Abdominal fat has two layers separated by a layer of superficial fascia. These layers have different vascular supplies. The overlying skin is reliant on blood supply through the superficial fat layer, whereas the deep fat vascularity is distinct from the skin. For this reason, superficial fat should be preserved when flap thinning is required. After raising a skin flap during an abdominoplasty, the blood supply arises from superolateral, which will correspond to Huger’s zone III. Huger’s zone I normally supplies the central area of the flap through the rectus abdominis muscles, but these perforating vessels are divided during flap elevation (Fig. 120.1).1 Vascularity of the soft tissue of the elevated abdominoplasty flap is reduced compared with normal levels of perfusion in the surrounding tissues.2 The normal sensory innervation to this part of the abdomen arises from T7–T12 (ventral) intercostal nerves, which have anterior and lateral branches. The lateral branches are preserved during an abdominoplasty and travel within the superficial tissues anterior to the anterior axillary line. The anterior branches remain deep to the internal intercostal until they reach the rectus sheath. At this point they pass anteriorly through the sheath to supply overlying skin and will be divided during flap elevation. Patients probably will not have long-term sensory loss at this level because of sensory nerve arborization and reinnervation.3 The umbilicus normally receives its vascular supply through perforators from the deep inferior epigastric arteries (DIEAs), the subdermal plexus, the medial umbilical ligament, and the ligamentum teres.4 During an abdominoplasty, the subdermal supply is divided, but the main perforators from the DIEA are still preserved. The blood supply would normally rely only on the medial umbilical ligament and ligamentum teres, if, for example, a bilateral DIEP flap had been performed. Striae are caused by thinning or absence of the dermis. Those present below the umbilicus will be excised during a standard abdominoplasty procedure. However, those above this line will remain and are likely to appear worse, as the flap will be stretched during wound closure. This is a key concept to convey to patients preoperatively.1–5 Fig. 120.1 Huger’s vascular zones of the abdominal wall. Zone I Zone III Zone II Deep superior epigastric artery Eleventh posterior intercostal artery Superficial circumflex femoral artery Deep inferior epigastric artery Femoral artery External pudendal artery Superficial inferior epigastric artery 1074 Part I ■ Fundamentals and Basics
wall? The arcuate line is located halfway between the umbilicus and symphysis pubis. Above this line there are both anterior and posterior rectus sheaths. Below this line there is only an anterior rectus sheath present, therefore making this area of the abdomen more prone to weakness and herniation. It is particularly relevant when performing abdominal wall reconstruction and raising rectus abdominis flaps, as this area will need reinforcement if the anterior sheath is deficient. There may be deficiency in this area in patients undergoing abdominoplasty particularly if they have previously had significant weight loss or multiple pregnancies. The ideal anatomic position for the umbilicus is the midline at the level of the iliac crest, although in less than 2% of patients is the umbilicus truly sited in the midline. Diastasis should be repaired from the xiphisternum down to the top of the symphysis in most cases. For this reason, the superior limit of skin flap dissection in an abdominoplasty is also the xiphisternum. Scarpa’s fascia marks the junction between superficial and deep fat layers of the abdominal wall.1–3
3. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA: Elsevier Health Sciences; 2008 Abdominoplasty places a large stress on the abdominal wall flap vasculature and, accordingly, is not recommended in active smokers. During the preoperative consultation, patients should be asked about their smoking status and advised of the increased risks of surgery while actively smoking. For example, wound healing complications in smokers are nearly 50% as compared to 15% in nonsmokers.1 Any plans for surgery should be postponed until smoking cessation has been successfully completed. Urine or blood tests can be used to assess nicotine levels (cotinine test)2 and can help confirm whether patients have abstained from smoking. There remains debate regarding the effects of nicotine replacement therapy on wound healing; however, continuing with surgery in a patient who has recently stopped smoking and is on nicotine replacement therapy is still likely to carry a higher risk of postoperative complications. While some of the effects of smoking are reversed after a month of cessation, but other factors take longer to reverse. Given this is nonurgent elective surgery, waiting until the patient is optimized for surgery is common sense and medicolegally is the correct approach to take. Some patients will “vape” instead of smoking, but some of these still contain nicotine and should therefore also be avoided.1–3
Myofascial laxity of the anterior abdominal wall must be assessed before undertaking an abdominoplasty so that a plan to treat it can be made in advance of surgery. Laxity can be measured by the diver test, a pinch test, and by assessment of rectus diastasis. The diver test is performed with the patient standing and then flexing at the waist. Worsening of lower abdominal wall fullness indicates myofascial laxity is present (Figs. 120.2, A and B). The pinch test assesses abdominal fullness with the patient both relaxed and actively tensing the abdominal wall (Fig. 120.2, C). If the amount of fullness that can be pinched is significantly decreased by tensing the abdominal wall, then significant myofascial laxity is present. Midline rectus diastasis is assessed by asking the patient to raise their legs off the examination table while lying supine. This allows palpation of the rectus muscles in most patients. Examination of a hernia can also be undertaken at this time. Myofascial laxity can be reduced intraoperatively in most patients with a selection of suture- tightening techniques either laterally or medially depending on the anatomic location of the relative myofascial weakness.1–3
5. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA: Elsevier Health Sciences; 2008
has a moderate amount of skin and soft-tissue excess and wants to know about the likely outcomes. Which one This woman must be made aware of the extent of potential scarring that an abdominoplasty carries with it. She is unlikely to need a vertical component to the scar, but consent for this should be obtained in case she does not have sufficient laxity to fully remove the original periumbilical site, which subsequently closes with a vertical scar. She must also be informed of the risk of umbilical necrosis and be made aware that the periumbilical scar will still be visible in a bikini or underwear. In most cases, the transverse scar can be well hidden in underwear or swimwear, Fig. 120.2 A and B, Diver’s test. C, Pinch test. 1076 Part I ■ Fundamentals and Basics but a short vertical scar may not be. Minor revision surgery may be required following an abdominoplasty and this is usually done 3 to 6 months after the original surgery. Rectus plication can increase recovery time, due to discomfort and decreased mobility.1–3
Dog-ears (also known as “standing cones”) represent an excess of skin and subcutaneous fat at the end of a closed wound. Their formation is affected by wound geometry, and traditional thinking is that elliptical wounds with a length:width ratio of 3:1 or 4:1 (or maintaining closing angles of <30 degrees) can avoid dog-ear formation.1 However, other factors may also be responsible such as tissue dynamics, surface contour, and surgical technique. Dog-ears may be present after abdominoplasty where there is lateral skin and fat excess not incorporated into the original excision pattern. The decision to exclude this area from the abdominoplasty is normally made to limit lateral scar length, so it is not a surgical error. In cases where there is lateral and posterior soft-tissue excess, patients must be made aware that lateral fullness or dog-ears are likely to occur. Such patients may require belt lipectomy or liposuction to fully address these areas. Minimizing dog-ears during surgery is achieved by careful closure of the wound apex and serial halving or feeding in the shorter side of asymmetric wounds. In abdominoplasty, this usually means advancing the upper skin flap medially relative to the lower skin flap. Temporary tacking closure with staples can help ensure minimal dog ears and overall symmetry especially where two different operators are closing a side of the abdomen each simultaneously. Surgical removal of dog-ears will lengthen the original scar and a compromise must be reached between scar length and residual contour. Dog-ears do not usually resolve spontaneously unless they are very small. Massage to the scar will still be useful to help it soften. They should ideally be left to settle for at least a few months before revision.1–3
Following abdominoplasty, patients will have to initially mobilize slightly flexed at the hip due to the relatively tight wound closure, which is most often performed with the patient flexed. Postoperatively, they should be nursed with knees flexed on pillows and the hips also flexed. This takes tension off the wound repair during the early phase of healing. A standard abdominoplasty does not necessarily include liposuction, although it may do so. It is used to target lateral fullness that is not addressed by the abdominoplasty technique. Therefore, it is commonly directed at the flanks, rather than the central and upper abdomen which may risk flap viability, particularly if the suprascarpal fat is aspirated. The procedure is performed under general anesthetic and can typically be performed as an outpatient or overnight stay. This patient has an active job with heavy manual lifting of patients. She will require more than a week off work, even if light duties are possible. She will need to avoid heavy abdominal exercise such as sit-ups or heavy weights in the immediate postoperative period, but she can resume lighter cardiovascular work after a few weeks. She will certainly be recovered enough to resume going to the gym after 9 months.1,2
This woman has an excess of skin and fat to both the anterior and posterior abdominal walls and therefore will not be served well with a traditional abdominoplasty procedure. This would only address the anterior and some of the lateral excess for her. The best surgical procedure for this patient is a circumferential abdominoplasty, also termed a belt lipectomy or lower body lift, as this will address the circumferential tissue excess. It allows elevation of the buttocks and lateral thighs for a comprehensive lower body lift. The downside for the patient is that the scar will pass circumferentially and therefore be visible from behind. From a surgical perspective, there will be multiple patient turns required intraoperatively which will impact on timing and efficiency.1,2 The umbilical stalk may need to be shortened to accommodate the refined abdominal contour. A mini abdominoplasty would be unable to address the anterior excess, let alone the posterior excess. A reverse abdominoplasty would be used to address upper anterior abdominal excesses perhaps in the context of previous lower abdominoplasty with residual upper abdominal tissues, or where breast procedures are being performed concurrently. A fleur-de-lis procedure will address vertical and horizontal excesses anteriorly and laterally but not posteriorly.3
This patient could benefit from a mini abdominoplasty procedure. It will target both the excess skin and fat, as well as remove some of the striae. It will, however, have a tendency to lower the umbilicus, and she must be counseled about this. Furthermore, it will fail to address many of the striae if located near to or above the umbilicus. She would not be a good candidate for liposuction, given her skin quality. A full abdominoplasty would be excessive in her case. A reverse abdominoplasty would be ineffective at removing her tissue excess given its location and leave her with scars high in the abdomen which would be poorly hidden given her overall shape. The mini abdominoplasty is a great procedure for the right patient as in this scenario. It involves little or no soft- tissue flap undermining (unless rectus plication is to be incorporated), a relatively short intraoperative duration and overall recovery time. Often the transverse scar can be kept short and well hidden low on the abdominal wall. It effectively addresses the excess that slim patients can generate postpregnancy.
Current guidelines from the Surgical Care Improvement Project (SCIP)1 suggest that intravenous antibiotics are given 30 to 60 minutes before surgery begins. Cefazolin (Ancef) 1 g or clindamycin 900 mg are recommended, but institutions usually have their own individual guidelines based on local microbiological data. A full week’s course is not required. The pubic area should not be shaved in advance, as skin damage can increase the risk of infection, but clipping is acceptable shortly before skin prep is applied. Thrombo-embolic deterrent (TED) hose (stockings) are recommended in all patients undergoing abdominoplasty, as it carries a high risk of thromboembolic events. Patients must be educated about this risk and the potential effects of either a deep vein thrombosis (DVT) or pulmonary embolism. In addition to TED hose, calf compression devices should also be used intraoperatively. 1078 Part I ■ Fundamentals and Basics Most patients should be considered for prophylactic low-molecular-weight heparin (e.g., Lovenox 40 mg) on the evening of surgery and for 7 days after.2 Early ambulation and good hydration are also advocated to minimize problems with thrombus formation and chest complications. DVTs occur or at least are clinically recognized in less than 1% of patients undergoing abdominoplasty. Where there is doubt about risk stratification for each patient, use of the Caprini score may be helpful to guide their prophylactic management.3
It is very important to leave a small amount of fat on the fascia overlying the ASIS, as this helps prevent injury to the lateral femoral cutaneous nerve. Damage to this nerve can lead to significant postoperative pain, numbness, and dysesthesia in the hip and lateral thigh region. This condition is known as meralgia paresthetica.1,2 There is no proven benefit on seroma development of leaving this small area of fascia covered with fat, although in general leaving a thin layer of tissue overlying the rectus and external oblique fascia may help reduce seroma formation by preserving lymphatic channels. Quilting sutures may also reduce seroma formation following abdominoplasty.3 There is no reduction in hematoma rate secondary to leaving a layer of tissue over the fascia and there is no discernible difference on abdominal wall contour, as the layer preserved is very thin.
technique? Rectus diastasis is where the distance between the two vertical rectus abdominis muscles is increased. It is common after pregnancy and weight loss. Closing this gap can be helpful during abdominoplasty to optimize the overall abdominal contour. The repair is termed rectus plication. Choice of suture for repair of rectus diastasis is very important with regard to longevity of the repair and should be performed using a long-acting resorbable or permanent suture. Recurrence of diastasis following rectus plication is much higher when a short-acting resorbable suture is used.1–5 When using an absorbable suture, there was a 40% recurrence rate by 5 years as confirmed by ultrasound imaging.1 In contrast, a study conducted when a permanent suture material was used found no diastasis recurrence observed at 5 to 7 years after surgery. The findings were confirmed by CT imaging in this case.2 The upper skin flap needs to be elevated up to the xiphisternum during the abdominoplasty to allow access for rectus plication and a central area of undermining is adequate. Lateral undermining is unnecessary and reduces blood supply to the flap. Rectus plication must start just below the xiphisternum, otherwise a postoperative bulge may form and is apparent to the patient. It must also stop around the umbilicus to avoid strangulation and subsequent necrosis. There are different techniques of plication, but a typical example would be to use a two-layer approach combining interrupted and then continuous sutures to reinforce the repair. The use of plication does not negate the use of progressive tension sutures, as these are used to advance and distribute tension of wound closure away from the suture line. They may also reduce hematoma and seroma formation.1–5
The mini abdominoplasty is a useful technique for correcting small to moderate fat and skin excesses in the infraumbilical region. The benefits over a full abdominoplasty are that it creates a shorter transverse scar and avoids the periumbilical scar completely. Rectus plication is still possible but access will require transection of the umbilicus at the level of deep fascia, and the small fascial weak point this leaves must be closed over to prevent a hernia. Any upper or lateral abdominal wall skin and fat excess is not addressed. Because the umbilicus is not dissected and relocated, the umbilicus may be artificially lowered on the abdominal wall and will not sit level with the iliac crest. Transection of the umbilical stalk at the deep fascia will remove the dominant blood supply to it, but there will be sufficient blood supply from the surrounding subdermal plexus. In this case, the previous section scar can be excised and extended as required. Where the undermining is limited to below the umbilicus, i.e., where no rectus plication is required, the downtime will likely also be reduced compared to a full abdominoplasty. Overall this is a very useful procedure for a select number of patients, although the limitations must be fully explained preoperatively to the patient in order to minimize unrealistic expectations and dissatisfaction risk.1,2
tension sutures involve placement of interrupted resorbable sutures between the musculofascia and the underside of the abdominal flap. As the flap is advanced, progressive tension is exerted on each suture and thereby directed away from the incision. Decreased tension on the incision helps prevent wound-edge necrosis and hypertrophic scars. The dead space underneath the flap is closed, thereby reducing hematoma and seroma formation. Pollock and Pollock1,2 have shown extremely low rates of seroma formation when using this technique.
The main advantage of the fleur-de-lis abdominoplasty is that it facilitates correction of combined horizontal and vertical soft-tissue and skin excesses of the anterior abdominal wall. It is possible to achieve a good contour of the 1080 Part I ■ Fundamentals and Basics waistline with this technique at the expense of a long, vertical midline scar on the anterior abdomen. It is often a good choice in patients who may otherwise need a circumferential approach, such as a belt lipectomy, to address these areas. It can therefore avoid a posterior or very lateral scar for such patients. It is also particularly well suited to patients who have previous scarring to the upper abdominal wall that may compromise the vascularity of a standard abdominoplasty skin flap and those who already have a paramedian scar following laparotomy. It is important that no flap undermining is performed during this procedure. When performing a fleur-de-lis abdominoplasty, a standard lower abdominoplasty incision is made and the lower tissue ellipse is excised at the level of the umbilicus with no undermining of the flap above this point. The horizontal excess can be estimated at this stage by pinching the supraumbilical tissues together. A vertical elliptical excision can then be made from the umbilicus to the xiphisternum. It is important when performing this technique not to overestimate the amount of tissue that needs to be removed. It can also be difficult to avoid leaving epigastric fullness with this technique, particularly in massive-weight-loss patients. Careful feathering and thinning of the subcutaneous tissues at the apex can help minimize this. Following massive weight loss, this can be a particularly rewarding technique to use. The benefits and risks should be fully discussed with the patient before surgery. Postoperative complications are similar to a standard abdominoplasty. Rectus plication is generally required in patients undergoing fleur-de-lis abdominoplasty, because they tend to have been through significant fluctuations in body shape, such as multiple pregnancies or massive weight loss. This technique facilitates easy access to perform plication.1–3 The Lockwood high-lateral-tension technique addresses tissue excess on the thigh, but the fleur-de-lis does not.
Abdominoplasty is generally well tolerated by patients providing no adjunctive procedures have been performed. However, correction of rectus diastasis can be very painful in the early postoperative period. This is the most likely explanation in this case. It is often well controlled by using continuous local anesthetic infusion catheters placed near to the rectus or within the sheath. Alternatively, local anesthetic blocks placed intraoperatively into either the rectus sheath or the transversus abdominus plane can be highly effective.1–3 It is too early for a postoperative soft-tissue infection to be likely in a healthy patient and there would usually be evidence of swelling, cellulitis, or warmth to the abdomen if this were the case. CRP will be elevated as a result of surgery and does not by itself suggest infection. If peritonitis was present the patient would be acutely unwell and have guarding or a rigid abdomen. The possibility of a rectus sheath hematoma should also be considered.
The patient in this scenario most likely has epigastric fullness because the rectus plication was not started high enough. Failure to elevate the flap up to the xiphisternum is the most likely cause in this case. A dog-ear can occur here following a fleur-de-lis abdominoplasty if there has been inadequate fat removal or if the skin flaps are particularly thick. Seromas can present late but are unlikely at this stage, and usually occur around the waist rather than superiorly as in this case. Postoperative weight gain can often be a reason for late changes in appearance and patient dissatisfaction following surgery, but fat gain affecting this area alone is not likely.1–3