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TraditionalA b d o m in o p las ty

Alan Matarasso, MD*

The modern history of abdominoplasty can be

traced to the late 1960s and 1970s, and was

marked by acceptance of abdominoplasty as

a bona fide aesthetic procedure with excision ofthe pannus, tightening of the underlying muscula-

ture, numerous incision designs, recognition of

complications, and performing it in conjunction

with other cosmetic (eg, breast reduction, breast

augmentation, and so forth) and noncosmetic

procedures (eg, hysterectomy, cholecystectomy,

and so forth).

The introduction of liposuction in the 1980s

dramatically and permanently altered the

landscape of body contour surgery. Liposuction

as a sole contouring procedure or in combinationwith excisional procedures represented the

greatest advance in body contour surgery, even

to date. In many instances incisions were short-

ened and patients heretofore not considered

feasible as candidates were able to be treated.

Indeed the abdomen became a group of

contour procedures that were referred to as the

abdominolipoplasty system of classification and

treatment. This group included liposuction alone

(type I), mini abdominoplasty (type II), modified

abdominoplasty (type III) (type II and III are consid-

ered limited abdominoplasties), and a full standardabdominoplasty (type IV) with or without liposuc-

tion (Fig. 1).

Extensive abdominal liposuction in conjunction

with a full (type IV) abdominoplasty is known as lip-

oabdominoplasty, and is currently receiving re-

newed interest. Lipoabdominoplasty has also

been referred to by various other nomenclatures

such as suction-assisted abdominoplasty, ab-

dominolipoplasty or marriage abdominoplasty.

This article describes a standard abdominoplasty

without or with liposuction (lipoabdominoplasty).In the 1990s, with the increase in popularity of

laparoscopic and arthroscopic procedures,

attempts were made to perform abdominoplasty

endoscopically. These procedures met with tech-

nical difficulties, a lack of refinement in instrumen-

tation and, more significantly, the inability to

address remaining excess skin, which often

appears greater than anticipated after the rectus

muscle is plicated. If applicable these techniques

are most likely to be useful in males. It is this

excess skin that must be excised that is ultimatelythe rate-limiting factor in the surgeons ability to

shorten any abdominal incision. Unlike, for

example, the face, where incisions can success-

fully be shortened while still removing the amount

of skin necessary, in the abdomen as more skin

needs to be removed the incision must be made

longer.

The turn of the twenty-first century heralded the

increase in bariatric surgery and subsequently an

emerging field of bariatric plastic surgery. Abdom-

inal contour surgery is the cornerstone of the

numerous extensive excisional procedures under-gone by patients with massive weight loss. It is

interesting, then, that plastic surgery has gone

full circle in less than a generation, from small inci-

sional stab wounds for liposuction-dominated

procedures to extensive lengthy incisions now

deemed necessary for these large excisional

procedures. In terms of abdominal liposuction,

Department of Surgery (Plastic Surgery), Albert Einstein College of Medicine, 1009 Park Avenue, New York,NY 10028, USA* 1009 Park Avenue, New York, NY 10028.E-mail address:[email protected]

KEYWORDS

Lipoabdominoplasty Liposuction Abdominoplasty Body contour surgery Mini abdominoplasty Secondary abdominoplasty Massive weight loss

Clin Plastic Surg 37 (2010) 415437doi:10.1016/j.cps.2010.03.0060094-1298/10/$ see front matter 2010 Elsevier Inc. All rights reserved. p

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recent interest is now focusing on the benefits of

laser-assisted liposuction (and the various wave-

lengths), and its role in facilitating fat removal

and the unknown potential for skin tightening.

This article focuses on the most commonly

encountered abdominoplasty scenario of the post-

partum abdomen that manifests itself as loose,damaged, excess skin; widening (bony) pelvic

girth; rectus muscle diastasis and stretching; alter-

ation in the location of fatty deposits, umbilical

hernias, and altered appearance of the mons pubis

(with distortion, widening, and ptosis) (Fig. 2).

Emphasis is on technique. In addition 10 special

situations encountered in the abdominoplasty

population (eg, the scarred abdomen) are dis-

cussed. These often inevitable and irreversible

changes of pregnancy continue to plague the

physically fit, health-conscious baby-boomergeneration accustomed to obtaining optimal goals,

personally, professionally, and physically. Main-

taining their youthful physique, fashions, and

appeal, particularly in an environment that more

Fig. 1. The abdominolipoplasty system of classification and treatment. This system includes liposuction alone(type I), mini abdominoplasty (type II), modified abdominoplasty (type III) (types II and III are considered limited

abdominoplasties), and a full standard abdominoplasty (type IV) with or without liposuction. SAL, suction-assis-ted lipectomy. Pink arrows, liposuction; yellow, undermining; green, excision; cross-hatching, fascial plication.

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than ever idealizes slimness, youthfulness, and

vitality, along with the current trend of low-cut

clothing (creating the ubiquitous muffin top

appearance in pants) is a priority for these patients.

Indeed people have a tendency to perceive theirlevel of fitness or ideal weight (and the necessity

to diet or exercise) by the appearance of their

abdomen and flanks. In some it even acts as

a surrogate marker for the aging process.

MARKINGS

The patient is marked wearing preferred undergar-

ments to confine the incision to within the bound-

aries of her clothing, and the undergarments alsoserve as a useful guide to symmetry when planning

the incision. An ellipse (undermining wound

contraction, healing, and so forth can alter the final

location of the scar) of tissue to be excised is

Fig. 2. (AD) A 43-year-old gravida 5 para 5 woman complaining of a large diastasis of the rectus muscle and hy-pomastia. Pre- and postoperative lateral and frontal views following breast augmentation and abdominoplasty.

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fashioned by determining the ease in which the

lower abdominal skin (from umbilicus to hairline)

can be excised after grasping the pannus with

both hands in an attempt for the fingers to touch

the thumbs. While holding the pannus slightly

upward, the lower incision is designed to traverse

the natural lower skin crease, slightly below itsnormal position extending in length to just beyond

the lateral skin folds (noted in a sitting position) and

approximately 5 to 7 cm above the vulva cleft. The

upper incision is demarcated passing over the

umbilicus to encompass the old umbilical site

and only higher if there is extensive loose skin,

thereby forming an ellipse when joining the upper

and lower incisions. The elliptical excision is

drawn. Bisecting perpendicular lines are marked

through it (Fig. 3) to line up the skin edges for

subsequent closure. The incision for umbilical

circumscription and 4 quadrants on it are marked,

and the abdomen is infiltrated with approximately

1 liter of superwet anesthesia (1 L Ringer lactate,

1 mL 1:1000 epinephrine, 20 mL 1% lidocaine).

This action is desirable because it allows addi-

tional local anesthesia to safely be used in adja-

cent liposuction areas without concerns about

excess lidocaine or epinephrine; moreover, addi-

tional superwet fluid only interferes with

subsequent electrocoagulation. Liposuction is

then performed in the aesthetic units of the

abdomen as indicated (Fig. 4) in the suction areas

and on the entire upper flap, mons pubis, and

flanks. Patient risk is stratified as low to high ac-

cording to previously published guidelines. Candi-

dates for lipoabdominoplasty should be relativelylow risk, American Society of Anesthesiologists

class I, nonobese, nonsmokers, and without co-

morbid medical conditions. Furthermore, one

should keep in mind that liposuction, wound

tension, and undermining will influence flap

ischemia (Fig. 5). Alternatively, intraoperative de-

fatting of the flap below Scarpas fascia can also

be performed with scissors, which some investiga-

tors have claimed actually enhances flap perfu-

sion. After completing liposuction the symmetry

of the proposed incision is verified by placing 0-

silk sutures in the midline at the xiphoid and the

mons below the lower incision. The sutures are

left long, crisscrossed (overlapped), and grasped

with a clamp; these are then rotated to either

side of the midline at various points on the upper

and lower skin incision lines to ascertain symmetry

between sides. The surgical team then changes

gloves as they prepare for the open portion of

the procedure.

OPERATIVE PREPARATION

Before surgery the operating room table is

checked to be certain that it can be placed in

a maximal beach chair position. The symmetry

and angle of arm boards is also verified, and the

arms are secured by wrapping them with gauze.

A Foley catheter is inserted. Thromboembolic-

deterrent stockings and sequential pneumatic

compression devices and are placed prior to the

induction of anesthesia, and if indicated anticoag-

ulants are used. The abdomen is usually the final

procedure if multiple operations are performed.

OPERATIVE TECHNIQUE

The abdominoplasty proceeds by incising and

freeing the umbilicus. The pannus is then prepared

for preexcision in a vest-over-pants fashion (Pla-

nas). This maneuver is accomplished by incising

the upper limb of the ellipse to the level of the

rectus fascia while beveling the cut inward at

a 45 angle. The upper abdominal flap is then

completely undermined in a narrow tunnel resem-

bling an inverted v (corresponding to red suctionarea 3) (seeFig. 5) or zone of complete undermin-

ing (Fig. 6A), maintaining the intercostal blood

supply sufficiently to achieve rectus muscle repair

and anterior sheath plication. Preservation of the

Fig. 3. Typical markings for abdominoplasty withconcomitant liposuction. The red, yellow, and greenzones indicate safety according to the suction areasfor simultaneous liposuction of the flap.

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blood supply in this manner allows for appropriate

liposuction of the flap. Dissection is done byscalpel, electrocautery, or harmonic scalpel.

An intact zone surrounding this tunnel (yellow

area in Fig. 5, corresponding to suction area 2

or zone of selective undermining [Fig. 6A]) is

undermined as needed to diminish the inevitable

skin bunching that occurs after muscle closure.This action maintains a broad intact subcostal

perforator blood supply (green area in Fig. 5 or

zone of discontinuous undermining [Fig. 6A], of

axial blood supply corresponding to suction

Fig. 4. Aesthetic units of the abdomen in males (A) and females (B). When discussing the abdomen with femalesthey often also inquire about the back rolls.



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area 1). This intact area has been discontinuously

undermined by the liposuction. Consequently the

entire flap can be suctioned when performing

a full abdominoplasty, hence the term lipoabdomi-

noplasty. This operative technique is standard

unless patients do not require liposuction (Fig. 6).

The operating room table is flexed and the upper

skin flap is then pulled over the pannus to the

proposed lower skin marking to verify that it

reaches. Adjustments in the lower incision can

be made at this point if necessary. Vest-over-

pants preexcision has the following advantages:

leaving the pannus that will later be resected in

place preserves heat and blood, it is faster than

elevating a flap that will ultimately be excised,

and it avoids the tendency of wide upper flap

undermining ensuring flap tunneling, thereby

maintaining the lateral blood supply. Once it is

Fig. 5. (A) Blood supply to the abdomen before (left) and after (right) surgery. (B) Suction areas (SA) 1 to 4 arebased on the pre- (left) and postoperative (right) blood supplies. SA 4 is not actually on area it is excised. Notehow these correspond to zones in Fig. 6.

Fig. 6. (A, B) The lipoabdominoplasty procedure. Zone of complete undermining to the extent necessary forrectus repair is shown. In the zone of selective undermining tethering points are released to allow flap redraping.Zone of discontinuous undermining results from liposuction. Note how these zones also correspond to suctionareas (SA) 1 to 3 in Fig. 5B.

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determined that the upper flap reaches the lower

incision, it is committed to and an incision is

made to the level of the fascia. It has been sug-

gested that leaving a thin layer of fibrofatty tissue

on top of the fascia (and/or quilting sutures when

closing) reduces the incidence of seromas. In

patients with massive weight loss, a large pannuscan distort the anatomy and bring the spermato-

chord and so forth into the field; therefore care

must be taken as the incision proceeds down to

the rectus fascia. The pannus is then grasped

with Allis clamps and excised en bloc, from the

right to left side. A plastic button (ocular

conformer) is sutured to the umbilicus to be used

for subsequent identification and removed when

the umbilicus is later exteriorized. At each step

the surgeon and assistants achieve hemostasis

with electrocautery. The rectus muscle diastasis

is marked with ink in a long vertical ellipse from xy-

phoid to pubis. The section above and then below

the umbilicus is closed in layers with running 0-

loop nylon sutures and then a second layer of

buried interrupted 2-0 Neurolon sutures. In thin

patients with minimal intra-abdominal adiposity,

additional waistline narrowing can be performed

by placing 1 or 2 2-0 Neurolon sutures horizontal

to the umbilicus. No further fascial muscle tight-

ening is necessary or desirable. Once appropri-

ately closed, the amount of flattening achieved

with rectus plication cannot be predicted orincreased. Furthermore, some relaxation and

stretching of the fascial repair is likely to occur

over time. Puckering that develops in the upper

skin flap where it is still adherent to the underlying

muscle subsequent to fascial closure is gently

freed by blunt and sharp selective dissection

(zone of discontinuous undermining). Small

amounts of bunching are tolerated and indeed

desirable, as intact skin maintains lateral inter-

costal blood supply. This condition resolves in

the early postoperative period. Ten milliliters of1/4% marcaine with epinephrine is injected into

various points in the rectus sheath for analgesia

and on occasion pain pumps are tunneled below

the fascia. The cavity is irrigated with lidocaine

and epinephrine solution, and final inspection

and hemostasis is performed. The table is returned

to the degree of beach chair position required to

achieve wound closure, which begins by placing

a 2-0 Vicryl suture in the midline. The wound edges

are aligned with staples, minimizing dog-ear

formation. A 2-0 PDO bidirectional barbed suture

(Quill SRS, Angiotech, Vancouver, Canada) isused in the deep layers from Scarpas fascia to

the dermis on either side of the midline in a running

fashion. While in the flexed position and with most

of the wound closed, the umbilical button is

palpated below the flap and marked on the skin

in the midline slightly higher than its natural posi-

tion. The dimensions of the abdomenvertical,

horizontal, and so forthcan be expected to

change after an abdominoplasty (Fig. 7). A second

layer of 3-0 monoderm Quill sutures is used in the

subcuticular layer. The drains exit the wound andare sewn in place with 3-0 nylon sutures. Drains

remain in place for several days until wound

drainage subsides.

When preparing to exteriorize the umbilicus, the

patients midline is verified with the silk marking

sutures and by observing the position of the vulva

cleft. The marked umbilical site is determined and

a 2.5-cm inverted V-type incision is made in the

midline. The upper and (more so) lower skin edges

of the umbilical opening are defatted. The author

no longer tacks the umbilicus to the fascia. The

umbilicus is exteriorized and the button removed.

Deep absorbable sutures are placed from umbi-

licus to skin flap, and the umbilical skin is then

closed with 3-0 nylon sutures. The umbilicus is

packed with a strip of 26-cm xeroform gauze.

Antibiotic ointment is placed on the wound and it

is covered with a Telfa dressing. A binder can be

Fig. 7. The reduction in dimensions from xiphoid toumbilicus (2.8 cm; XU), change in waistline (7.9 cm;W) and umbilicus to vulva (5.09 cm; UV) 6 monthsfollowing an abdominoplasty. Note that all dimen-sions are shorter or narrower following an abdomino-plasty, regardless of whether liposuction wasperformed.



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used. The patient is transferred to a stretcher in the

same maximally flexed position. Patients should

ambulate that day as if they are using a walker,

and over the next few days progressively begin

to fully straighten out.

In most cases, the skin between umbilicus and

pubis is excised including the old umbilicus site,which is a significant patient preference. This

maneuver necessitates maximal flexion (Fig. 8) of

the operating room table and can result in tension

of the undermined flap. Concerns about the

appearance of a circumscribed umbilicus have

been among the reasons that have motivated

patients and surgeons to perform alternative

procedures such as lower abdominoplasty or pan-

niculectomy with extensive liposuction. These

procedures yield different results than a full ab-

dominoplasty, with a similar length of incision

albeit without an umbilical scar (Fig. 9). This cosm-

esis is part of the discussion and decision-making

process between patient and surgeon (see section

Special considerations).

COMPLICATIONS

A full abdominoplasty with or without liposuction,

and potentially additional aesthetic or nonaes-

thetic procedures, are extensive operations that

can be associated with a wide array of local or

systematic complications that can range from

a trivial nuisance to a lethal condition. Tables 13

review local and systemic complications in

abdominal contour surgery and in a full abdomino-

plasty, by comparing major case series.

Untoward sequels of abdominoplasty are those

issues that tend to resolve spontaneously, such as

hypesthesias, edema, ecchymosis, induration,

and erythema.

TISSUE ISCHEMIA

Plastic surgery has long been regarded as a battle

between beauty and blood supply (patients

consider it a battle between beauty and a scar).

The abdomen, which involves a large surface

area, wide undermining, concomitant liposuction,and tension on wound closure only serves to under-

score the importance of this relationship. A meticu-

lous technique, awareness of theblood supply, and

reconciliation between the extent of liposuction,

tension on wound closure, and the method and

extent of undermining are critical components to

safety. Ischemia noted intraoperatively has been

addressed by delayed wound closure or even by

waiting to exteriorize the umbilicus until thepostop-

erative period to preserve blood supply.

All wounds are examined the night of surgery and

the next morning. If ischemia is noted any reversiblecauses such as fluid collection, cellulitis, infections,

or wound tension (that can be relieved by suture

removal) are addressed. Should ischemia prog-

ress, the author has used a regime of calcium

chemical blockers (nifedipine), nitropaste (NTP),

and solumedrol. At present, the author prefers

a protocol using dimethyl sulfoxide (Spectrum

Chemical Mfg. Corp, Gardena, CA, USA). Ischemia

that progresses to necrosis most often manifests it-

self in the terrible abdominoplasty triangle with

the apex located at the umbilicus and the base atthe top of the mons pubis. The flap is most vulner-

able to lack of blood supply here, as this represents

the cross-over watershed blood supply zones from

Huger zones II and III (see Fig. 5). Umbilical

ischemia/necrosis is most often due to torsion,

skeletalization, or entering the stalk to repair

a hernia (which devitalizes the second blood

supply; the first is via theskin). A prior umbilical float

(transection) that is later circumscribed could also

similarly result in umbilical ischemia.

Standard conservative wound management

protocols are followed for necrotic tissue, and oneshould avoid early, unnecessary debridement, as it

has been postulated that this can lead to retrograde

thrombosis. Suction areas (14) have been estab-

lished to reconcile the location, extent, and degrees

of liposuction of the undermined flap and

surrounding areas. Combining this with undermining

in an inverted V to the extent necessary to close

the diastasis and achieve wound closure with oper-

ating room table maximally flexed are important in

safely achieving an optimal aesthetic outcome.

SPECIAL CONSIDERATIONS

Certain circumstances in situations of a full

abdominoplasty merit further discussion.

Fig. 8. The operating room table should be maximallybeach chaired to allow sufficient removal of skin andexcision of the old umbilical site.

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Preexisting Upper Abdominal Scars

Conflicting reports in the literature suggest that

scars (eg, Chevron incision) may or may not

increase complications. Non-midline upper

abdominal scars that limit the crossover bloodsupply to the abdominal wall rendering patients

at risk for wound ischemia require considering an

alteration in approach. One alternative is a fleur-

de-lis excision that incorporates the old scar in

the excision and tightens tissue laterally. The exci-

sion of the old scar avoids issues of it blocking the

blood supply. If a fleur-de-lis is not indicated in

patients with scars, another alternative is limited

flap undermining to the level of the scar, but this

may limit the extent the diastasis can be repaired

or the amount of skin removed (Fig. 10). A reverse

abdominoplasty is another option that rejuvenates

the upper abdomen. This procedure is ideally

Fig. 9. Pre- (A) and postoperative (B) frontal view of a 39-year-old woman who was downstaged to a lower ab-dominoplasty rather than a full abdominoplasty at her request. Lateral view of the same patient before (C) andafter (D) lower abdominoplasty with 2175 mL of abdominal and flank liposuction, secondary breast reduction,and lower lid blepharoplasty. No incision is necessary around the umbilicus.



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performed in patients with 2 preexisting inframam-

mary scars, or it can be done through one gull-

wing incision. Finally, delaying the flap by incising

the deep and superficial epigastric arteries is

possible. The author does not find that

unconventionally designed excisions are good

alternatives in scarred abdomens. Consequently,

an in-depth discussion about the specific risks

associated with upper abdominal scars is

appropriate.

Table 1Local abdominal contour surgery complications

Complications LiposuctionLimitedAbdominoplasties

FullAbdominoplasties

Contour irregularity 9.20% 4.90% 5%

Major skin necrosis (requiringreoperation)

0% 1% 1%

Minor skin necrosis (healedspontaneously)

0% 4% 4.40%

Scar revision 0.03% 2.40% 4.90%

Hematoma 0.04% 0.08% 1.40%

Wound infection 1% 0.02% 1.10%

Wound dehiscence 0% 1% 1%

Umbilical abnormality(requiring reoperation)

0% 0.05% 1.20%

Dissatisfied patients(unfulfilled expectations) 3.30% 2.90% 2.20%

Need for second surgery 3.50% 2.40% 3.40%

FromMatarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a National Plastic Surgery Survey.Plastic Reconstr Surg 2006;117(6):1797808; with permission.

Table 2Systemic abdominal contour surgery complications

Complications LiposuctionLimitedAbdominoplasties

FullAbdominoplasties

Local anesthesia (ie,wetting solution)

0% 0% 0%

Major anesthesia 0% 0% 0%

Malpractice action 0% 0% 0.01%

Blood transfusion 0% 0% 0.04%

Deep veinthrombophlebitis

0% 0.01% 0.04%

Pulmonary embolism 0% 0% 0.02%

Pulmonary fatembolism

0% 0% 0%

Intra-abdominalperforation

0% 0% 0%

Death 0% 0% 0%

Readmission tohospital

0.01% 0.01% 0.05%

FromMatarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a National Plastic Surgery Survey.Plastic Reconstr Surg 2006;117(6):1797808; with permission.

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Achieving a Narrower Waistline

Narrowing the waistline is a common request of

patients seeking abdominal contour surgery, but

in general it is not a result that can be predicted

or assured. The author finds that often when dis-

cussing this, these patients state that they have

always had a disparity between their hips and

waistline (narrow hips), and as intra-abdominalfat increases and the pelvis widens with age, this

problem is exacerbated. Rectus fascial plication

does not dictate the extent of abdominal flat-

tening. When rectus closure is done appropriately,

no further flattening or waistline narrowing can be

achieved. Selective liposuction in the area of the

waistline may add slight improvement, though by

virtue of the abdominoplasty waistline measure-

ments do change (see Fig. 6). In the individuals

with minimal visceral fat, waistline sutures, as

described by Jackson, can be useful (Fig. 11).

Downstaging to Less Invasive Alternatives

Downstaging is a term used for candidates for ab-

dominoplasty who want less invasive surgery.

These patients may not want the scar or the

Table 3Comparison of results of abdominoplasty complications

Matarassoet al

Hesteret al1,a

Grazer andGoldwyn2,b Pitanguy3,c

Teimourianand Rogers4,d

No. of procedures 11,016 563 10,490 539 25,562

Local, %

Necrosis minor 4.4 0.9% (minimalslough)

5.4 (wounddehiscence)

1.4

Necrosis major 1.0 0.3

Seroma 2.5% 5.8 8.58

Infection 1.1 1.1 7.3

Blood loss


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recovery period of an abdominoplasty. For

example, downstaging from a full (open) abdomi-

noplasty to a less invasive procedure such as lipo-

suction alone is feasible when reconciling thepatients anatomy with their goals. However,

different and less invasive procedures will not yield

the same results, and this must be emphasized to

the patient (Figs. 9 and 12).

Liposuction as an Adjunct to a FullAbdominoplasty or Lipoabdominoplasty

Liposuction as an adjunct to a full abdomino-plasty is routinely incorporated according to

the published guidelines of the suction areas

(14) and in accordance with stratifying risk

factors and balancing the extent of liposuction

Fig. 10. (A) Preoperative front view of a 43-year-old gravida 1 para 1 woman with a subcostal scar on the left side.(B) Postoperative appearance. Lateral view before (C) and after (D) surgery. Undermining was performed to thelevel of the scar.

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with the amount of tension on wound closure,

and the degree of wound undermining. This

procedure is previously described in the

section operative technique. If deemed inap-

propriate, liposuction and abdominoplasty can

be separated and performed as staged proce-

dures. Some surgeons prefer defatting the

undermined flap with scissors. Studies oncombining liposuction of surrounding areas or

the flap itself have suggested a higher seroma

rate; however those patients requiring defatting

by definition are having more surgery, and

might be expected to have a higher seroma

rate.

Lipoabdominoplasty has recently became

a popular term; however, the exact meaning

varies according to who is using it. The author

describes an abdominoplasty with limited upper

abdominal undermining (or inverted V fashion),

thereby preserving lateral intercostal bloodsupply, and then performing liposuction more

aggressively on the upper flap (Fig. 13) as ab-

dominoplasty with liposuction or lipoabdomino-

plasty (see Fig. 6).

Fig. 11. (A, B) The patient is shown before and after abdominoplasty, demonstrating a narrower waistline. ( C, D)Frontal view of another patient with a narrower waistline after a full abdominoplasty.



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Panniculectomy with Extensive Suction-Assisted Lipectomy or Liposuction with LowerSkin Resection or Lower Abdominoplasty

Essentially these terms describe similar tech-

niques that combine extensive liposuction with

en bloc resection of approximately the lower

25% of abdominal skin (half of tissue from umbi-

licus to the mons pubis) without direct flap under-

mining, just discontinuous undermining of the

upper flap by liposuction, with or without umbilicus

Fig. 12. Downstaging. The patient who is shown here preoperatively (A) and preoperatively (B) would be anappropriate candidate for abdominoplasty but requested liposuction only. A different patient who did notwant an abdominoplasty and was downstaged to liposuction is shown before (C) and 1 week after (D) 4200mL of abdominal and flank liposuction.

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circumscription, and with or without lower rectus

tightening. If the umbilicus is circumscribed

enough, partial undermining should be done to

ensure old umbilicus site removal with the pannus

of excised skin (Fig. 14). If the umbilicus is not cir-

cumscribed, the excision should be designed with

enough skin below the umbilicus to reach the

mons pubis and to be aesthetically pleasing.

Patients may prefer this because there is not anincision around the umbilicus, although the lower

incision is nearly the same as a full abdomino-

plasty but it does not fully address supraumbilical

skin laxity if present (seeFig. 9).

As mentioned, concern for the appearance of

a circumscribed umbilicus, preference for a less

invasive option, the desire to do more liposuction,

and potentially less risky procedure are among the

reasons that have led some patients and surgeons

to consider these procedures. Other purported

advantages of lower abdominoplasty include less

fluid drainage, being a good option for smokers,

those with scarred abdomens, or obese patients.These procedures yield different results than

a full abdominoplasty, with a similar length of

incision albeit potentially without an umbilical

scar. This cosmesis forms part of the discussion

Fig. 13. An example of a 39 year old gravida 2 para 2 woman pre (A, C) and post (B, D) abdominoplasty with 2750mL of liposuction of the abdomen, thighs, and backrolls. (E, F) same patient frontal view.



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and decision-making process between patientand surgeon. These or other alternatives are indi-

cated based on the patients anatomy and goals.

Fig. 14demonstrates various alternative excisions

and incisions; the lower 3 choices do not create

umbilical scars. Just as in other situations of

downstaging whereby less invasive alternatives

are selected, lower abdominoplasty will not neces-

sarily yield the same outcome as a standard full

abdominoplasty. Lower abdominoplasty is essen-

tially the most recent reincarnation of a procedure

somewhere between a mini and a modified

abdominoplasty with (Fig. 15) or without (Fig. 9)

transection or floating of the umbilicus.

If one chooses to operate on obese patients

(Fig. 15), who are generally at a higher risk for

complications from a full abdominoplasty and

present with significant visceral and subcutaneous

fat, and possibly umbilical hernias, then they may

also be better suited for this procedure than a full

abdominoplasty. In addition to the advantages

mentioned: (1) less flap undermining makes lipo-

suction safer and reduces wound complications;

(2) if the umbilicus is not circumscribed, thenumbilical hernias can potentially be repaired; (3)

not repairing the entire rectus muscle diastasis

avoids the discomfort and pulmonary complica-

tions associated with this operation. It prevents

increased pressure in the abdomen (abdominalcompartment syndrome), which may contribute

to deep vein thrombosis/pulmonary embolism,

and it avoids technical complications associated

with muscle repair such as inadequate plication

or recurrent defect. Moreover, rectus muscle

closure has little benefit in those patients with

abundant visceral fat. In fact the author often

avoids rectus repair in males, nulliparous females

(or those anticipating a pregnancy), patients with

massive weight loss, or other patients who might

not benefit from the repair. Overall this alternative

should be associated with fewer complications

than a full abdominoplasty, including those prob-

lems associated with maintaining a flexed position

or achieving early ambulation.

Abdominoplasty in Patients who Previouslyhad Liposuction

Several observations can be made about these

patients, who will now accept an abdominoplasty

incision to address loose skin or diastasis of the

rectus muscle when they might not have requiredit before. Changes that earlier liposuction can

cause include small pseudo-bursas or scars and

the fact that the upper flap will have less laxity/

elasticity due to the prior surgery, so it is tighter

Fig. 14. Drawing of excision for various abdominal contour alternatives. Note the mini is a drawing of the inci-sion. Note that a mini abdominoplasty, lower abdominoplasty, or panniculectomy without umbilical circumscrip-tion avoids umbilical scars.

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and unfurls less than in an unoperated abdomen.

Consequently, the planned excision should be

more conservative than would have been antici-

pated. Scoring the undersurface of the flap

similar to what is done on the galea of the scalpreleases some of the tension. Also, because it is

essentially a delayed flap, wider undermining can

also be safely performed. The operating room

team should be prepared to maximally flex the

patient and drains should be left in place for an

extended period of time, as these patients can

have longer postoperative drainage. These

patients may also have concerns with laxity ofthe flank areas, and extending the incision to

incorporate a flankplasty can be discussed

(Fig. 16).

Fig. 15. An obese patient is shown before (A) and after (B) lower abdominoplasty (panniculectomy) with exten-sive, unrestricted liposuction and circumscription of the umbilicus (and breast reduction).

Fig. 16. (A, B) Example of a patient who had prior liposuction (left) and then a full abdominoplasty (right).



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Secondary Full Abdominoplasty

Secondary full abdominoplasty is an uncommon

event unless there have been additional preg-

nancies, a long time interval from the first

surgery, or issues related to the outcome of

the primary surgery including failed diastasis

repair. These patients are often concerned with

many of the same problems as primary patients,

including excess loose skin, rectus muscle dia-

stasis, and adipose tissue that may or may not

have been treated at the time of the first opera-

tion. The second abdominoplasty design is

Fig. 17. (A) Lateral view of a 59-year-old woman complaining of loose skin and rectus diastasis years after anearlier abdominoplasty. (B) The patient is shown following a secondary abdominoplasty. Frontal view of thesame patient before (C) and after (D) a secondary abdominoplasty. Note the second incision is somewhat dictatedby the location of the first abdominoplasty incision.

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somewhat committed to the location of the

previous incision. At the time of secondary

surgery, improvements in appearance can be

made by liposuction, excising skin, excising

a closed prior umbilical site, improving the

scar, or additional muscle tightening (Fig. 17).

Removing the Old Umbilical Site

Designing and performing the procedure to re-

move the old umbilical site is an important concern

of patients who, despite pleasing results, will

complain that a retained umbilical site looks

unsightly or like a second umbilicus. Enough

upper abdominal skin should be recruited to

excise the old umbilical site. Therefore, the incision

design should be appropriate and the operating

table maximally flexed (see Fig. 8) to ensure

removal of the umbilical site. This removal canlead to more wound tension than the surgeon is

accustomed to, so other factors such as liposuc-

tion and the nature of flap undermining must be

reconciled to account for this (Figs. 18and 19).

Performing the Wrong Operation

This scenario occurs most frequently when

substituting a mini abdominoplasty for a full

abdominoplasty but anticipating the same

outcome. In postpartum patients a limited

abdominoplasty is often not adequate to achieve

their goals; it is most appropriate in nulliparous

females. The prospect of a mini procedure

with a smaller scar, shorter recovery, and less

complications is appealing to the patient and the

surgeon; but should only be performed with the

understanding of what can be achieved. Indeed

the most common error in this group of patientsis performing this procedure that does not

adequately address the patients concerns. In

those patients that have had a modified or limited

abdominoplasty and are unsatisfied if the umbi-

licus has been transected and they now require

a full abdominoplasty, 2 main problems will be

encountered: (a) harvesting enough skin to excise

the old umbilical site and reaching the full extent of

the rectus diastasis, and (b) devitalizing a previ-

ously transected umbilicus by now circumscribing

it (Fig. 20).

Bariatric Plastic Surgery

Bariatric plastic surgery is performed in the patient

with massive weight loss, whether surgically

induced or resulting from lifestyle changes. The

abdomen is one of the primary concerns in this

patient population, who have a variety of options

based on their concerns. These options include

panniculectomy with extensive liposuction (as

previously described), abdominoplasty (Fig. 21),

extended abdominoplasty (which extends the

Fig. 18. (A) Preoperative view 45-year-old woman marked for an abdominoplasty by another surgeon. (B) Post-operatively after first abdominoplasty. Not the vertical slit closure of old umbilical site (arrow), which was notremoved at surgery. (C) Following secondary abdominoplasty with removal of old umbilical site. Again the inci-sion is not optimal but based on the previous abdominoplasty incision.



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resection to include the flanks), or a circumferential

abdominoplasty. Metabolic changes associated

with massive weight loss should be addressed

preoperatively. If there is a port from a lap band,

this must be accounted for during dissection and

muscle plication, taking care not to disturb it. If

the lap band requires adjustment postoperatively,

the bariatric surgeon must also be made aware

Fig. 19. (A) 31-year-old gravida 2 para 2 long-waisted patient who was a concerned about the ability to excise theold umbilical site. (B) Frontal view postoperatively, following abdominoplasty and breast augmentation. Lateralview of the same patient before (C) and after (D) surgery.

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Fig. 20. (A) The frontal appearance of 39 year old gravida 2 para 2 woman who had previously undergone a miniabdominoplasty with an umbilical float. (B) The patient is shown after a secondary procedure, with a full abdom-inoplasty and umbilical circumscription, excision of lower skin with old umbilical site, and complete rectus musclerepair. (C) Lateral view of the same patient after mini abdominoplasty. (D) Following a full abdominoplasty.



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that the scars used to place the port have been

moved. Finally, in these patients one must be

prepared for the unexpected, such as incisional

or umbilical hernias.

MALES

Males have some different considerations than

females that are beyond the scope of this article.In general males benefit from circumferential lipo-

suction of the abdomen and flanks, or a full ab-

dominoplasty without rectus muscle plication.

These are the preferred techniques in males.

SUMMARY

Abdominal contour surgery represents a spectrum

of treatment options available to improve the

appearance of the abdomen. Abdominoplasty is

a successful operative procedure that excises

excess abdominalskin, closes rectus muscle diasta-

sis, and improves lipodystrophy. Abdominoplasty

has proven to be an effective and safe treatment

for rejuvenating the postpartum patient alone or in

conjunction with breast, body surgery, or other

procedures.

Fig. 21. Frontal view of a 45-year-old massive weight loss (125 pounds) patient before (A) and after (B) an abdom-inoplasty and mastopexy. Lateral view of the same patient before (C) and after (D) surgery.

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SUGGESTED READING

See the Suggested Reading list (available online

at http://www.plasticsurgery.theclinics.com/) for

further reading.

REFERENCES

1. Hester TR Jr, Baird W, Bostwick J III, et al. Ab-

dominoplasty combined with other major surgical

procedures: safe or sorry? Plast Reconstr Surg

1989;83:997.

2. Grazer FM, Goldwyn RM. Abdominoplasty assessed

by survey, with emphasis on complications. Plast Re-

constr Surg 1977;59:513.

3. Pitanguy I. Abdominal lipectomy. Clin Plast Surg

1975;2:401.4. Teimourian B, Rogers WB III. A national survey of

complications associated with suction lipectomy:

a comparative study. Plast ReconstrSurg 1989;84:628.

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