Abdominoplasty

Chapter
122
Abdominoplasty
Al Aly, Silvia Cristina Rotemberg and Albert Cram
Summary
1. Abdominoplasty is indicated for skin and subcutaneous tissue
excess and/or laxity limited to the anterior abdomen and
abdominal wall musculoaponeurotic laxity
2. Contraindications include generalized obesity, excessive intraabdominal content, circumferential lower truncal excess,
smoking, and planned pregnancy in the near future.
3. A subcostal, open cholecystectomy scar is a relitive
contraindication for traditional abdominoplasty
4. Lipoabdominoplasty is an alternative technique to traditional
abdominoplasty that may be safer and associated with less
complications.
5. A high lateral tension abdominoplasty (HLTA) is fundamentally
different from the traditional abdominoplasty in that maximum
tension is created laterally, rather than centrally and it
attempts to not only improve abdominal contour, but also
enhance the appearance of the anterior thighs.
6. Regardless of the technique used, vascular territories are
interrupted and should be taken into account, especially when
upper abdominal scars are present. Zone I is supplied by the
deep epigastric arcade and these vessels are almost always
interrupted by flap elevation.
7. Many abdominoplasty scar patterns have been introduced
over the past five decades to accommodate different clothing
patterns and potential improvements in contour.
8. The surgeon has to balance the needs of limiting the width of
the scar, eliminating lateral standing cones or dog-ears, and
appropriately positioning the mons pubis in the vertical
dimension.
9. Postoperatively patients are kept flexed, in ‘beach chair’
position, but are expected to be walking later on the day of
surgery bent at the waist. They are not allowed to straighten
up for 1 week after surgery.
10. Abdominoplasty is an extensive operation and complications
include wound dehiscence, hematoma, wound infection
(including toxic shock syndrome), seroma, tissue necrosis,
contour irregularity, scarring, umbilical deformity, paresthesia,
deep vein thrombosis, and pulmonary embolus.
INTRODUCTION
The modern history of abdominal contouring began in 1899 with
Kelly1,2 performing an abdominal apronectomy or dermolipectomy to
eliminate a large abdominal pannus. In 1957, Vernon3 described umbilicus transposition. Gonzalez-Ulloa4 in 1959 popularized the abdominoplasty technique describe by Somalo5 in 1946 where he resected a
circular skin pattern from the lower abdominal region extending
around the waist in a belt lipectomy fashion. In 1967, Pitanguy6 presented his technique consisting of inconspicuous scars in the lower
abdomen and groin, wide superior dissection up to the costal margins
and xiphoid, plication of the transverse abdominal rectus muscle and
umbilicoplasty. Regnault,7 in 1972, introduced the concept of abdominoplasty in a ‘W’ pattern, and in subsequent years described modifications of the technique including a fleur-de-lis and modified belt
lipectomy. Grazer,8 in 1973, reported 44 cases of abdominoplasty
hiding the incision in the bikini line. The concept of miniabdominoplasty was introduced by Elbaz and Flageul9 in 1971, and later modified
by Glicenstein10 in 1975. The introduction of liposuction in the late
70s added a significant tool to abdominoplasty and body contouring
in general.11 Matarasso,12,13 in the late 80s, made a significant contribution by introducing his classification scheme and by describing the
incorporation of liposuction with modified abdominoplasty procedures.
Lockwood,14 in 1991, described a new concept – the superficial fascial
system (SFS), which is a highly organized collagen structure responsible for anchoring the skin of the body and for supporting the weight
of the fat throughout life. In 1995 he introduced a high lateral tension
abdominoplasty (HLTA), which was designed to create more lateral
abdominal improvement and anterior thigh elevation.15 Within the
past decade Saldanha16 introduced and popularized ‘lipoabdominoplasty’, which has become fairly popular in South America and Europe.
It is a technique that utilizes extensive liposuction of the entire
abdomen combined with minimal undermining in the hope of reducing the risks of tissue necrosis and seroma formation.
INDICATIONS
Abdominoplasty
Indications
●
Skin and subcutaneous tissue excess and/or laxity limited to
the anterior abdomen
●
Abdominal wall musculoaponeurotic laxity
Contraindications
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●
Generalized obesity
●
Excessive intra-abdominal content
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9
Aesthetic Surgery
●
Circumferential lower truncal excess (requires circumferential
treatment)
●
Unrealistic expectations
●
Medical or psychiatric instability
●
Smoking (considered to be a contraindication by most plastic
surgeons)
●
Planned pregnancy in the near future
Relative contraindications
●
Previous abdominal scars compromising blood supply
●
History of diabetes mellitus, chronic obstructive pulmonary
disease, cardiovascular disease, thromboembolic events
controlled diabetes mellitus is too high is controversial. Many surgeons
consider the risk posed by the decreased ability to fight infection,
potential vascular compromise, and decreased wound healing ability
too high.
Smoking has been implicated in occlusive microvascular thrombosis and delayed wound healing and when associated with a procedure
that already compromises the blood supply of the abdominal skin flap,
can result in tissue necrosis and jeopardize the outcome. Active
smokers are excluded by most surgeons, but some surgeons are willing
to operate on them utilizing techniques that reduce abdominal flap
elevation to reduce the risk of vascular compromise.21–23
Abdominal wall plication can increase intra-abdominal cavity pressure and this can potentiate certain problems.
●
First, the increased intra-abdominal pressure may elevate the
diaphragm and compromise pulmonary function, especially in
patients who have chronic obstructive pulmonary disease. Thus it
is important to work-up these patients and make sure that they
can withstand further pulmonary stress prior to contemplating
abdominoplasty surgery.
●
Second, increased intra-abdominal pressure after abdominoplasty
results in decreased venous blood flow through the common iliac
vessels, which predisposes patients to deep venous thrombosis
(DVT) and pulmonary embolus (PE). Therefore, patients with a
history of DVT and/or PE should undergo a thorough evaluation
for potential recurrence, and in some, surgery may be contraindicated. A temporary or traditional Greenfield filter may be considered in this instance in conjunction with a vascular surgery
consultation.
Mini-abdominoplasty
Indications
●
Abdominal laxity restricted to the infraumbilical region
High lateral tension abdominoplasty (HLTA)
●
To improve abdominal contour and enhance the appearance of
the anterior thighs
Lipoabdominoplasty
●
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Alternative technique to traditional abdominoplasty but may
be safer and associated with less complications
Patients seeking abdominoplasty most often complain of excess skin
and subcutaneous tissue in the abdomen and abdominal protrusion
due to laxity of abdominal wall caused by previous pregnancy, weight
fluctuations and/or aging. Many of these patients will present with
lipodystrophy of the hips and lateral thighs as well.17 A traditional
abdominoplasty is indicated when the deformities involve both the
supra and infraumbilical regions whereas a mini-abdominoplasty is
usually indicated if the problems are limited to the infraumbilical
region. Although most patients are female, males do present with
similar problems, but often complain of adiposity in the flank areas
and supraumbilical rectus diastasis.18–20
The ideal candidate for abdominoplasty is a young healthy woman
who is a nonsmoker and whose weight is within, or slightly above, the
normal range. In many cases, especially in middle-aged and older
women, patients present with concomitant lipodystrophy of the hips
and lateral thighs, as well as the abdominal deformities. These patients
are still amenable to abdominoplasty in combination with liposuction
of the areas of lipodystrophy. However, if the deformities involve the
lower trunk circumferentially, as in the massive-weight-loss patient or
some overweight patients, abdominoplasty can have disappointing
results. These patients usually require a circumferential truncal dermatolipectomy to treat their deformities.
Obese patients are not good candidates for abdominoplasty because
they have excess intra-abdominal or visceral fat. The intra-abdominal
cavity can be thought of as a balloon that fits inside a second external
skin balloon. If the internal balloon is overly inflated by visceral fat, it
cannot be effectively flattened by musculoaponeurotic plication. Thus
it will maintain a convex profile, which is translated to the external
balloon and will lead to a convex appearance for the entire abdomen.
This defeats the major reason why most patients seek abdominoplasty
surgery.
As with any elective plastic surgery procedure patients who have
unrealistic expectations of the potential results should either be advised
by their surgeon to change their expectations or should not be operated
on. Similarly patients who present with unstable psychiatric or medical
conditions should be avoided. The question about whether the risk
of carrying out an abdominoplasty in an individual who has well-
Although it is always best for women to undergo abdominoplasty after
they have had children and when they do not plan any more, many
patients do become pregnant and have children after the procedure.
Some of the benefits of abdominoplasty may be reduced or eliminated
by pregnancy, thus it is wise to postpone the procedure if a pregnancy
is anticipated in the near future.
Previous abdominal scars
Patients with previous abdominal scars may require special considerations if abdominoplasty is contemplated.
●
McBurney-type appendectomy scars have little effect on surgical
planning because they are simply resected during panniculus
excision.
●
Lower abdominal transverse scars, usually utilized for hysterectomy, are similarly nonproblematic because they are generally
resected during abdominoplasty.
●
A subcostal, open cholecystectomy scar can contraindicate a traditional abdominoplasty, with its extensive abdominal flap undermining, which reaches up to the costal margins and xiphoid. The
only feeding vessels to the elevated abdominal flap in that instance
consist of the lateral intercostals, subcostal, and lumbar perforator
vessels, which course anteriorly in the fat superficial to Scarpa’s
fascia. These vessels are interrupted by a subcostal scar and this
can lead to abdominal flap necrosis inferomedial to the scar.
Recently created subcostal scars, within the past 2–3 years, usually
contraindicate traditional abdominoplasty. Patients who present
with old subcostal scars can sometimes undergo an abdominoplasty, but with techniques that limit flap elevation.
●
A midline abdominal scar does not usually prevent abdominoplasty
surgery. If the scar is limited to the infraumbilical level, it will
usually be removed with the abdominal panniculus and should not
prevent the procedure from creating the best possible abdominal
contour. If the incision is supraumbilical, it usually does not
prevent the flap from being advanced appropriately. However in
some patients, the scar may be hypertrophic and may restrict
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Box 122.1 Theoretical advantages of
lipoabdominoplasty
Mini-abdominoplasty
Indications for mini-abdominoplasty are limited to patients who
present with abdominal laxity restricted to the infraumbilical region.24
The laxity has to be minimal and may be of the abdominal wall and/
or of the skin/fat envelope. Physical examination of the abdomen in
the supine position will demonstrate infraumbilical rectus diastasis,
which can be confirmed by the ‘diver’s test’ (see Fig. 122.1). These
patients are usually young women who have had one or two pregnancies, have good skin elasticity, and are not overweight. Mini-abdominoplasty, with any of its modifications, is not a procedure that is often
employed because it is the unusual patient that will fit its required
criteria.
High lateral tension abdominoplasty
An HLTA15,25 is fundamentally different from the traditional abdominoplasty in the following ways:
●
maximum tension is created laterally, rather than centrally as in
traditional abdominoplasty;
●
HLTA attempts to not only improve abdominal contour, but also
enhance the appearance of the anterior thighs by lifting that area
and creating a narrowing at the waist as a result of the lateral
emphasis;
●
tension is maximized laterally, so the defect created by the circumumbilical incision is often not excised;
●
the procedure allows for extensive liposuction of the abdominal flap
because of the dependence on discontinuous undermining for flap
mobilization, which leaves the flap with a more robust blood supply
when compared to a traditional abdominoplasty;
●
because of the emphasis on lateral tension, HLTA often requires
an extension of the scar laterally to accommodate for the more
aggressive lateral resection.
Reduction in seroma rate because of a lack of abdominal wall
fascia exposure, which has been implicated in increasing the
risk of seromas by some authors. Also, if lymphatic tissues,
especially of the femoral region, are left intact, seromas should
be less likely.
●
Because there is minimal elevation of the supraumbilical
abdominal flap, there should be an abundance of remaining
abdominal wall muscle perforators intact to supply the
abdominal skin and thus decrease the risk of tissue vascular
compromise.
●
In cases of a thick abdominal flap, liposuction and thinning
can be performed safely.
to weight fluctuations, any history of pregnancy, diet and exercise
regimens, and previous abdominal surgery and/or hernias. A careful
medical history should be obtained along with a smoking history.
Physical examination
On physical examination the patient’s weight and height should be
determined. The body mass index (BMI), should be calculated based
on the formula: weight in kg/(height in m)2. The patient is initially
examined circumferentially in the standing position to evaluate the
abdominal contour from the rib cage to the mons pubis. However it
is also important to pay attention to the surrounding contours of the
posterior trunk, thoracic region, and thighs.
Three main components need to be evaluated in the physical
examination of the abdomen: the skin, the subcutaneous fat, and the
abdominal wall.
Skin
The overall quality of skin, including scars and stretch marks should
be noted. The skin should be examined to determine its vertical excess
and the extent of its laxity in the different regions of the abdomen.
Often multiparous women present with stretch marks that involve the
infra and supraumbilical regions.26 The patient needs to understand
that infraumbilical skin will most often be removed, but supraumbilical stretch marks will not. These remaining stretch marks are often
less unattractive when stretched by the procedure and can be hidden
by some bikini patterns because of their transference to the lower
abdomen.
Subcutaneous fat
Lipoabdominoplasty
16
Lipoabdominoplasty was introduced and popularized by Saldanha
from Brazil. This technique, with a variety of its forms, is becoming
more popular around the world especially in South America and
Europe. For the surgeons who espouse lipoabdominoplasty, it is an
alternative technique that accomplishes many of the same goals as
traditional abdominoplasty but maybe safer and associated with less
complications (Box 122.1). Currently many American plastic surgeons
are starting to utilize the technique in its entirety or at least in some
of its main aspects. Lipoabdominoplasty has some similarities to
HLTA.
PREOPERATIVE CONSIDERATIONS
Preoperative evaluation of potential abdominoplasty patients includes
a good history and physical examination, and determination of their
primary concerns and expectations. Special attention should be paid
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●
122
Abdominoplasty
abdominal flap advancement during the tailoring process. In these
patients resecting the scar only, without the underlying fat layers,
will allow the advancement. However, even this maneuver may
lead to an increased risk of flap necrosis, because dermal vessels
cross over in the midline and can lead to a decrease in blood supply
of the inferomedial aspects of the abdominal flap. A less risky way
to attain the desired flap advancement is to create multiple small
puncture stab incisions along the hypertrophic scar allowing release
of the contracted tissues. If a patient desires a revision of the
midline scar, it is generally best to perform that in a subsequent
procedure after the flap has had enough time to revitalize its blood
supply in its new position.
The thickness of the subcutaneous fat of the anterior abdomen and
the surrounding lateral and posterior lower truncal regions should be
determined.
A protruding abdomen may be caused by a number of factors, alone
or in combination.
●
In obese patients and some male patients, intra-abdominal fat
excess is responsible. In male patients, in particular, who have a
fat deposition pattern that predisposes them to large visceral fat
deposits, the abdominal panniculus thickness may be minimal
despite an extremely protrudent abdomen.18–20 These patients are
definitely not good candidates for abdominoplasty.
●
Another reason for a protruding abdomen is a thick panniculus,
which is often encountered in overweight, obese, or post-massive
weight loss patients. If abdominoplasty surgery is contemplated on
a patient with a thick panniculus, it is important to choose a technique that allows for thinning of the flap. This usually involves
liposuction and limited undermining.
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9
Abdominal wall laxity
Aesthetic Surgery
A third reason for a protruding abdomen is abdominal wall laxity. It
is essential to ascertain the integrity of the abdominal wall, whether
there are any hernias present, and the extent of intra-abdominal or
visceral fat. The exam is fairly easy in thin patients, but can be more
cumbersome and difficult in the overweight or obese patient.
A number of tests can be performed, which alone or in combination, can give the examiner a feel for the degree and extent of any
laxity. Initially the patient is asked to stand and relax their abdominal
wall completely. For many this is not easy and they must be coaxed
into cooperating. An appreciable amount of abdominal protrusion in
this position usually indicates significant abdominal wall laxity. To
confirm the result of this simple test, the patient is asked to perform
the classic ‘diver’s test’ (Fig. 122.1).
To get a more accurate estimation of abdominal wall laxity, the
patient is placed in the supine position and asked to lift the head and
upper back off the table while the examiner palpates the abdominal
wall. The extent of generalized laxity and the separation between the
rectus muscles should be noted. Most patients presenting for abdominoplasty will demonstrate at least some degree of rectus diastasis.
Men have a propensity toward a supraumbilical diastasis, whereas
women most often present with infraumbilical muscle separation.
Abdominal wall laxity can be difficult to examine in patients with
thick panniculi. A distinction between subcutaneous and visceral fat
must be made because none of the techniques of abdominal contouring are designed to address excess intra-abdominal fat. A helpful test
for these patients is to place them in the supine position and observe
their abdominal contour. If it dips below the level of the ribs, it is likely
that rectus fascia plication will be effective; if not, it can be presumed
that there is an excessive amount of intra-abdominal adipose tissue.
Attempting to perform an abdominoplasty on a patient with excessive
intra-abdominal content most often yields an unfavorable outcome.
Other features
The abdominal physical exam should also include an evaluation of the
mons pubis. The amount of excess fat should be determined. Any
degree of ptosis should be noted because it should be treated as part
of any abdominal contouring procedure. This is especially important
in high-BMI patients and those who have experienced appreciable
weight fluctuations.
The classic “diver’s test” is shown
In examining the back, attention should be paid to the waist, hips,
localized fat deposits especially in the flank and lateral thigh regions,
any deviations in the spine, the depth of lumbar lordosis, and the
extent of buttock’s projection.
Counselling
Finally the patient is counseled about the risks, benefits, and alternatives to surgery. He or she should have the opportunity to ask questions and express concerns and doubts. The patient should be well
informed about major and minor complications, how they may occur,
and how to prevent and treat them, should they occur. A good rapport
between patient and surgeon is essential and protects both patient and
surgeon when results are unfavorable.
Preoperative photographs
Preoperative photographs are taken in the anterior, posterior, lateral
and oblique views to demonstrate the full extent of deformities; they
guide surgical planning and serve as an important tool in the post­
operative assessment of the results.
OPERATIVE APPROACH
Relevant anatomy
In young, healthy men and women the waist is the narrowest circumference of the torso, usually 2.5 cm cephalad to the umbilicus, which
lies on the midline at about the level of the iliac crests. Ideally, the
distance from the umbilicus to the anterior vulvar commissure is
18–21 cm, and the pubic hair line is 5–7 cm cephalad to the anterior
vulvar commissure.
The anterior abdominal muscle wall may be considered to have
two parts:
an anterolateral portion composed of the external oblique, internal
oblique, and transversus abdominis muscles;
●
a midline portion composed of the rectus abdominis muscle
(Fig. 122.2).
●
Anterior abdominal wall musculature
Anterior rectus
sheath
External oblique
muscle
Posterior rectus
sheath
Internal oblique
muscle
Arcuate line
Transected rectus
abdominis muscle
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Fig. 122.1 The classic ‘diver’s test’. When the patient is flexed at
the waist the lower abdominal musculature is relaxed enough to
demonstrate laxity in the infraumbilical region.
Fig. 122.2 Anterior abdominal wall musculature.
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Layers of the abdominal wall
122
Three zones of vascularity
Abdominoplasty
Skin
Superficial fat layer
Superficial fascial
system (Scarpa’s fascia
anteriorly)
Deep fat layer
Deep muscular fascia
Muscle
Superior epigastric
artery
Fig. 122.3 Layers of the abdominal wall.
Intercostal artery
Subcostal artery
The rectus muscle is enclosed in a stout sheath formed by a bilaminar
aponeurosis, which passes anteriorly and posteriorly around the
muscle, decussating in the midline to form the linea alba. Anteriorly
the sheath is made up of the external oblique fascia and the anterior
portion of internal oblique fascia. Posteriorly the sheath is made of
the posterior portion of the internal oblique fascia and the transversus
abdominis muscle fascia. Halfway between the umbilicus and the
pubis, the posterior sheath layers pass anteriorly at the arcuate line
of Douglas. The lack of support below the line of Douglas leads to a
natural tendency toward lower abdominal fullness.
The umbilicus lies in the midline at varying distances between the
xiphoid and the pubis symphysis, but usually level with the anterior
superior iliac spines (ASIS). It has a dual blood supply, from the deep
layer and from the skin, and it is able to survive on either. Caution is
warranted in patients with large umbilical hernias and previous
transections of the umbilicus.
Subcutaneous abdominal fat is compartmentalized into superficial
and deep layers divided by the superficial fascial system, which in this
region of the body is called Scarpa’s fascia. In patients who are relatively thin, the two layers of fat are fairly close to each other in thickness. In patients who have a large BMI the superficial fat layer is often
much thicker than the deep layer (Fig. 122.3). The superficial fat layer
is compact, dense with fat cells contained within well organized fibrous
septa, whereas the deep fat is a loose areolar layer.
Vascular zones
Regardless of the technique used when performing abdominoplasty,
vascular territories are interrupted and should be taken into account
especially when upper abdominal scars are present.27 Thus a thorough
knowledge of the blood supply of the abdominal skin and fat is essential. Huger28 studied the blood supply to the abdomen and designated
three vascular zones (Fig. 122.4):
Zone I is supplied by the deep epigastric arcade. It extends from
the xiphoid to the pubis and from one lateral edge of the rectus
sheath to the other. The deep superior and inferior epigastric
vessels run through the rectus muscle, emitting musculocutaneous
perforators to the overlying fat and skin.
●
Zone II extends from one ASIS to the other, down to the inguinal
creases and pubis. Its blood supply is derived from the superficial
branches of the circumflex iliac and external pudendal vessels.
Some branches of the deep circumflex iliac vessels, which course
above the ASIS course inferiorly into zone II from zone III above
as well.
●
Zone III provides the blood supply to the anterolateral abdominal
wall, extending above the ASIS just lateral to the rectus sheath on
either side of zone I. It is supplied by intercostals, subcostal, and
lumbar arteries. Because these vessels travel inferomedially in the
superficial layer of abdominal fat, they overlap zone I vessels in
supplying medial skin.
●
Ch122-X4081.indd 1613
Zone I
Lumbar branches
Ascending branch
of deep circumflex
iliac artery
Inferior epigastric
artery
Superficial epigastric
artery
Zone III
Zone II
Fig. 122.4 Blood vessels that supply the abdominal wall. There are
three zones of vascularity.
Zone I vessels are almost always interrupted by flap elevation in an
abdominoplasty, leaving zone III vessels as the only remaining blood
supply. If zone III vessels are interfered with, such as in a subcostal
cholycystecomy scar, tissue inferomedial to the interruption may
necrose.
Sensory innervation
The sensory innervation of the anterior abdominal wall originates
laterally from the 6th to 12th thoracic nerves and 1st lumbar nerve.
The lateral femoral cutaneous nerve ( L2–L3) provides sensation
to the anterolateral thigh, is located 1–6 cm medial to the ASIS and
can be injured during dissection and closure of an abdominoplasty,
resulting in painful neuroma or anterolateral thigh paresthesia.
Iliohypogastric and ilioinguinal nerves supply sensory innervation
to the groin and symphysis pubis, proximal portions of the scrotum
and labia, and small adjacent area on the inner aspect of the thigh.
These nerves can be entrapped during plication of the anterior rectus
sheath in the lower abdomen.29,30
Fascial attachments
The lower trunk has fascial attachments between the skin and underlying muscle fascia that act as anchoring points or zones of adherence31
(Fig. 122.5), which tether the overlying skin to the underlying
musculoskeletal anatomy, not allowing either descent or elevation
with aging, weight fluctuation, or surgical manipulation.
Posteriorly the midline has a zone of adherence that overlies the
spine.
●
The anterior midline of the abdomen has a less defined zone of
adherence overlying the linea alba.
●
There are three horizontal zones of adherence in the inferior aspect
of the lower trunk, which are responsible for the fact that
abdominoplasty scars do not end up in much higher positions
because they prevent unrestricted superior movement. The first is
bilaterally located at the inguinal ligament extending towards the
●
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9
Aesthetic Surgery
A
B
Fig. 122.5 Zones of adherence of the upper and lower trunk. A–C, The anterior midline of the abdomen has a less defined zone of adherence
overlying the linea alba. Posteriorly the midline has a zone of adherence that overlies the spine. There are three horizontal zones of
adherence in the inferior aspect of the lower trunk: bilaterally at the inguinal ligament extending towards the ASIS; just above the mons
pubis, and bilaterally between the hip and lateral thigh fat deposits.
ASIS. The second is located just above the mons pubis, and though
this particular zone of adherence may occasionally not be vigorously adherent, it is usually a strong zone of adherence. The third
is located bilaterally between the hip and lateral thigh fat
deposits.
Truncal tissues become lax due to aging, pregnancy, and/or massive
weight loss. They descend the greatest distance laterally, caused by a
combination of tissue laxity and central tethering of the midline zones
of adherence. As tissues descend around the pelvis they also migrate
centrally.
Operative techniques
Plastic surgeons vary in their approaches to any surgical procedure
and abdominoplasty is no exception. We present our preferred technique, though we tend to vary the technique depending on the patient
and his or her particular desires.
Markings
Many abdominoplasty scar patterns have been introduced over the
past five decades. They have evolved over time to accommodate different clothing patterns and potential improvements in contour. We
prefer a ‘French Bikini’ pattern because it places the scar at the
natural junction between the abdominal and thigh units. However,
because of recent fashion trends we often utilize lower patterns to
accommodate patient wishes.
Preoperative markings are performed 1–2 two days prior to the
procedure to allow photography of the markings and evaluation of any
need for adjustments. However, some surgeons perform the markings
immediately prior to surgery or in the operating room.
In abdominoplasty the surgeon has to balance the needs of limiting
the width of the scar, eliminating lateral standing cones or dog-ears,
and appropriately positioning the mons pubis in the vertical dimension. The inferior aspect of the elliptical excision is generally longer
than the superior aspect creating a mismatch, which can lead to the
dog-ears. Patients who present in the lower BMI range generally do
not cause as much difficulty with dog-ears as the patients who have a
larger BMI. Patients who have relatively inferiorly positioned umbilici
are also less troublesome with respect to dog-ears compared to those
who have fairly high umbilici.
To eliminate dog-ears three general approaches, individually or
in combination, can be utilized.
First, the excision and scar can simply be extended laterally.
●
1614
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C
Second, the lateral aspect can be closed first to create a flat surface
and subsequently the abdominal flap is cheated medially.
●
Third, in cases of a superiorly located umbilicus, the umbilical
defect created by the circumumbilical incision can be closed on
itself leaving behind a vertical scar in varying positions. This will
reduce the vertical distance resected thus leading to less lateral
fullness.
●
The marking process begins by delineating the midline from the
xiphoid to the mons pubis. Centrally, the proposed lower abdominal
incision is marked in the natural suprapubic crease in most patients
who are within the normal weight range. For most patients undergoing abdominoplasty the superior pubic hairline coincides with the
natural crease, but if there is no natural crease present then the
mark can usually be placed at the edge of the hairline. In massiveweight-loss patients, and occasionally in fairly lax non-massiveweight-loss patients, the mons pubis is ptotic and it is necessary to
place the incision a few centimeters within the hair-bearing pubic skin.
A good guide for most patients is a 7 cm distance from the top of the
fourchette or penis to the incision line.
It is obviously important to control final scar position in abdominoplasty, and it is therefore helpful to think of an abdominoplasty
closure in the same way as the closure of any elliptical defect. The
greatest tension and tissue distortion occurs centrally, with minimal
to no tension or distortion laterally (Fig. 122.6).
In abdominoplasty the final position of the central scar, between
the lateral edges of the mons pubis, is a result of the balance of the
upward pull of the tailored abdominal flap and the opposing inferior
pull down of the zone of adherence at the suprapubic crease. A great
deal of attention should be paid to how this central area of greatest
tension will be manipulated to allow for the resection of the appropriate amount of vertical excess without lifting the mons pubis to an
unnatural superior position. Once central tension is set, which actually takes place at the time of surgical resection, scar position lateral
to the mons pubis is much easier to predict because there is little tension
on either a superior or inferior direction by the lateral aspects of the
resected ellipse. Thus to complete the inferior aspect of the abdominoplasty ellipse the marking is extended laterally, based on the desired
pattern of the final scar. In a French-bikini pattern the extension is
made towards the ASIS. If a flatter scar is desired, the mark is angulated at the desired level. In general the scar will end up 1–2 cm above
the initial inferior incision in the area lateral to the mons pubis.
To approximate the superior extent of the ellipse, the patient is
placed supine and flexed at the waist, and the ‘pinch technique’ is
utilized to approximate the superior extent of the incision. Ideally the
patient should have enough excess skin to allow for excision of the
skin from above the umbilicus to the inferior mark. Lipodystrophy of
any surrounding regions such as the flanks, hips, and lateral thighs is
also marked for liposuction.
9/19/2008 1:26:23 PM
122
Abdominoplasty
Fig. 122.6 Tension created by abdominoplasty across the abdomen.
Note that tension is significant centrally and essentially goes to zero
laterally.
Fig. 122.7 Traction sutures. These put traction on the umbilicus to
facilitate the circumumbilical incision.
Abdominoplasty
In the operating room, the patient is placed in the supine position,
intermittent compression devices are applied to the lower extremities, and a dose of perioperative antibiotic is given.
●
Most plastic surgeons prefer to perform abdominoplasty under
general anesthesia because it allows complete muscle relaxation,
which is helpful during abdominal wall plication.
●
If the procedure is going to require a long operative time, which
can occur when multiple other procedures are planned, an indwelling urinary bladder catheter is placed.
●
After the patient is prepped and draped, the operation begins by
circumferentially incising around the umbilicus. To facilitate the
incision and the subsequent creation of a neoumbilicus, retraction
sutures are placed at 12 and 6 o’clock (Fig. 122.7).
●
A periumbilical dissection down to the level of the surrounding
rectus fascia is then performed making sure that a generous amount
of fat is left attached to the umbilicus to preserve its blood
supply.
●
Next, the inferior mark of the proposed elliptical excision is incised
and abdominal flap elevation is performed. In traditional abdominoplasty, an abdominal flap is elevated at the level of the underlying muscle fascia, around the umbilicus, and up to the xiphoid and
costal margins. This type of wide undermining allows the greatest
amount of inferior abdominal flap advancement at the time of flap
tailoring, but it also compromises the greatest number of muscle
wall perforating vessels that directly supply the overlying fat and
skin. We, like many plastic surgeons, prefer to leave the subscarpal
fat down in the femoral region during abdominal flap elevation in
the hope of maintaining the prominent lymphatics of that region to
help reduce postoperative seroma formation (Fig. 122.8).
●
Some surgeons prefer not to liposuction an extensively elevated
abdominal flap in fear of injuring its remaining blood supply – the
intercostal, subcostal, and lumbar vessels, which run in the fat
superficial to Scarpa’s fascia. Others liposuction the flap only if
they limit their elevation to either side of the midline, which is only
wide enough to allow for the needed plication (Fig. 122.9). This
conservative central elevation maximizes the number of intact
muscle perforator vessels to supply the tailored abdominal flap. As
●
Ch122-X4081.indd 1615
Fig. 122.8 Abdominal flap dissection is performed at the level of
Scarpa’s fascia, or just deep to it, in the femoral regions bilaterally.
This leaves behind important lymphatic channels to help drain the
lower abdominal region and presumably reduce seroma formation.
a general rule, flap elevation should be restricted to just what will
allow both appropriate abdominal wall plication and adequate flap
advancement. Thus no matter which type of flap elevation is contemplated in any particular patient, it is usually best to limit the
elevation initially and then release the tissues incrementally to
allow for appropriate plication and contour.
Next, the patient is flexed at the waist, abdominal wall laxity is
examined, and a vertical elliptical plication is marked from the
xiphoid to the symphysis pubis (Fig. 122.10).
●
Often the anesthesiologist is asked to relax the patient prior to
starting the plication, especially in patients who seem to have tense
abdominal walls. If there are any concerns about excessive gastric
air content, nasogastric tube aspiration should also be performed.
The authors prefer a two-layer vertical plication. The first layer is
●
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9
Aesthetic Surgery
Fig. 122.9 Extent of abdominal flap dissection in the supraumbilical
region, if abdominal flap liposuction is to be performed.
Fig. 122.11 Second layer of plication. This is completed
infraumbilically, and partially completed in the supraumbilical
region.
between the newly created umbilicus and the horizontal abdominal
scar. If the mons pubis is overly thick, it can be defatted by reducing subscarpal fat to balance its proportions in relation to the new
abdominal contour. If the mons pubis appears to rise too high, its
superficial fascial layer may be anchored to the underlying muscle
fascia to hold it in the appropriate position. The abdominal flap is
then tailored based on that position.
Fig. 122.10 First layer of plication.
performed utilizing interrupted permanent braided suture and the
second layer is performed with permanent monofilament running
suture (Fig. 122.11).
In some patients vertical laxity may persist after the two-layer
plication is completed. In these instances, one or two rows of
horizontal plications can be performed to further flatten the
abdominal wall.
●
With the plication accomplished, the patient is maintained in the
flexed position. The abdominal flap is advanced inferiorly to facilitate the process of flap tailoring (Fig. 122.12). The tailoring
process must be a balance between eliminating vertical abdominal
flap excess, not elevating the mons pubis too high, and limiting
scar width. Often, however, it is necessary to make adjustments to
accommodate all three desires. For example if eliminating the
umbilical defect will lead to an abnormally high mons pubis, the
defect can be left as part of the remaining flap and closed on itself
leading to a midline vertical scar located at varying distances
●
1616
Ch122-X4081.indd 1616
To aggressively improve waist definition and elevate the anterior
thighs, proponents of the HLTA technique place a great deal of
tension laterally, from the lateral border of the mons to the ASIS.15,25
This method of abdominal flap tailoring decreases central tension
on the mons pubis. However, it often necessitate a lateral extension
of the scar to eliminate the dog-ears created by the lateral tension.
Conversely limiting scar width, and thus lateral tension, will lead
to less aggressive improvements in waist definition and anterior
thigh elevation. We tend not to choose a particular method to use
on all patients, but rather adjust the resection to the particular
patient’s condition and desires, at the time of surgery.
●
Our preferred method of umbilicoplasty
With the abdominal flap tailored and temporarily tacked in place,
the position of the underlying umbilicus is marked in preparation
for umbilicoplasty. The particular method of umbilicoplasty is
quite variable from surgeon to surgeon. As a general rule however,
the neoumbilicus should be fairly small, vertically oriented,
●
9/19/2008 1:26:42 PM
Three point fixation sutures at 3, 6 and 9 o’clock
122
Abdominoplasty
Fig. 122.13 Three point fixation sutures at 3, 6, and 9 o’clock are
placed from the subcuticular level of the abdominal flap to the
subcuticular level of the umbilicus and through the fascia of the
surrounding abdominal wall. These sutures allow inversion of the
neoumbilicus without having to de-fat the surrounding tissues.
Fig. 122.12 Abdominal flap after being advanced. The amount to be
resected is determined at key points.
prefer to thread the pain pump catheter below the rectus fascia,
but we have not found that to be necessary for it to function
well.
inverted, and its suture line should be buried within the cone
shaped structure. We describe our preferred method because of its
simplicity and the results it produces.
A 1.5–2.0-cm vertical incision is made in the midline overlying the
buried umbilicus and a path is created by bluntly dissecting a
passageway for the stalk to be brought through to surface.
●
We prefer not to de-fat this area to avoid possible vascular
compromise of the abdominal flap and because the desired inversion can be accomplished by the suture technique we describe
here.
●
At 3, 6, and 9 o’clock, three point fixation sutures are placed from
the surrounding abdominal wall fascia, to the subcuticular level of
the umbilicus, and through the subcuticular level of the abdominal
flap (Fig. 122.13). As these sutures are tied, the neoumbilicus is
inverted. The remainder of the closure is accomplished with simple
inverted, subcuticular, nonpermanent sutures from the abdominal
flap to the umbilicus.
●
Closure of the abdominal wound
Prior to beginning closure of the abdominal wound two closedsuction drains are placed through the hair-bearing skin of the
mons pubis.
●
Closure is accomplished in multiple layers, with the most important layer being the superficial fascial system, or Scarpa’s fascia.14
It is assumed that reapproximating this layer reduces the significant tension on skin that can be generated in an abdominoplasty.
It also prevents acute wound dehiscence and reduces scar widening in the long run. Traditionally it has been accomplished with a
0- or #1-sized permanent braided suture. We, however, have abandoned permanent sutures and currently utilize a longlasting nonpermanent, non-braided, 0 suture, with no discernible decrease in
the quality of the scars.
●
The skin is closed with either interrupted or a running subcuticular
layer of 2-0 to 3-0 non-permanent, non-braided, suture followed
by an overlying layer of medical grade skin glue.
●
Recently, we have started utilizing an indwelling pain pump catheter that drips local anesthetic in the operative field, which helps
decrease pain over the first 3–4 days after surgery. Some surgeons
●
Ch122-X4081.indd 1617
We use an epidural infusion for postoperative pain management
for patients who are going to be admitted to the hospital.
●
An abdominal binder is applied to the patient’s abdomen at the
end of the surgical procedure and is utilized for a few weeks after
surgery.
●
Mini-abdominoplasty
Preoperative markings are performed 1 or 2 days prior to the
procedure in the office. The midline from the xiphoid to the umbilicus and midline of the mons pubis is marked. A lower abdominal
incision in the natural suprapubic crease is marked and often can
be limited to the width of the pubic hair or just beyond its lateral
borders.
●
In the operating room intermittent compression devices are applied
to the lower extremities, a dose of perioperative antibiotic is given,
and general anesthesia is induced.
●
The operation begins with the lower abdominal incision. The
abdominal flap is raised to the level of the umbilicus. The patient
is flexed at the waist and abdominal muscle wall laxity is examined.
The rectus abdominis muscle fascia is vertically plicated from the
umbilicus to the pubis (Fig. 122.14).
●
The abdominal flap is then advanced inferiorly and tailored to
remove the excess skin and fat. This advancement will usually pull
the umbilicus down 1–3 cm, and should be taken into consideration
if the patient has a low umbilicus preoperatively.
●
A closed suction drain is placed through a separate stab incision.
●
The incision is closed in layers, with interrupted 0-sized longlasting nonpermanent monofilament suture used to reapproximate the
superficial fascial system, followed by interrupted, inverted 2-0 to
3-0 monofilament nonpermanent suture and an overlying layer of
medical grade skin glue.
●
Modifications
A modification of this technique can be applied to patients who present
with minimal lower abdominal skin and subcutaneous tissue excess,
but have both supra and infraumbilical abdominal muscle wall
laxity.
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9
creating multiple points that are connected and thus form the
lower proposed incision.
Mini-abdominoplasty
Next, the superior proposed incision line is marked utilizing the
pinch technique, with the thumb placed on the inferior proposed
incision, pinching, and then observing that the appropriate abdominal contour is created by the pinch. As previously mentioned, the
central aspect of the superior proposed incision often does not
reach the level of the umbilicus because the emphasis of maximal
resection and tension in a HLTA is lateral.
Aesthetic Surgery
●
In the operating room intermittent compression devices are applied
to the lower extremities and a dose of perioperative antibiotic is
given. General anesthesia is induced and an indwelling urinary
catheter is placed if required.
●
The umbilicus is circum-incised and left attached by a generous
subcutaneous pedicle.
●
The lower reference line is incised and the abdominal flap is
elevated off the rectus fascia up to the umbilicus.
●
Above the level of the umbilicus, undermining is limited to a narrow
strip around the midline centrally, just enough to allow the desired
supraumbilical plication. This type of central undermining preserves more rectus muscle perforators, which allows the surgeon
to liposuction the flap if it is deemed too thick.
●
Fig. 122.14 Mini-abdominoplasty. The extent of flap dissection and
abdominal wall plication is shown.
Vertical plication of the abdominal wall fascia is accomplished in
a similar manner to the traditional abdominoplasty.
●
Next the abdominal flap is advanced inferiorly to start the tailoring
process. Whether the abdominal flap has been liposuctioned or not,
at this point in the operation, the attachments of the abdominal
flap to the underlying muscle fascia can be discontinuously undermined using large scissors that are opened parallel to the path of
the remaining vessels. This maneuver allows for further abdominal
flap inferior advancement.
●
In order to obtain access to the supraumbilical rectus diastasis,
the umbilical base is amputated as the abdominal flap is elevated
from pubis to xiphoid and the umbilicus is ‘floated’ with the
abdominal flap.
●
The supraumbilical flap elevation is limited to a distance on either
side of the midline that allows for the planned plication. The
muscle diastasis is repaired from the xiphoid to the pubis in a
similar manner to a routine abdominoplasty.
●
The actual tailoring process is begun by pulling on the abdominal
flap laterally and inferiorly, thus placing the greatest tension laterally. The excess tissue is then tailored appropriately.
●
Often the incision has to be extended laterally to eliminate dogears.
●
The abdominal flap is then advanced inferiorly and tailored; the
umbilical stalk is resutured to the plication at its more inferiorly
positioned final level.
●
With the abdominal flap tacked to the inferior incision, the neoumbilicus position is determined. The performance of the umbilicoplasty and the closure are similar to that described in the more
traditional abdominoplasty technique.
●
In a variation of this technique, a superior periumbilical incision is
made and an endoscopic elevation of the abdominal flap, from umbilicus to xiphoid, on either side of the midline is performed to allow for
rectus fascia plication. The inferior abdominal flap is tailored in a
similar manner to a more traditional mini-abdominoplasty with the
umbilicus inferiorly advanced a few centimeters.
Lipoabdominoplasty
High lateral tension abdominoplasty
●
Preoperative markings are performed in the office a day or two
prior to surgery. First, the final location of the scar is determined
with the patient in standing position. This is accomplished by
marking a horizontal line 7 cm superior to the anterior vulvar
commissure (or base of the penis) and two lateral marks at either
ASIS. These three marks are then connected to create the proposed
final scar position in the shape of ‘French bikini’ pattern. However,
the proposed final scar shape can be manipulated to fit beneath
any preferred underwear pattern by altering the position of the
lateral marks.
The markings can be performed in a similar manner to the more
traditional abdominoplasty or the HLTA pattern.
●
The operation begins by tumescent infiltration of the entire
abdomen.
●
Next, the inferior margin of excision is marked. This is accomplished by holding the marking pen at the level of the previously
made central mark and displacing the central abdominal tissues
superiorly to the extent that the appropriate mons pubis contour is
created. A mark is made on the elevated skin at the level where the
pen has been steadily held in position. This maneuver is repeated
all along the path from the central mark to the lateral marks
Both infra and supraumbilical regions are liposuctioned, superficial and deep to Scarpa’s fascia.
●
Realistically, most of the liposuction occurs superficial to the fascia
because subscarpal fat is often fairly thin and would be difficult to
significantly reduce in thickness without injuring abdominal muscle
wall fascia. Some surgeons aggressively liposuction the infraumbilical fat, and so when it is time to tailor the flap the skin will
essentially just peel off the underlying liposuctioned tissue, which
should contain a large component of the lymphatic system. Other
surgeons, including us, aggressively liposuction the supraumbilical region and then raise the infraumbilical abdominal flap at, or
just below Scarpa’s fascia. In either case the intent is to leave some
fat behind to maintain lymphatic tissues, which theoretically
reduces the risk of seromas.
●
●
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Ch122-X4081.indd 1618
Supraumbilically a narrow swath of central elevation is performed
on either side of the midline to allow for plication.
●
9/19/2008 1:26:46 PM
In the infraumbilical region a small strip of fat is resected or
elevated from either side of the midline to allow for plication.
●
Although there is minimal elevation of the flap, flap advancement
is possible due to the indirect undermining caused by the liposuction aspect of the procedure. If more advancement is required
further blunt dissection can be performed, as in a HLTA, to allow
for release of the flap.
●
Umbilicoplasty and flap tailoring are similar to the other techniques. Some surgeons do not utilize any drains with this technique, especially if they use quilting sutures from the abdominal
flap to the underlying tissues.
●
Optimizing outcomes
●
Avoid patients who have excessive intra-abdominal fat
content because the results of abdominoplasty will be
unsatisfactory.
●
Patients best suited for abdominoplasty surgery present with
lower truncal excess limited to the anterior abdomen.
●
Evaluate and treat areas surrounding the abdomen, usually
with concomitant liposuction, to attain better overall lower
truncal contour.
●
The extent of flap elevation in abdominoplasty, no matter
which technique is utilized, should be as minimal as possible
to reduce vascular compromise and accomplish the desired
contour.
●
If liposuctioning of the abdominal flap is contemplated,
supraumbilical flap undermining should be only wide enough
to allow for the needed plication, thus reducing the risk of flap
necrosis.
●
Wide undermining in smokers, diabetics, hypertensives, and if
there are pre-existing scars in the upper abdomen should be
auoided.
●
During flap tailoring the mons pubis should not be elevated to
an aesthetically unappealing level.
●
Most lateral dog-ears should be taken care of at the time of
surgery by either extending the scars or cheating the
abdominal flap medially.
●
Reapproximation of the superficial fascial system is essential
to obtain a high-quality fine-line scar.
●
The neoumbilicus should be small, vertically oriented, and
superiorly hooded, with a slight hollow around it.
●
Patients who present with a high BMI greater than or equal to
30 have a greater complication rate.
●
Use of sequential compression devices, early ambulation,
vigorous pulmonary toilet, appropriate hydration, discontinuing
nicotine, birth control pills, and hormone replacement therapy,
and avoiding lengthy operations improve outcome.
●
The technique utilized in any particular patient should be
individualized to accommodate the patient’s anatomy and
desires.
COMPLICATIONS
Abdominoplasty is an extensive operation with potential risks and
complications that need to be considered by both the patient and
plastic surgeon.21,32–38 Abdominoplasty, alone or in combination with
other procedures, carries the highest risk among body contouring pro-
Ch122-X4081.indd 1619
Wound dehiscence
Wound dehiscence, described as separation of the wound at the level
of the superficial fascial system, can occur after abdominoplasty. It can
arise due to inadequate deep closure or inadvertent straightening up
during the early postoperative period. It can usually be avoided by
strong reapproximation of Scarpa’s fascia and good preoperative patient
education about staying flexed at the waist for 5–7 days after surgery
and maintaining that position even during sleep. Small areas of nonhealing, defined as superficial wound separations that do not reach the
level of Scarpa’s fascia, may occur anywhere along the wound after an
abdominoplasty. Generally, as long as they are small, conservative
wound management and avoiding further stretch on the wound will
allow these areas to heal by secondary intention with no significant
long-term effect on the overall quality of the scar.
122
Abdominoplasty
Plication is performed in a similar manner to any other abdominoplasty technique.
●
cedures. As a general rule complications are more common in higher
BMI patients and because many patients that present for abdominoplasty may be in the overweight-to-obese range, they need to be
approached with caution and full disclosure.
Hematoma
Hematomas are potential complications of any surgery including
abdominoplasty. They can be minimized by meticulous intraoperative
hemostasis; and by avoiding bucking and coughing during extubation.
They generally occur between the first and second postoperative
day.
Large hematomas present with swelling, pressure and pain,
and require evacuation and drainage to avoid compromise of the
abdominal flap. Some small hematomas can be managed expectantly,
especially if they happen to be adequately drained by a drain. Often
this will lead to prolonged periods of drainage from that area of the
wound.
Wound infection
Wound infections can occur after abdominoplasty, but tend to occur
in patients with increased risk factors such as obesity, diabetes, and
smoking. They can present in the form of wound cellulitis and/or an
infected seroma. The most common organisms are Staphylococcus,
Streptococcus, and Pseudomonas spp. and Escherichia coli.
Infection is manifested by redness, heat, pain and then purulent
collection.
The treatment is appropriate antibiotics, evacuation and drainage
of an abscess if present, debridement and dressing changes.
Toxic shock syndrome has been reported after abdominoplasty.
Any postoperative patient, who presents with signs of malaise, appears
very ill, and complains of generalized discomfort, with or without
fever, should always be evaluated to rule out toxic shock syndrome
even if there is no significant evidence of sequestered fluid in the
abdominal wound. These patients can be difficult to diagnose because
they may not have any obvious pus-containing collections, an elevated
wide blood cell count, or fever, but they will appear very ill. Thus
a high index of suspicion is needed to pick up this dangerous problem early and treat it appropriately. Treatment involves expeditious
return to the operating room, opening up the wound, and washing
it out vigorously. A consultation with an infectious disease specialist
and good intravenous staphylococcus coverage is also warranted,
but incision and drainage should not be delayed for any laboratory
tests or consultations if a significant potential for this problem is
suspected.
Seroma
Seromas can occur after any abdominoplasty technique. The etiology
is not completely understood and is probably multifactorial. Thus it
is not clear how they form or how to prevent them.
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9
Aesthetic Surgery
Most surgeons believe that closed suction drainage is the best way
to prevent seromas from occurring, along with compression. Surgeons
who utilize lipoabdominoplasty techniques consider that the etiology
of seromas is related to creating a very large dissection pocket and the
elimination of lymphatics, especially of the femoral region. Thus this
technique tries to minimize both problems in the hope of reducing
seroma occurrence. Other surgeons feel that it is the lack of adherence
of the abdominal flap to the underlying abdominal wall that is responsible for seroma formation and advocate eliminating as much dead
space as possible with mattress sutures.
No matter which approach is used, should a seroma occur it is
usually initially treated by repeat aspiration. If it persists some surgeons try to adhere the two sides of the seroma pocket by injecting a
sclerosing agent into the pocket. If this is not successful and the
seroma volume is large, sometimes reinsertion of a closed suction
drain is required. At this stage if a seroma still persists the surgeon
may choose to either go back to the operating room and excise the
seroma capsule that has formed and mattress suture the two walls, or
open the seroma pocket to the outside through a dependent point of
the wound and leave a wick in place to essentially exteriorize the
seroma pocket. We do not believe that the presence of a seroma capsule
necessitates surgical excision as previously advocated because we have
found that almost all prolonged drainage wounds have capsules that
may or may not produce a clinically relevant seroma. We also do not
drain relatively small nonexpanding seromas because we have found
that they tend to resolve without any therapy, but may take an extended
period of time to do so.
Tissue necrosis
Box 122.2 Inverted ‘T’ or fleur-de-lis
abdominoplasty
Some plastic surgeons prefer to utilize inverted ‘T’ or fleur-de-lis39pattern procedures in patients that present with circumferential
lower truncal excess, especially if the patient presents with a
midline abdominal scar. We have almost abandoned this pattern as
a primary procedure, especially since circumferential
dermatolipectomy procedures have become main stream in plastic
surgery as a reaction to the frequent presentation of the massiveweight-loss patient. The theoretical advantage of utilizing this
technique is that it can eliminate horizontal as well as vertical
excess and create waist narrowing by pulling the lateral tissues
centrally. It is important to note that to safely utilize this technique
it must not be thought of as a traditional abdominoplasty with a
simple addition of a vertical wedge.
Disadvantages
It is dangerous to combine extensive undermining of the
abdominal flap up to the xiphoid and costal margins with vertical
midline resection because it further compromises the blood supply
of the flap, and combined with a great deal of tension on the
closure can lead to an increased risk of flap necrosis, especially at
the T intersection. Thus if a T-type resection is contemplated, it is
wise to not undermine any of the vertical pillars on either side of
the vertical resection, and limit the dissection to only what is
required to accomplish the central plication.
Other disadvantages of a T-type resection are:
●
in eliminating the central vertical wedge, the epigastric region
can be left with fullness secondary to a ‘dog-ear’ and attempts
to eliminate the fullness by extending the incision may lead to
a scar that is carried onto the sternal region;
●
if the vertical component of the T is overly aggressive in one
region versus the other, the resultant contour can create a
bizarre shape to the abdominal wall (Fig. 122.15A–F);
●
if the umbilicus is not intentionally made small, then it will
eventually widen due to the lateral tension created by the
vertical excision;
●
no matter how expertly the T resection is performed, it does
not adequately address problems with the lateral thighs,
buttocks, and back; all problems that are much better
addressed by a circumferential procedure.
Tissue necrosis can occur after abdominoplasty due to vascular compromise of the abdominal flap which can be made worse by the tension
at closure. Predisposing factors include:
●
●
●
●
●
a history of smoking;
the presence of transverse upper abdominal scars;
excessive tension at wound closure;
liposuction in zone III;
unrecognized and undrained postoperative hematomas.
The patient initially presents with a bluish and ecchymotic area, cooler
than the surrounding tissue and between the third and fifth post­
operative day skin slough will be noticed clinically.
Postoperative skin necrosis should be treated with conservative
debridement and dressing changes. Some surgeons believe that hyperbaric oxygen therapy may reduce the extent of necrosis. Most wounds will
heal within 6 weeks and scar revision will improve aesthetic outcome.
As discussed on p. 5, the blood supply of the abdominal flap skin
and fat is reduced to varying degrees depending on the particular technique utilized and whether the patient has any concomitant risk factors
such as a history of smoking or diabetes. Based on the pattern of the
blood supply, the area most likely to necrose is located in a triangle of
the abdominal flap that has its apex at the umbilicus and its base along
the scar on either side of the midline, especially if there is T-shaped
closure. To help reduce the risk of tissue necrosis it is wise to avoid
operating on high-risk patients such as diabetics and smokers if possible, though not all surgeons steer clear of them. As a general rule, it is
wise to perform as little elevation of the abdominal flap as possible that
will create the desired contour, no matter which technique is utilized.
Contour irregularity
1620
Ch122-X4081.indd 1620
Contour irregularity is not an uncommon complication after
abdominoplasty.
Epigastric bulging after abdominoplasty results from inadequate
plication of the superior abdominal wall superiorly, near the xiphoid.
To avoid this problem, appropriate midline undermining of the flap
up to the xiphoid must be performed, to allow complete access for the
full extent of superior plication.
Lateral dog-ears can occur, especially in patients with a larger BMI,
and are best managed at the time of the actual procedure, though some
fairly small dog-ears will disappear over time without formal treatment. Intraoperatively, one way to avoid dog-ears is to start out with
the lateral closure first, creating perfect contour there, and then adjusting the remainder of the incision accordingly. A second method is to
extend the incision laterally, with or without de-fatting the lateral soft
tissues to allow for a straight-line closure.
The position of the mons pubis can be altered for better or worse
after abdominoplasty. If the mons is ptotic prior to surgery, it should
be lifted, which is easy to accomplish because of the tension created
by the resection of an abdominoplasty. It is more difficult, however,
to keep the mons pubis from ending up too high, especially in patients
who have a highly positioned umbilicus. To avoid this problem it best
to place the mons pubis where it is felt to be most ideal and then tailor
the abdominal flap based on that position. This may necessitate
leaving the umbilical defect behind as a vertical scar either as part of
a midline T-shaped closure or a vertical scar between the neoumbilicus
and the mons. If such scars are contemplated, it is imperative that the
patient is warned about the possibility prior to surgery with an expla-
9/19/2008 1:26:46 PM
Scarring
Widened depressed scars are often the result of inadequate reapproximation of the deeper tissues. Thus, closure of Scarpa’s fascia is essential to avoid tension and wound distortion. Unsatisfactory scars are
difficult to predict and should be discussed at length preoperatively,
especially if the patient has a previous hypertrophic scar or history of
keloids. Drawing the incision in the lower abdomen may help patients
visualize the scar postoperatively. Scars can be revised after a year
when the scar has attained full maturation.
Umbilical deformity
Umbilical malposition or deformity can occur after abdominoplasty
and can be avoided with careful preoperative marking of the midline,
assessment of the position of the umbilicus preoperatively and discussion with the patient if the asymmetries are noted. Previous surgery
or pregnancy can alter the umbilicus position and should be noticed
preoperatively. Lateral malposition of the umbilicus can be seen with
asymmetric musculoaponeurotic plication, and avoided by marking
the midline of the abdominal wall after flap elevation.
Paresthesia
Paresthesias are often temporary, but may in certain cases be permanent or longlasting. Almost all patients will have an area of numbness
located below the umbilicus in the shape of a triangle with its apex at
the umbilicus and its base on the transverse scar. The area of numbness tends to decrease with time with the last remnant located at the
most inferior midline point. Paresthesias result from the undermining
process, regardless of the extent.
Nerve injuries and pain have been reported in the lateral femoral
cutaneous, ilioinguinal and iliohypogastric nerves. Patients present
with persistent paresthesia and pain in the lower abdomen despite a
negative gastrointestinal and gynecologic workup. A nerve block will
alleviate the symptoms and work as a diagnostic tool. Treatment
consists of neurectomy with proximal resection into the peritoneum
to avoid painful recurrent neuroma within the anterior abdominal
wall.
Deep vein thrombosis/pulmonary embolus
The increased intra-abdominal pressure caused by abdominal wall
plication has been implicated as the cause of decreased venous return
from the lower extremity back into the pelvis, thus leading to an
increased risk of DVT and pulmonary embolus. Thus intrinsically
abdominoplasty may predispose patients to these complications.
Although it is impossible to eliminate the risks completely, they
can be minimized. Simple measures that can be taken include the
following.
●
Utilization of sequential compression garments prior to the induction of general anesthesia and maintaining their use while patients
are still nonambulatory.
●
Very early ambulation, as early as the same day of surgery, is
probably the best method known to reduce the risk of DVT and
PE and should be part of all postoperative abdominoplasty
regimens.
Ch122-X4081.indd 1621
●
Because birth control pills are associated with thrombotic complications, it is best to stop their use for at least one cycle in the
perioperative period.
●
Some plastic surgeons use chemoprophylaxis, treating high-risk
patients with low-molecular-weight heparin routinely, but their use
may be associated with an increased risk of bleeding.
●
We utilize an epidural catheter infusion for postoperative pain
control and have found a definite decrease in DVT and PE when
this modality is utilized. However, this is an empirical finding that
needs to be confirmed in larger studies.
●
Overall a high index of suspicion looking for DVT and PE should
be maintained in the postoperative period along with an aggressive
approach to investigating patients with any symptoms suggestive
of these problems.
122
Abdominoplasty
nation of why this may be necessary. To further hold the position
of the mons in its ideal position, its underlying Scarpa’s fascia can
be sutured to the underlying muscle fascia to prevent superior
migration.
Scar symmetry can often be accomplished by a careful marking
process; however, some patients have intrinsic musculoskeletal
asymmetries that are not amenable to surgical manipulation. It is best
to warn the patient about this problem prior to surgery to avoid postoperative difficulties.
POSTOPERATIVE CARE
Abdominoplasty
Intravenous fluids and antibiotics are given for 24 hours. Patients
are kept flexed, in ‘beach chair’ position. Intermittent compression
devices continue to be used until full ambulation is obtained. A
clear liquid diet is started and advanced to regular as tolerated.
Postoperative pain is controlled with narcotic analgesics and a pain
pump. The pain pump is turned on before leaving the operating
room.
Patients are expected to be walking later on the day of surgery bent
at the waist. They are not allowed to straighten up for 1 week after
surgery, and then they are instructed on exercises that will allow them
to straighten to full extension. The exercises entail the patients
straightening until they feel tension and holding that position for 30 s,
then releasing the tension by re-bending at the waist. This is repeated
20–30 times during the day, and most patients are able to get to a fully
erect position in 2–3 days.
Abdominoplasty can be performed as an outpatient procedure, but
we usually keep our patients overnight. They are discharged home with
drains and instructed to record their output daily. Each drain is
removed when its output is less than 40 mL/24 hours. Showering, but
no bathing, is allowed while drains are in place.
The abdominal binder is kept on for the first week and then the
patients are instructed to wear a tight garment that is more comfortable, for as long as they can tolerate wearing it.
Patients are instructed not to apply heating pads to the abdomen,
take hot showers, or sunbathe until they regain sensation in the
abdominal skin to avoid potential burns.
Driving is allowed when narcotic pain medication is no longer
required and the patient can perform emergency driving maneuvers
without the fear of pain from the surgical sight.
Light, lower extremity exercises, like walking or stationary biking,
can be resumed 2–3 weeks after surgery. Abdominal muscle exercises
are discouraged for 3 months after surgery to protect the abdominal
wall plication suture.
Photographs before and after abdominoplasty performed on three
different categories of patient are shown in Fig. 122.16A–F, Fig.
122.17A–F and Fig. 122.18A–F.
CONCLUSION
Patients best suited for abdominoplasty surgery present with lower
truncal excess limited to the anterior abdomen. Those with a high BMI
greater than or equal to 30 have a greater complication rate. The technique used in any particular patient should be individualized to accommodate the patient’s anatomy and desires, but the extent of flap should
be minimal to reduce vascular compromise. Complications are minimized by use of sequential compression devices, early ambulation,
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9
Aesthetic Surgery
A
B
C
F
D
E
Fig. 122.15 A poorly performed T-type abdominoplasty. A–F, These photographs demonstrate resultant epigastric fullness, asymmetries, and
a bizarre-appearing pubic region.
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122
Abdominoplasty
A
B
C
D
E
F
Fig. 122.16 Before and after abdominoplasty. A–C, White woman in her late 20s who presented with complaints of a protrudent lower
abdomen after having two children. D–F, The postoperative photographs demonstrate a French-bikini-pattern scar 6 months after surgery.
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9
Aesthetic Surgery
A
B
C
D
E
F
Fig. 122.17 Before and after abdominoplasty. A–C, A 32-year-old woman patient who underwent an abdominoplasty with liposuction of the
hips and lateral thighs. She desired her scar to fit under a fairly low underwear line. D–F, 7 weeks after surgery. Note the swelling above
the incision line, which typically resolves over a few months. (Note: this patient is shown on the accompanying video.)
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A
B
C
D
E
F
vigorous pulmonary toilet, appropriate hydration, discontinuing nicotine, birth control pills, and hormone replacement therapy, and avoiding lengthy operations.
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Fig. 122.18 Before and after
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