Demystifying High-Lateral

Second Thoughts
Demystifying High-Lateral-Tension
Abdominoplasty
The author clarifies “high-lateral-tension abdominoplasty”
(HLT), a procedure based on the premise that the greatest
abdominal excess is usually in the lateral abdomen and
that tightening of lateral excess is what most improves
contour the central abdomen. While the classic approach
improves contour by pulling inferiorly on the central
abdomen, thereby creating the highest tension along the
central incision, HLT pulls obliquely from each of the
incision’s 2 lateral arms, thereby placing the highest
tension laterally. (Aesthetic Surg J 2006;26:325-329.)
The fourth principle,
which gives this procedure its
name and uniquely distinguishes it, is the placement of
tension along the incision.
With the classic approach,
tension is greatest in the central area. Using the HLT
approach, the greatest tension
occurs laterally.12,13
Steven Teitelbaum, MD,
Santa Monica, CA, is a boardcertified plastic surgeon and an
ASAPS member.
Why the Confusion
I
became fascinated with high-lateral-tension
abdominoplasty (HLT) after noticing that patients
who had undergone circumferential body lift had
more attractive abdomens than comparable patients who
had undergone only an abdominoplasty. It was a similar
observation that prompted Ted Lockwood to conceive of
the HLT, which he published 2 years after publishing his
lower body lift paper.1-3 Although several components of
HLT have become widely used, the technique itself remains
somewhat of a mystery to many surgeons. Here, I will clarify its defining principles, advantages, and disadvantages.
Background
Lockwood recognized 2 flaws in the classic abdominoplasty technique. The first flaw was that abdominoplasty was
based on the concept that abdominal laxity was due to vertical excess in the central abdomen. His experience with body
lifting went counter to that notion, convincing him that the
greatest excess was usually in the lateral abdomen, and that
tightening of that excess was what most improved the central
abdomen. The second flaw was the standard practice of wide
undermining, which he felt was unnecessary.4
Working from these underlying premises he created
HLT, including 4 defining principles, 3 of which can be
incorporated into any abdominoplasty: (1) no undermining
beyond what is excised or needed for rectus plication; (2)
extensive, safe, simultaneous lipoplasty in nonundermined
areas; and (3) closing of the superficial fascial system (SFS)
with permanent sutures. Some of these principles have been
widely adopted.5-11
An abdominoplasty does
not become distinguished as an HLT abdominoplasty until
the wound edges are brought together at final closure.
Because this is determined intraoperatively, this defining step
cannot be shown in preoperative markings. It was only after
I visited Dr. Lockwood in the operating room that this
became clear. Further, preoperative markings become substantially distorted based on patient position. Therefore, it is
confusing to compare a preoperative marking with what is
observed intraoperatively (Figure 1). Finally, it is difficult to
apply markings from a single illustration in an article to the
multitude of possible configurations that exist in the
abdomen.
Understanding HLT
High-lateral-tension abdominoplasty becomes demystified
after one recognizes that it is really the anterior portion of a
Lockwood lower body lift that invariably results in a greater
quantity of skin removal (Figure 2).14 The difference is not
just the amount of excision, but also the concept behind it.
In a standard abdominoplasty, the surgeon focuses on
excising the umbilical site. Once that is accomplished, there
is a feeling of relief. When vertical laxity in the central
abdomen is the target area, the surgeon views tension on the
central portion of the incision as the necessary means to an
optimal outcome. Operating under this premise, only
insignificant contouring gains are expected from the lateral
incisions; conceptually, they are relegated to the ancillary
function of removing dog ears (Figure 3, A and B).15-17
The concept of HLT embodies the opposite premise.
Epigastric improvement is achieved by pulling obliquely
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B
A
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Figure 1. A, Preoperative view of a 32-year-old woman. Horizontal markings were drawn on the patient with the aid of a laser level. The superimposed blue line indicates the ultimate HLT excision in Figure 3. The green marking represents a likely resection using a standard approach. B, The
patient is now supine. Note that the preoperative horizontal lines have curved superiorly over the lateral abdomen. The superimposed blue represents
the final resection, and the green represents what would likely be a standard resection. C, The patient is seen after resection. Note that the lateral horizontal line drifts up even more. Even a horizontal incision would appear to angle far superiorly in the lateral abdomen. Although the superior wound
margins curve superiorly, if you look at the preoperative lines it is obvious that the resection is closer to horizontal. The superimposed blue lines indicate where a dog ear had to be excised, and the green lines represent the likely standard resection pattern. In executing this HLT, a purist may have
resected less in the central abdomen, requiring closure of the umbilical site with a vertical scar.
from the incision’s lateral arms. Tension on the mons is an
effect to be avoided. Dr. Lockwood conceived of HLT as a
lower body lifting procedure in which the operating surgeon considers not just the abdomen, but also the flanks,
inguinal region, and thighs. This approach translates into
high lateral tension and a longer incision. If this final resection were to be drawn preoperatively, HLT would look
similar to what has been alternately termed a “wide,”
“extended,” or “270-degree” abdominoplasty, but always
with high, angled lateral incisions (Figure 3, C ).
Surgeons frequently think of final scars as assuming
the position of the initial incision; however, the final
resection incision is as important as the initial incision.
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With greater central tension, the mid portion of the
final scar rises, resulting in a relatively horizontal scar
orientation, even if the lateral initial incision did curve
superiorly. With higher lateral tension, the scar
remains low in the center and rises laterally. The final
position of the scar is determined by the opposing
forces above and below the incision, and the HLT
resection takes into account the laxity on both sides of
the initial incision.
Advantages
HLT avoids raising and distorting the mons pubis.
It corrects epigastric flaccidity better than traditional
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A
B
Figure 2. A, Preoperative view of a 36-year-old woman marked for a Lockwood lower body lift type #2 (combination of an HLT abdominoplasty and
a lateral thigh/buttock lift).The green dotted line represents this patient’s favorite bikini line and will be used as an incision guide. The red marking represents the planned final scar location. The black marking is the inferior incision. The blue vertical lines serve as alignment guides. The horizontal blue
line indicates the expected final resection. The superimposed blue shows how the resection might have looked if an HLT were performed. B, This postoperative view after 10 days is very similar to the way an HLT patient would look at this stage from this angle, except that with an HLT there would
be less improvement in the lateral-most abdomen and thigh. The central incision is higher and the lateral incision is lower than indicated by the green
line marking her favorite bikini (Figure 2, A). (However, this more horizontal scar is typical of the scar position that is presently most frequently preferred.) To have avoided this, closing with the same tension, the inferior incision could have been made more inferior centrally, and the flap could have
been resected less centrally with less central flap resection, and the opposite laterally. The final scar location is the result of these 2 opposing forces.
abdominoplasty by pulling from 2 inferolateral directions. If you imagine standing at the foot of a bed
looking at folds in the sheets, it is easy to visualize
smoothing those folds more successfully by pulling
obliquely to the corners, rather than pulling only
towards yourself. If you examine a patient with a lax
abdomen, it is easy to demonstrate that the epigastrium will be better improved by pulling obliquely
towards each groin than by pulling straight down the
midline towards the pubis. Dr. Lockwood must be
credited with recognizing that abdominoplasty can do
far more than improve the hypogastrium and epigastrium; it is also an opportunity to improve the thigh,
flanks, and even the buttocks.
Demystifying High-Lateral-Tension
Abdominoplasty
Disadvantages
Patients must be prepared for a longer scar. Some
patients may notice boxiness or laxity beyond the end
of the scar because of the abrupt transition from highly tightened to untightened skin. Because of the tensions, conscientious SFS closure is recommended.
Achieving the proper oblique angle of pull requires
higher lateral scars that would be obvious in a
“French cut” bikini and could be visible with some
“low-riding” garments.
Avoiding mons distortion means that in more cases, the umbilical site is not excised and needs to be
closed with a vertical scar. In fact, since epigastric
laxity is often fully corrected by HLT, this procedure
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A
C
Figure 3. A, Preoperative view demonstrating many of the complaints characteristic of the patient seeking abdominoplasty: aged mons, inguinal laxity, cellulite of thighs, hypogastric laxity, epigastric flaccidity, and redundancy of flank and abdominal skin. B, The patient is illustrated with a likely
closure if using classic abdominoplasty principles. The greatest tension is central, raising the mons, shortening the distance to the umbilicus, and exposing the labia minora. There is little improvement to the inguinal and thigh regions. C, The patient is now illustrated with a typical closure if using HLT
principles. The greatest tension is along the longer oblique lateral limbs, achieving better improvement in the epigastrium, and transferring forces to the
inguinal and thigh regions, which are much improved. The mons is rejuvenated, but not excessively raised or distorted.
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can lead to patients in whom the umbilicus does not
need to be relocated, but may be floated several centimeters or even left in place.
I prefer excision of the umbilical site. Even if there
is high mons tension, so long as tension lateral to it is
even greater, distortion is not significant and, in my
opinion, is preferable to the vertical scar, which is far
too often a source of consternation for patients. I have
ceased floating the umbilicus because even a minimally lowered umbilicus often looks too low and by
impairing its blood supply puts the umbilicus at risk
in the event of a possible transposition at a later time.
Lockwood also suggested creating a vertical slit for
the new umbilical site, since the oblique tensions tend
to pull it open. Whether or not you do this, it is
important to realize that HLT does tend to widen the
umbilicus, and you should plan for this (as shown in
Figure 3, A).
Conclusion
As different as the HLT and classic approaches
seem, they are at opposite ends of the same spectrum.
A little more here, a little less there, and one operation gradually morphs into the other. Most surgeons
probably incorporate some principles of each into
their technique without awareness that they are doing
so. The most important lesson of HLT is that an anterior incision can correct much more than just the central abdomen. One must look for the laxity in each
patient and design the custom resection that will create the maximum benefit. ■
9. Matarasso A. Liposuction as an adjunct to a full abdominoplasty
revisited. Plast Reconstr Surg 2000;106:1197-1202.
10. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg 1991;87:1009-1018.
11. Saldanha OR, Pinto EBdS, Matos WN, Lucon RL, Magalhães F, Bello
ÉML. Lipoabdominoplasty without undermining. Aesthetic Surg J
2001;21:518.
12. Grolleau JL, Lavigne B, Chavoin JP, Costagliola M. A predetermined
design for easier aesthetic abdominoplasty. Plast Reconstr Surg
1998;101:215-221.
13. Coskunfirat K, Velidedeoglu H. Is “predetermined design” different
from “high lateral tension abdominoplasty?” Plast Reconstr Surg
1999;103:330-331.
14. Lockwood TE. Lower-body lift. Aesthetic Surg J 2001;21:355-370.
15. Grazer FM. Abdominoplasty. In: McCarthy JG, editor. Plastic Surgery.
Philadelphia: W.B. Saunders: 1990. p. 3929-3963.
16. Fix RJ. Standard abdominoplasty. In: Jurkiewicz MJ, Culbertson JH,
editors. Operative Techniques In Plastic and Reconstructive Surgery:
Abdominoplasty. Vol. 3. Philadelphia: W.B. Saunders 1996. p. 15-22.
17. LaTrenta GS. Abdominoplasty. In: Rees TD, LaTrenta GS, editors.
Aesthetic Plastic Surgery. 2nd ed, Vol 2. W.B. Saunders 1994. p.
1126-1178.
Reprint requests: Steven Teitelbaum, MD, 1301 20th Street, Suite 350,
Santa Monica, CA 90404.
Copyright © 2006 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$32.00
doi:10.1016/j.asj.2006.03.006
References
1. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg 1993;92:1112-1122.
2. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg 1995;96:603-615.
3. Lockwood T. Is the standard abdominoplasty obsolete? In: Jurkiewicz
MJ, Culbertson JH, editors. Operative Techniques in Plastic and
Reconstructive Surgery: Abdominoplasty. Vol 3. Philadelphia: W.B.
Saunders, 1996. p. 77-81.
4. Lockwood T. The role of excisional lifting in body contour surgery.
Clin Plast Surg 1996;23:695-712.
5. Lockwood TE. Maximizing aesthetics in lateral-tension abdominoplasty and body lifts. Clin Plast Surg 2004;31:523-537.
6. Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty concept. Plast Reconstr Surg 1999;103:1020-1031.
7. Matarasso A. Abdominolipoplasty: a system of classification and
treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg 1991;15:111-121.
8. Matarasso A. Liposuction as an adjunct to a full abdominoplasty.
Plast Reconstr Surg 1995;95:829-836.
Demystifying High-Lateral-Tension
Abdominoplasty
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