ABDOMINOPLASTY
History

1899-Kelly was one of the first surgeons to attempt to correct excess abdominal skin and fat.

1924-Thorek was the first to devise a procedure that preserved the umbilicus.

1972-Regnault published the W technique

1973-Graze described bikini line technique

1978-Psillakis suggested suture plication of the external oblique musculature after raising it in a
beltlike fashion to dramatically reduce the diameter of the waist.

1988-Matarasso added combined liposuction
Patient Selection
Indications

With age, three problems become apparent
1) excess skin with increasing laxity and striae
2) excess fat deposition resistant to dietary changes and exercise
3) weakness of musculoaponeurotic system

These changes need to be elucidated and addressed.

The most significant area of the defect is around and below the umbilicus, where excess skin over a
diastasis of the rectus muscles is most apparent.
Striae are reported to be the result of rupture and separation of dermal collagen with resultant
thinning. Striae are not treatable except by excision.
Ideal patient is within normal limits for his or her weight and height (ie, body mass index), has no
plans for future pregnancies, has a moderate amount of excess of skin and fat, and has a mild diastasis
of the rectus muscles
Following massive weight loss (loss >50kg or loss equal to patients ideal weight)
(1) Should not be considered within 1year of achieving weight goal
(2) Consider in a psychological stable patient with stable constant weight>1yr, and willing to
accept multiple operations with significant scarring
(3) Aim for minimal undermining



Contraindications
1. right, left, or bilateral upper quadrant scars (relative)
2. severe comorbid conditions (eg, heart disease, diabetes, morbid obesity, previous PE/DVT)
3. cigarette smoking
a. PRS 2003 - 47.9% smokers showed wound healing problems before hospital discharge vs
14.8% with nonsmokers
4. future plans for pregnancy (relative)
5. a history of thromboembolic disease (relative)
6. unrealistic patient expectations.
Goals
1) place the incisions within the bikini line
2) reduce or eliminate striae
3) flatten and tighten the abdomen
4) decrease the size of the waistline
5) decrease the thickness of the subcutaneous fat throughout the abdomen, flanks, and iliac areas
6) rejuvenate the pubis from a triangular senescent to an oval youthful form
7) lift the lax anterolateral thigh skin near the groin crease and iliac areas
8) create a well-defined xiphoumbilical depression
9) give an illusion of an athletic abdomen
10) change body posture
11) correct any hernia
12) relieve back pain if this is related to muscle laxity of the abdomen
Surgery involves:
(1) dermolipectomy for removal of excess fat and skin
(2) plication of the anterior rectus sheath for muscle diastasis
(3) high lateral suspension
(4) transposition of the umbilicus to a new location in the abdominal wall skin
(5) skin closure with hips flexed
History

Dietary habits

Weight changes

Exercise pattern

Eating disorders eg anorexia or bulimia

Previous and planned pregnancies and their effects

Severe heart disease, diabetes, and a history of thromboembolic disease
Examination

examine ant, pos, both sides

Height and weight - BMI (kg/m2)

Circumferences

Skin quality , Wrinkles, laxity, scars

Fat disposition

Pinch test- thickness>3cm to benefit from liposuction

Assess contribution to deformity by skin laxity and fat

Abdominal wall for diastasis and hernias
Lockwood - Sagging of skin in horizontal and vertical directions
Below umbilicus—vertical and horizontal laxity
Above umbilicus—mainly horizontal laxity
Least amount of vertical laxity occurs in anterior midline—as much lateral resection as possible
Preop

Stable weight

Stop smoking >4 weeks pre and 4 weeks post

Screen for hereditary thrombophilias such as protein C deficiency, protein S deficiency factor V
Leiden mutation, or prothrombin 20210 A mutation where indicated
IntraOp

Consider systemic steroids for prophylaxis against pulmonary fat embolism syndrome

Pneumatic calf compression pump
Classification
Techniques based on

Skin incision

Degree of undermining

Management of musculoaponeurotic layer

Umbilicoplasty
Bozola and Psillakis Classification (PRS 1988)
Type
Skin
Fat
Musculoaponeurotic system
Treatment
I
No excess
Fat
Normal
Liposuction
deposit
II
Mild excess
Variable
Normal
Elliptical skin resection
III
Mild excess
Variable
Infraumbilical laxity
Miniabdominoplasty
IV
Mild excess
Variable
Overall laxity
Modified AP
V
Large excess
Variable
Overall laxity
Modified AP
Types of abdominoplasty (Matarasso 1995)
Type
Skin
Fat
Musculofascial system
Treatment
I
Minimal laxity
Variable
Minimal flaccidity
Liposuction
Mild laxity
Increased
Minimal flaccidity
Extended lipo
Mild laxity
Variable
Mild lower abdominal flaccidity
Miniabdominoplasty
Mild laxity with Variable
Mild lower abdominal flaccidity
Open miniAP
Modified AP
Ia
II
IIa
vertical scar
III
IIIa
IV
Moderate laxity
Variable
Moderate lower abdo flaccidity
Moderate laxity
Variable
Moderate
Severe laxity
Variable
lower
and
upper Endoscopic
abdominal flaccidity
modified AP
Significant upper/lower flaccidity
Standard
assisted
abdominoplasty lipo
Miniabdominoplasty (Wilkinson/Swartz 1986)

For infraumbilical skin and fat excess

based on the theory that musculofascial support below the semicircular line is weaker than above the
line because of absent posterior rectus fascia.

Increasing trend to use this in conjunction with liposuction for Matarasso Type III abdomens. With
the infraumbilical dissection exclusively, a complete and exhaustive liposuction of the whole
abdomen and the trunk, in general, can be performed without incurring risks of necrosis of the
infraumbilical cutaneous flap.

Method: Short elliptical skin excision, plication of infraumbilical fascia, liposuction. Umbilicus left in
situ. If midline scar exists, then this may be used to transpose the umbilicus .
Modified abdominoplasty

Limited undermining to umbilicus. For those too slight for full abdominoplasty and too much for
liposuction

Alternative incision (Grolleau, PRS 1998):
The arc of a circle is
drawn with A as its
center with a radius
of I - 0.5 cm,
followed by the arc
of a circle with C as
its center with a
radius of L - 1 cm.
These measurements
are made with the
skin taut. Points B
are placed at the
intersection of these
two arcs.
Concomitant Liposuction

Adding liposuction downgrades the operation required
Matarasso 1995: The anatomic regions (suction areas) for suction lipectomy in abdominoplasty: SA3 (cautious), SA2 (limited),
SA1 (safe), and SA4 (unrestricted).

Not recommended if extensive dissection done i.e belt lipectomy, inverted T incisions

Consider staged procedures if extensive liposuction required

If in doubt, deep liposuction (below Scarpa’s) is safer than superficial
Circumferential Suction Lipectomy of the Trunk with Anterior Rectus Fascia Plication through a
Periumbilical Incision (PRS 2004)

Suitable for minimal skin laxity, moderate fatty tissue distribution, musculofascial diastases, and no
concern for abdominal stretch marks
Marriage abdominoplasty (Shestak PRS 1999)

minoabdominoplasty with aggressive liposculpture of the deep and superficial fat layer in the
abdomen and inframammary, waist, and flank areas.

Undermines to below umbilicus, endoscope supraumbilical plication if required.
A. Variations of classical abdominoplasty dermolipectomy

W abdominoplasty – Regnault 1975

Bicycle handlebar - Baroudi 1995

Grazer 1990

French-line abdominoplasty – Gerow 1996

U-M dermolipectomy – Ramirez 2000
Lockwood abdominoplasty – lower body lift (1995)
o SFS is a three-dimensional fibrous meshwork of the subcutaneous tissue that shapes and
supports the fat and holds the skin on the body. It is the main support structure of the
skin/fat unit
o Lockwood identified problems with conventional abdominoplasty:
1. initial overtightening of the central abdomen
o felt that standard abdominoplasty techniques based on faulty principles. The greatest
truncal laxity occurs laterally, not centrally as assumed by standard abdominoplasty
designs
o strong midline adherence of the epigastrium to the linea alba limits true vertical
descent above the umbilicus
2. residual laxity of the inguinal and lateral abdominal areas
3. late suprapubic scar depression with soft tissue bulges above
4. poor waist definition – addressed AP dimension but did not reduce overall circumference
5. elevation of pubic hair.
6. asymmetric, irregular, and hypertrophic scars
o Lockwood’s ideal aesthetics
1. Tight lateral trunk and inguinal tissue with deep waist concavity
2. Central tissues not pulled tightly, with convexity of the hypogastrium and concavity of
the epigastrium
3. Midline epigastric valley between rectus muscles
4. Vertical umbilicus
5. Vertical valley lateral to rectus muscles
6. S-shaped outlines of the anterior and lateral silhouette
o Lockwood principles:
o tightening the lateral abdomen, waist, and inguinal regions more than the central abdomen,
followed by circumferential “liposculpturing of the posterolateral trunk” performed in a
single procedure.
o vertical truncal laxity is greatest along the lateral body contour and is smallest in the
anterior and posterior midline as a result of superficial fascial system adherence
o Lockwood’s procedure
1. Limited direct undermining confined to rectus diastasis and medial edge of rectus
o Inferior flap - Only excised areas are undermined.
o Superior flap - direct undermining superior to the umbilicus is limited to the medial
rectus border
2. Midline plication
o diastasis from the xiphoid to the pubis is repaired in two layers: interrupted 0 braided
nylon is followed by a running, interlocking 0 Prolene suture.
o After vertical midline plication has treated horizontal fascial laxity, there may still be
residual vertical laxity of the muscle fascia in the inferior quadrants.
o Lockwood adds a horizontal plication from iliac crest to iliac crest for optimal fascial
toning.
3. Wide discontinuous undermining
o Midline bunching of the abdominal skin and fat occurs after muscle plication.
o This bunching may be partially released by discontinuous undermining of the
abdominal flap with vertical spreading scissor dissection
o Liposuction usually feathers out the bunches
4. Lateral skin resection with highest-tension wound closure along lateral limbs
o Less tension in the central area reduces the risk of skin necrosis and superior migration
of the pubic hair
5. 2 layer closure of Superficial fascial system suspension
o SFS repair reduces tensions on the skin repair, resulting in improved scars with less
late scar depression
o Important to use permanent sutures – SFS repair collapse noted when PDS sutures
used.
o SFS closed in 2 layers – deep (o braided nylon) and superficial (2/0 braided nylon)
o Skin closed with 2 layers (3/0 PDS) and 3/0 Prolene
6. umbilicoplasty
o due to the significant horizontal tension, a vertical 3cm umbilicoplasty incision is
made. A V-type umbilicoplasty incision will result in a wide, unaesthetic umbilicus
7. significant truncal liposuction when needed (mainly epigastric)
Lockwood Extended Abdominoplasty version 1
Extended abdominoplasty

Fleur-de-lis excision (Dellon 1985) or anchor line abdominoplasty
o Lower medial obesity with significant apron
o Improves contour and redefines waist
o Ideal if already has midline/paramedian scar
o Depends on Huger zone III. Avoid concomitant liposuction

Reverse abdominoplasty (Grazer) – submammary excision for upper abdominal fullness

Belt lipectomy/ circumferential torsoplasty (Gonzalez-Ulloa 1960)
o effective in improving abdominal contour, abdominal wall laxity, mons pubis ptosis, back
rolls, waist contour, and buttock contour.
o The anterior and lateral resections are stressed more than the posterior resection.
o ideal for the post-weight reduction group, the 10-20kg overweight group, and the normalweight group.
o High risk of seromas (38%) and PE(9%) …PRS 2003
o Not recommended for obese patients
Complications

Increased risk of complications :
o when abdominoplasty combined with gynaecological procedures. Don’t combine if risk of
PID or bowel surgery planned
o Smokers – wound related complications
o Morbidly obese (40-80%) – wound related

Overall complication rate =32%

Revision rate = 30-40%
Major (1.4%)
1) Death – 1:2000 (up to 50% due to PE)
2) Pulmonary embolus (1%)
3) DVT (1%)
a. History of DVT, family history of DVT
b. Age>40, female
c. Surgery>2hrs, recent surgery, GA>30minutes
d. Obesity (risk doubles), smoker
4) Fat embolism syndrome
5) Bowel perforation – unsuspected hernias
6) Atelactasis/Respiratory compromise
a. Tight muscle plication
b. Binding garments
c. Flexed posture
Minor
1) Bleeding 14%
2) Skin Necrosis 1-8% – increased risk :
a.
Inverted T junction(35%)
b. Extensive undermining – principle: undermine in an inverted-V fashion, preserving the
intercostal blood supply and elevating the flap only to the degree necessary to achieve
wound closure without tension and repair of the diastasis.
c. Smokers – 48% wound healing problems vs 15% in non smokers
d. Obesity
e. Liposuction
f. Supraumbilical scar 23%
g. Medial thigh lifts procedures most associated with delayed wound healing (35%)
3) Umbilical necrosis
4) Fat necrosis – more common if there are supraumbilical scars
5) Seroma 3-9% – increased risk with extensive undermining, and concomitant liposuction
6) Infection
7) Decreased sensation – especially centrally below the umbilicus (PRS 2004)
8) Damage to lateral cutaneous nerve of thigh (L2,3) – 10-30%, also ilioinguinal, iliohypogastric and
genitofemoral
a. Triad of burning pain, impaired sensation and relieve with block in distribution of the
nerve
b. Treatment – neurectomy with proximal resection and placement of stump into
retroperitoneum (Dellon).
9) Suture reaction, palpable deep sutures (especially if Nylon used)
10) Hypertrophic, hyperpigmented or stretched scar
11) Scar aymmetry
12) Dog ears
13) Residual adiposity
14) Surface irregularies
15) Relative increase in lateral girth due to decrease in AP girth
B. Umbilicoplasty
Options
1) Umbilical float (amputating the stalk) – used in miniabdominoplasty (usual move 2cm) and
indicated where there is excess upper abdominal skin
2) Umbilical transposition
a. Various skin designs – most to avoid circumferial scar causing stenosis and minimising
scar visibility
b. Some methods described
i. Scarless transposition – defatting overlying skin, and deepithelialise stalk
ii. Suture to rectus fascia
iii. triangle flap (Ramirez 2000)
iv. Anchoring stalk around rectus sheath
v. Anchoring surrounding skin dermis down to scarpa’s fascia to create downslope
3) Neoumbilicoplasty
4) Umbilical sacrifice – historical (pre 1950s - not recommended)
Complications
1. stenosis – treat with modified double opposing Z plasty
2. malposition
3. necrosis
4. scar
5. Unaesthetic appearance
C. Musculofascial Repair
1. None
a. Some do not repair if there is significant intraabdominal volume/fat as believes recurrence
is high
2. Endoscopic repair
a. Indication - protuberant abdomen caused by rectus muscle diastasis with minimal actual or
potential skin laxity.. Most women not suitable as usually have lax skin.
b. May also be used in limited abdominoplasty for supraumbilical plication
3. Vertical rectus plication – standard imbrication method
NAHAS PRS 2001: Types of abdominal deformity and their correction.
Type A, rectus diastasis secondary to pregnancy; correction is by plication of the anterior rectus sheath.
Type B, rectus diastasis with laxity of the musculoaponeurotic layer; correction by plication of the anterior rectus sheath
and external oblique aponeurosis.
Type C, congenital lateral insertion of the rectus muscles at the costal margins and probable hernias. Correction by
undermining the posterior rectus sheath, invagination of the linea alba, and anchoring the anterior rectus sheath to the
midline.
Type D, rectus diastasis and poor waistline definition. Correction by anterior rectus sheath plication and medial
advancement of the external oblique muscles.
4. Transverse rectus plication (Hanh Nguyen PRS 2004)
a. Aims to preserve the width of the rectus sheath for a more pleasing contour
Transverse rectus plication with bilateral crescent-shaped plications of the external oblique fascia. (Left) A
minimal vertical plication of the rectus sheath is performed to correct diastasis, if present (midline vertical shaded
area). Transverse plications of the rectus sheath are performed as drawn (midline horizontal shaded areas); a
third supraumbilical plication may be performed if a patient has a particularly long abdomen. Bilateral crescentshaped plications of the external oblique fascia are performed next (crescent-shaped shaded areas). The dotted
lines designate the linea alba and semilunaris; the lower drawings show the rectus sheath in cross-section.
5. H pattern – Abramo 1999
a. Midline plication with subcostal and suprapubic transverse fascial plications
6. T pattern – Marques 1990
a. Midline with subcostal plication
7. Psillakis 1984 - suturing the aponeurosis of the external oblique muscles to the rectus fascia under
tension to reduce waist diameter.
a. In severe cases, undermining the external oblique aponeurosis from the rectus and
resuturing it in the midline, together with possible resection of the 7th and 8th rib cartilage,
to further narrow the waist and decrease the diameter of the upper abdomen.
8. Myofascial release and repair (Ramirez 2000)
a. Borrowed from component separation
b. principle is that a gradual release and undermining of the components of the abdominal
wall diminishes the index of tension during abdominal wall closure
c. release is done about the junction between the medial third and the central third of the
width of the rectus sheath. Incisions meet at the xiphoid and suprapubic areas.

Netscher—long term effects of plication—some minor separation after 3/52; stable at 1 yr
Complications
1) Recurrence – highest risk with morbidly obese and those with high intraabdominal fat content
2) Postoperative pain although may relieve back pain in the long term
3) Intraabdominal compartment syndrome (>20mm Hg)
a. Largely a theoretical risk involving respiratory function, renal function, and the
cardiovascular system
b. Respiratory compromise is mainly short term (atelactasis)
c. CVS - decreased venous return from the inferior vena cava and portal vein compression.
This, in turn, reduces cardiac output and stroke volume; however, a compensatory increase
in heart rate maintains nearly normal blood pressure
d. Renal - results from a reduction in absolute and proportional renal arterial blood flow and
increased renal vascular resistance and reduced glomerular filtration. Not due to
compression of ureters.
4) aggravate gastroesophageal reflux
Male Abdominoplasty
Differences:
1. Thicker less elastic skin than women
2. Less skin excess than in women – if only has rectus diastasis, then do endoscopic repair
3. Pubic hair is less well defined than women so place incision higher
4. Different superficial fat distribution
5. More intraabdominal fat
6. SFS anatomy different
7. Silhouette not desirable
8. Higher complications than females
Contraindications
Abdominal wall scars above umbilicus—below umbilicus will be excised
If below inferior incision—modify inferior incision
Abnormal positions of appendix scars
Can use inferiorly based flap with a Kocher’s incision
(combined with BRM)
Midline upper abdominal scar is an effective delay—so OK
Increased complication rate with supraumbilical scars (fat necrosis under scar)
Future pregnancy. Will disrupt results but won’t affect pregnancy
Smoker—may alter degree of undermining (post-op chest physio)
DM
Hx of thromboembolism
Gross obesity
No possibility of TRAM post abdominoplasty (has been done)
Ancillary procedures performed at the same time (PRS Jan 2004)
1. Breast Augmentation
a. bilateral tunnels (usually not longer than 6 to 8 cm) are created lateral to the xiphoid toward the
central inframammary fold.
b. These two tunnels are kept separate to minimize the risk of developing a symmastia
c. Because the inframammary fold has been violated in creating the pocket from this approach, 20 polydioxanone sutures are used in an interrupted fashion to recreate the fold.
d. if uncontrolled bleeding develops in the dissected pocket, an endoscope will be required to
visualize the bleeding source through the tunnel, or exposure through an alternate incision on the
breast if this is unavailable
2. Rib cartilage harvest
a. If rhinoplasty performed at the same time
3. Autologous fillers
a. Harvest of fat grafts, fascial grafts and dermal-fat grafts