupta S., Peterson F., et al.:
Increased intraabdominal pressure in abdominoplasty:
25- Psillakis J.M.: Plastic surgery of the abdomen with improvement in the body contour: Physiopathology and
treatment of the aponeurotic musculature. Clin. Plast.
Surg., 11: 465, 1984.
26- Abu-Hijleh M.F., Roshier A.L., Al-Shboul Q., Dharap
A.S., et al.: The membranous layer of superficial fascia:
Evidence for its widespread distribution in the body. Surg.
Radiol. Anat., 28 (6): 606-619, 2006.
27- Costa-Ferreira A., Rebelo M., Vásconez L.O., Amarante
J.: Scarpa’s fascia preservation during abdominoplasty:
A prospective study. Plast. Reconstr. Surg., 125 (4): 12321239, 2010.