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Background: The number of patients after gastricbypass being referred to plastic surgery units for sec-ondary plastic surgery procedures is increasing. Thecharacteristic abdominal deformity includes a drap-ing apron of panniculus, occasionally associated withprevious transverse surgical scars in the upperabdomen. Often a limited abdominoplasty of the lowtransverse type with limited undermining only up tothe level of the umbilicus is performed in order not tocompromise blood supply in the zone between theold transverse and the new transverse scar.

Method: We propose a new, modified and safe sur-gical technique to perform a complete abdominoplas-ty with wide undermining up to the xiphoid process inpatients with preexisting transverse subcostal scarsafter gastric bypass surgery, by selectively dissectingand preserving one to three periumbilical abdominalwall perforator vessels to secure flap blood supply.Vessel tunnelling through the rectus sheath and mus-cle and ligation of the cephalad branch of the perfo-rator provide sufficient flap mobility without perfora-tor tension or traction. Flap undermining is performedaround these perforator vessels. To match dissectedflap perforators with blood-flow, we performed post-operative color-flow duplex scanning.

Results: We treated two patients according to thisnew technique. In both cases the postoperativecourse was uneventful and a good aesthetic resultwas achieved.

Conclusion: We conclude from our experience thatwith this perforator-sparing abdominoplasty tech-nique, safe and complete abdominoplasty can be per-formed with no additional risk of complications andthat a good cosmetic result can be achieved inpatients after open gastric bypass surgery.

Key words: Perforator, abdominoplasty, scar, obesity

Introduction

The number of patients being referred for abdomino-plasty following gastric bypass (GBP) surgery1 isconstantly increasing. In these patients, we occasion-ally encounter a long transverse supraumbilical orsubcostal scar compromising blood supply from thesuperior epigastric arteries. The left oblique or leftand right oblique incisions are the standard incisionsof some surgeons for bariatric surgery, because of avery low rate of incisional hernia compared to verti-cal midline incisons.2-4 Scarring after oblique inci-sions on both sides is a real problem and a great lim-itation to performing full abdominoplasty later, due toa higher postoperative risk of complications.5 On theone hand, previous scarring and subsequent subder-mal fibrosis can compromise blood supply, leading topartial or complete tissue necrosis. On the other hand,patients following GBP need full abdominoplasty byextensive lifting also above the umbilicus. Limitingthe mobilization of the abdominal flap leads topreservation of vascular zones,6 but not to an estheti-cally acceptable result. Traditionally, to perform fullabdominoplasty with lifting effects both above undbelow the navel, a two-stage procedure was neces-sary: the first step was a limited abdominoplasty ofthe lower abdomen, and the second step consisted ofa reversed abdominoplasty with scar positioning inthe submammary folds to complete satisfactory bodycontouring. Beside the two-stage procedure itself, themain disadvantage is an insensible abdominal skinbetween the two transverse scars.

Perforator-Sparing Abdominoplasty Technique inthe Presence of Bilateral Subcostal Scars afterGastric Bypass

Ulrich M. Rieger, MD1; Markus Aschwanden, MD2; Dominik Schmid, MD1;Daniel F. Kalbermatten, MD1; Gerhard Pierer, MD1; Martin Haug, MD1

1Department of Plastic, Reconstructive and Aesthetic Surgery, and 2Department of InternalMedicine, Division of Angiology, University Hospital of Basel, Basel, Switzerland

Correspondence to: Ulrich M. Rieger, MD, Department of Plastic,Reconstructive and Aesthetic Surgery, University Hospital ofBasel, Spitalstrasse 21, 4031 Basel, Switzerland. Fax: ++41 61265 7301; e-mail: riegeru@uhbs.ch

We describe a new technique that allows perform-ance of a full abdominoplasty in patients with trans-verse supraumbilical or subcostal scars after openGBP surgery as a single-stage procedure. This tech-nique appears not to have higher postoperative com-plication rates than the traditional aforementionedtwo-stage procedure.

Materials and Methods

Operative Technique

The abdominoplasty procedure was performed by a sin-gle faculty member (M.H.), under general anesthesiawith muscle relaxation. Basically, the operative proce-dure was done according to Pitanguy.7 However, in orderto prevent hypoperfusion of the flap, we selectively dis-sected and perserved 1 to 3 abdominal wall perforatorvessels. Vessel tunnelling through the rectus sheaths andrectus muscles and ligation of the cranial perforatorbranches provided sufficient flap mobility without perfo-rator tension or traction. Flap undermining was per-formed around those perforator vessels (Figure 1).

The abdominal flap was then elevated to thexiphoid process centrally and the costal margins lat-erally, and excess skin and subcutaneous tissue wereexcised. Hereby the lifting effect could be extendedall over the abdominal flap up to the xiphoid. Theumbilicus was circumcised and reinserted in a trian-gular incision on the abdominal flap. In presence of

true diastasis of the rectus muscle, midline sutureplication of the fascia was performed, beginningbelow the xiphoid process and continuing down tothe pubis. Layered closure of the abdominal woundwas performed over two suction drains. Cephazoline1 gram was administered intravenously 1 hour pre-operatively for antibiotic prophylaxis.

In order to measure postoperative blood-flowthrough the dissected perforator vessels, we per-formed color-flow duplex imaging 10 weeks post-operatively. Duplex imaging was done as previous-ly described,8,9 the patient was examined supine,and a Siemens Sonoline VERSA PRO apparatus(Siemens, Munich, Germany) was used.

Case Reports

Case 1A 37-year-old female underwent GBP surgery formorbid obesity (height 175 cm, weight 106 kg, bodymass index, BMI, 42 kg/m2). A bilateral subcostalincision was used for this surgery. Seven years later,she presented for abdominoplasty and excess skinresection (weight loss 23 kg, weight 83 kg, BMI 34kg/m2) (Figure 2).

Perforator-sparing abdominoplasty was performed asdescribed above with two major periumbilical perfora-tors (latero-cephalad to the umbilicus) dissected, withtunneling through the rectus fascia and muscles and lig-ation of the cephalad branch of each perforator. The post-operative course was uneventful with good wound heal-ing (Figure 3). Postoperative duplex imaging showedblood-flow in both dissected perforators (Figure 4).

Case 2A 32-year-old female underwent GBP surgery formorbid obesity (height 160 cm, weight 130 kg, BMI50.8 kg/m2). A bilateral subcostal incision was usedfor this surgery. Two years later, she presented forabdominoplasty and excess skin resection (weightloss 58 kg, weight 72 kg, BMI 28.1 kg/m2).

Perforator-sparing abdominoplasty was performedas described above with three major periumbilical per-forators (two lateral to the umbilicus, one cranio-later-al to the umbilicus) dissected, with tunneling throughthe rectus fascia and muscles and ligation of the cepha-lad branch of each perforator (Figure 5). The postoper-ative course was uneventful with good wound healing.

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Figure 1. Outline of perforator-sparing abdominoplasty.Displayed are the area of undermining, the rectus abdo-minis muscles and one exemplary dissected perforatorwith ligated ascending branch.

ascending branch of perforator(ligated)

dissected perforator

area of undermining

rectus abdominis muscle

Results

Both cases had uneventful postoperative courses andwere successful in terms of the aesthetic result.Blood supply through the dissected perforator ves-sels was proven by color-flow duplex imaging(blood-flow is indicated by red and yellow color).

Discussion

Extended flap undermining is the surgical standardin abdominoplasty. Nine out of ten plastic surgeonsreported that they performed complete underminingup to the costal margin.10 Reports describing limit-ed dissection of the abdominal flap in a triangularshape from the xiphoid to anterior superior iliacspine,11 with discontinuous undermining by dissect-

ing the supraumbilical flap by liposuction,12 havebeen described to improve flap perfusion. In thesereports, adequate flap mobility was achieved withgood flap perfusion by arterial perforators.12-14

However, in patients being referred for abdomino-plasty after GBP, a long transverse supraumbilicalor subcostal scar is occasionally encountered15 thatcompromises blood supply from the superior epi-gastric arteries. In a study by De Castro et al5 on fullabdominoplasties on previously scarred abdomens,the authors claimed that the supraumbilical scar is asignificant problem, and they considered it to be aconsiderable limitation for abdominoplasty due to a

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A

B

Figure 2. Preoperative views (the bilateral subcostal scaris indicated with a dotted line): A. frontal; B. lateral.

A

B

Figure 3. Postoperative views 6 weeks after abdomino-plasty: A. front view: two major black dots indicate the twodissected perforator vessels that were detected by colorduplex imaging; B. anterolateral view.

higher rate of postoperative complications. One riskfactor that is responsible for jeopardizing the bloodsupply of the abdominal flap is the existence ofthese previous scars and the subsequent subdermalfibrosis. Propositions have been made to limit theextent of mobilization of the abdominal flap to pre-serve the vascular zones.6 A fluorescence perfusog-raphy study from Germany on effects of abdomino-plasty on abdominal wall perfusion showed signifi-cant impairment of vascular supply of the so-calledzone 1 in all patients.16 Saulis et al17 have reported asignificant reduction of postoperative wound com-plications in midline ventral hernia repairs bypreservation of peri-umbilical rectus abdominis per-forator vessels. Selective dissection and preserva-tion of one perforator vessel from the inferior epi-gastric artery has been described in a patient with norisk factors undergoing aesthetic abdominoplasty.The effect was visualized by indocyanine green per-fusography.16 Through this technique the blood sup-ply of the abdominal flap may be changed from arandom pattern into an axial pattern blood supply.

This assumption gains significant importancewhen the random pattern blood supply is compro-mised by oblique subcostal incisions. Oscar et al18

have described a rat model that showed that most ofthe abdominal rat skin could survive through thesupply of a single musculo-cutaneous perforatorvessel. This is consistent with the clinical experi-ence that we have had with the deep inferior epigas-tric perforator flap (DIEP). Schoeller et al19 havereported a case of successful raising of a DIEP flapfor breast reconstruction in a patient with subcostal

scars and successful wound closure by dissectingone single perforator to provide perfusion for thedistal part of the cranial abdominal flap below thescar for wound closure. This finding of safe abdom-inal flap preparation is consistent with our experi-ence with the two described cases of perforator-sparing abdominoplasty in patients with bilateralsubcostal scars after open GBP.

As previously described,20 patients requiring sur-gical skin excision after massive weight loss forfunctional and/ or aesthetic reasons are challenging,and require individualized approaches. We believe

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Figure 4. Blood-flow through dissected perforator vesselvisualized by color-flow duplex imaging 10 weeks postop-eratively.

Figure 5. Intraoperative Views: A. Two dissected para-umbilical perforator vessels (arrows) and umbilicus(marked *); B. Perforator (arrow) cranio-lateral to umbilicus.

A

B

that preoperative marking of perforators in the prox-imity of the umbilicus by color duplex imaging canhelp find the necessary perforator vessels,7 whichmay be of great use to a microsurgically less-expe-rienced surgeon. Our approach shows that the dis-tinct use of sonographic equipment enhances notonly microsurgical flap surgery, but also may be ofgreat use in abdominoplasty. We recommend a cus-tomized approach using duplex imaging for any“non-standard” abdominoplasty to enhance safety.

Although massive weight loss improves healthstatus in general, the formerly obese patients stilloften carry significant residual co-morbidities, suchas hypertension, diabetes or hypercholesterolemia.19

Through an adequate surgical technique, excellentresults can be achieved even in the presence of theseco-morbidities using the described perforator-spar-ing technique. In none of our cases was flap survivalor wound healing a problem.

In conclusion, our concept of improving bloodsupply to the abdominal flap by selective dissectionof perforator vessels in patients with bilateral sub-costal scars, which enables us to perform a fullabominoplasty with complete flap undermining, hasnot been described before. By color-flow dupleximaging, we show that a major blood supply comesfrom the dissected perforators.

We suggest that our perforator-sparing abdomino-plasty technique should be considered as a treatmentoption in patients after open GBP with oblique sub-costal incisions. Furthermore, we recommend pre-operative color flow duplex mapping of the abdom-inal wall for microsurgically less-experienced sur-geons, for easier detection of perforator vessels for“non-standard” abdominoplasties.

We thank Stefan De Maddalena for excellent photo documentation.

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16. Mayr M, Holm C, Hofter E et al. Effects of aestheticabdominoplasty on abdominal wall perfusion: a quantita-tive evaluation. Plast Reconstr Surg 2004; 114: 1586-94.

17. Saulis AS, Dumanian GA. Periumbilical rectus abdo-minis perforator preservation significantly reducessuperficial wound complications in “separation ofparts” hernia repairs. Plast Reconstr Surg 2002; 109:2275-80 ; discussion 2281-2.

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(Received July 10, 2006; accepted September 2, 2006)

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