25 Abdominoplasty procedures

Synopsis

The abdominal area is the one of the most common areas treated in plastic surgery procedures. Mostly after pregnancies or weight changes, patients desire improvement of the abdominal wall, including the repair of additional ventral hernias.

Assessment of the abdominal region includes a detailed medical and physical history, including pregnancies, prior surgeries especially in the lower truncal area, and weight changes. Preoperative identification of any existing ventral hernia including diastasis recti is imperative.

Essential issues of abdominal findings are the existence and localization of vertical and horizontal tissue excess, the relation of fatty and skin excess, the examination of the umbilical stalk with exclusion of umbilical hernia. Further perioperative issues are preoperative bowel evacuation for reduction of intraabdominal pressure, careful intraoperative handling, maintenance of an adequate body temperature, sufficient medical thromboembolism prophylaxis, precise intraoperative preparation with respect to anatomical key points, postoperative compression treatment and early management of postoperative complications such as seromas.

The “fleur-de-lis” abdominoplasty allows an improvement of the entire abdominal area with simultaneous tightening of the waist circumference. It is essential to initially assess and temporarily close the vertical line prior to resection of the lower abdominal redundant tissue. Care should be taken to avoid extending the vertical incision line cranially between the breasts.

In patients with massive weight loss (MWL), aesthetic outcome will improve by high-lateral-tension and fleur-de-lis abdominoplasty, and in most cases, circumferential truncal procedures are necessary for superior results.

The preparation epifascial to the Scarpa fascia allows a preservation of subfascial lymphatic vessels for prevention of seroma formation and enables an additional tightening of Scarpa fascia for improvement of the inner thigh region.

It is mandatory to analyze any suspected skin tumor in the area of excised tissue.

Introduction

Abdominoplasty is one of the most commonly performed aesthetic procedures, which encompasses not only aesthetic features but also structural reconstruction of the abdominal wall. Aesthetic enhancements include improvement in abdominal wall contour, reconstruction of a natural appearing umbilicus and optimal placement of the resulting abdominal scar. The reconstructive component includes recreation of the original fascial and muscular anatomy as well as the restoration of any other anatomical deformations, which may be present.

The primary goals in abdominoplasty procedures are to achieve an optimal resection of abdominal skin and subcutaneous tissue in a three-dimensional manner, with a resulting wound tension that is distant from the area of tissue resection; the purpose of keeping wound tension distant from the resection is to prevent an impairment of perfusion. In addition, the abdominal musculoaponeurotic layer should be restored to prevent abdominal hernias, diastasis and consequent muscular imbalance of the trunk, while at the same time, improving the abdominal wall contour.

Due to the number of variations and modifications of abdominoplasties, it is key to select the appropriate technique in every individual case, determining the best procedure by minimizing morbidity and postoperative disability for desirable and predictable results.¹

History

One of the first publications in abdominal wall surgery dates back to 1899. Kelly attempted to correct excess abdominal skin and fat using a large horizontal midabdominal incision,^2,³ resecting a panniculus weighing over 7000 g. In 1916, Babcock presented a vertical midline incision.⁴ Since that time, numerous variations have been suggested. Thorek (1924) was the first to devise an abdominal procedure including the nowadays preferred lower transverse incision that preserved the umbilicus.^5,⁶

In 1957, Vernon published a modern version of abdominoplasty, including an umbilical transposition and plication of the musculoaponeurotic layer.⁷ Pitanguy reported in 1967 of 300 abdominal lipectomies,⁸ Regnault published the W-technique for abdominoplasty in 1972.⁹ In 1973, Grazer described the so-called bikini line incision.¹⁰ The St Tropez bikini, fashioned in the 1960s with a very low waistline, favored the abdominoplasty with a nearly horizontal incision. In the mid-1980s, the French-line bikini (cut high at the lateral aspect and low centrally) became popular, favoring the abdominoplasty incision to be converted from a nearly horizontal line to an incision line that accompanied the inguinal fold.^9,¹⁰ Nowadays, bikinis with very low waistlines have gained higher popularity again. Therefore, proper adjustments in every single technique, is necessary to achieve a tailor-made abdominoplasty.

In 1977, Grazer and Goldwyn reported the first complications using new abdominoplasty techniques.¹¹ They had noted the ability to reduce the anterior projection of the abdominal wall by aponeurotic suturing without decreasing the diameter of the waist. Psillakis published, in 1978, the external belt for extensive waist diameter reduction by suture plication of the external oblique muscle after raising it in a beltlike fashion.¹²

The addition of liposuction to body contouring surgery in the 1980s allowed a further evolution of abdominoplasty procedures. In 1985, Dellon published the new approach to a combined vertical and transverse resection of the abdominal wall resulting in a fleur-de-lis pattern.¹³ Matarasso expanded, in 1988, the use of abdominal contour surgery to a classification based on variations in patients’ anatomy, from liposuction alone to limited and full abdominoplastic surgery.¹⁴

Ted Lockwood described the high lateral tension abdominoplasty in 1997, differing from conventional abdominoplasty by limited direct undermining, increased lateral skin resection with high tension wound closure along the lateral flanks with reconstruction of the superficial fascial system (SFS).¹⁵

In 2001, Saldanha published a new technique combining lipoplasty with traditional abdominoplasty without undermining of the abdominal flap, followed by modifications of this technique by extended undermining (Fig. 25.1).¹⁶

Fig. 25.1 Development of abdominoplasty procedure, demonstrating the different types of abdominoplasty and the historical highlights.

(Modified from Moufarrege R: The Moufarrege horseshoe abdominoplasty. Aesthetic Surg J. 1997;17:91. Reproduced with permission from The American Society for Aesthetic Plastic Surgery, Inc.)

According to the American Society for Aesthetic Plastic Surgery (ASAP)’s 2008 Cosmetic Surgery National Data Bank, the number of abdominoplasty procedures performed has increased approximately 333% since 1997.¹⁷

Anatomy

Knowledge of the anatomy of the abdominal wall is essential for aesthetic and reconstructive abdominal procedures. The abdominal wall is embryonically derived in a segmental manner, reflected in blood supply and innervation. The formation of the abdominal wall is initiated by the transition of the embryo from a trilaminar disk to a three-dimensional structure on the 22nd day of gestation. The further intrauterine development of the abdominal wall has multiple crucial stages, which can lead to congenital defects of the abdominal wall. After separation of the umbilical cord the abdominal wall becomes a definitive structure.

Abdominal skin and fat tend to be distributed in the lower abdomen with aging and pregnancy. Especially as a result of multiple pregnancies, striae become common, resulting in a rupture and separation of dermal collagen with consequent skin thinning.¹⁸ At this time, the therapy of striae is exclusively by surgical excision (Fig. 25.2).

Fig. 25.2 Anatomical landmarks. Normal abdominal anatomic proportions. The approximate measurements for an average female abdomen are listed. These vary according to individual height and bone structure. The umbilicus is located in line with the most superior point of the iliac crest in 99% of patients. (A) Distance between top of mons and anterior valvar commissure. Average height is 5–7 cm. (B) Distance between umbilicus and top of mons. Average height is 11–13 cm. (C) = (A + B) Distance between umbilicus and top of anterior and vulvar commissure (C = D). (E) Distance between the costal marginal and the iliac crest. The proportion of this distance to the width of the base of the rib cage (R) determines whether the patient is long waisted or short waisted. The normal proportion (E : R) is roughly 1 : 3 (long waisted approaches 1 : 2, short waisted approaches 1 : 3).The rib cage tapers inferiorly. A narrower lower rib cage relative to the width under the armpits helps to emphasize the waist by creating a subtle V. (H) Hip width. A wider pelvis than rib cage emphasizes the waist; the waist is more defined when R<H. (W) Natural waist – the narrowest point of the torso. (Note that the umbilicus usually sits below the natural waist by about 1–4 cm). Relative to the hips, this waist-to-hip (W : H) ratio in healthy women is roughly 0.72 : 1; in healthy men, it is roughly 0.83 : 1. Note that the natural contour of the healthy abdomen reveals a subtle epigastric sagittal depression transitioning to a mild infraumbilical convexity. A subtle vertical sulcus at ‘eh’ lateral rectus border, which is more distinct in a muscular person, may also be seen.

The umbilicus

As one of the most visible and aesthetically recognized landmarks of the abdominal wall, the umbilicus is situated in the midline, approximately 9–12 cm above the top of the mons pubis. The periumbilical area is characterized by a round or ellipsoid shape with a slight depression of 4–6 cm in diameter. The fascia surrounding the umbilicus can be unstable with an increased incidence for hernias, resulting in a risk of bowel injury during umbilical dissection. The blood supply to the periumbilical area is supplied by branches from the subdermal plexus, from both deep inferior epigastric arteries as well as a blood supply from the median umbilical ligament.

Skin, muscle, and fascia

The skin of the abdomen has areas of increased adherence to the underlying fascia (“zones of adherence”), such as the anterior superior iliac crest and the linea alba. The abdominal subcutaneous tissue is divided by two layers of fascia, the superficial Camper’s fascia and the deep Scarpa’s fascia, a strong fibrous layer of connective tissue, which is continuous with the fascia lata of the thigh.¹⁹

The superficial fat layer has a more compact character, with smaller lobules and a rich vascularization, while the deeper fat layer contains larger lobules with a more scattered pattern.

Since patients presenting for abdominal wall surgery often have musculoaponeurotic laxity, the knowledge of these anatomical structures is crucial. The abdominal musculature includes four paired muscles, which are the rectus abdominis, connected in the median linea alba, the external oblique and internal oblique and the transversus abdominis muscle, which incorporate into the anterior and posterior rectus sheath at the linea semilunaris. The rectus abdominis muscles are enclosed by an anterior and posterior sheath, originating at the infracostal margin and attaching at the symphysis pubis. Above the arcuate line (or semicircular line of Douglas, situated approximately midway between umbilicus and pubic symphysis), the anterior rectus sheath is formed by the external oblique and internal oblique aponeurosis, while the posterior rectus sheath is formed by the internal oblique and transversus aponeurosis. Below the arcuate line, the posterior rectus sheath is absent, except for the transversus fascia and the peritoneum, which are found posteriorly. At the inferior aspect of the rectus muscles, the pyramidalis muscles are present in 80–90% of patients (Fig. 25.3).

Fig. 25.3 (A) Anatomy of the musculature of the abdominal wall with arterial supply. (B) Arcuate line and linea semilunaris.

The correction of frequently accompanying rectus diastasis with consequent muscular imbalance is an important step in abdominal wall surgery in order to avoid back complaints.

Lymphatic system

The lymph vessels collect the subdermal accumulated lymph fluid and drain into the deeper fat layer, passing into larger vessels. The abdominal lymphatic system is divided into supraumbilical drainage into the ipsilateral axillary lymph nodes and infraumbilical drainage into the superficial inguinal lymph nodes. The lymph vessels in the infraumbilical area pass through the sub-scarpal plane, explaining the importance of Scarpa’s fascia preservation in abdominal wall surgery.¹⁸

Blood supply

The blood supply to the abdominal wall comes from numerous major arteries of the thorax and pelvic region, which communicate through many anastomotic interconnections. Taylor and Palmer introduced the concept of angiosomes, or vascular territories of the body.²⁰ They describe two types of cutaneous blood supply: (1) direct vessels that directly supply the skin and (2) indirect vessels that “emerge from the deep fascia as terminal spent branches of arteries whose main purpose is to supply the muscles and other deep tissues.” In a subsequent study in 1988, Moon and Taylor were able to demonstrate connections between the deep superior and deep inferior epigastric systems and their relationship to the cutaneous circulation.²¹^–²³

A detailed knowledge of the arterial supply of the abdominal wall is important for abdominal wall surgery, especially in cases of prior abdominal or chest wall surgeries. Huger described different zones of the abdominal blood supply, which should guide the surgeon in planning and performing a safe operation (Fig. 25.4).²² Huger defined zone I of the abdominal wall as the area that is fed anteriorly by the vertically oriented deep epigastric arcade. Zone III was defined as the lateral aspect of the abdominal wall (flanks) that are fed by the six lateral intercostal and four lumbar arteries. The lower abdominal circulation is provided by the superficial epigastric, superficial external pudendal, and superficial circumflex iliac systems (zone II). A rich plexus between these systems allows collateral flow.

Fig. 25.4 Zones of blood supply.²²

In standard abdominoplasty procedures, after mobilization of the abdominal flap in the lower abdominal area and midline region up to the xiphoid, the cutaneous blood supply to zone I and a main part of zone II is disrupted, resulting in an abdominal flap perfusion mainly supplied by zone III. Since the mobilized abdominal flap is dependent on the lateral perforating branches from the lateral intercostals and lumbar arteries, it is imperative to preserve these vessels. Therefore, it is crucial to study any preoperative existing scar, such as subcostal cholecystectomy incisions. In certain circumstances, even a vertical midline incision can jeopardize flap perfusion.

Nerves

Cutaneous sensation of the abdominal wall is derived from the anterior and lateral cutaneous branches of the intercostal nerves 8–12, which pass between the internal oblique and transversus abdominis muscles, entering the rectus abdominis muscle and reaching the overlying fascia and skin. The lateral cutaneous branches penetrate the intercostal muscles in the midaxillary line, ending in the subcutaneous layer. Both branches are responsible for the overlapping of the sensory dermatomes T5–L1. The motor branches of the oblique and transversus abdominis muscle derive from lower thoracic and lumbar dorsal nerves, while the rectus abdominis muscle is innervated from branches of the intercostals nerves 5–12, which pass behind the rectus muscles and enter the muscles at the junction of the lateral one-third and medial two-thirds.²³

As peripheral nerves with either motor nor sensory innervations to the abdominal wall, the iliohypogastric and iliohypogastric have to be mentioned, since their course can be disrupted in lateral transverse lower abdominal incisions, resulting in consistent loss of sensory in the area of the groin and medioventral thigh (Fig. 25.5).

Fig. 25.5 Abdominal nerves.

Pathology

Pregnancy is the commonest cause of abdominal wall deformities because the skin and musculoaponeurotic structures are stretched beyond their biomechanical capability to retract. Consequently, there is thinning and loss of elasticity of the skin with possible striae and diastasis of the rectus muscles. Postpartum weight loss contributes to the process of abdominal wall deformities, because of limited skin retraction. Massive weight loss after dieting or bariatric surgery results in similar pathophysiologic changing of the abdominal wall, including excess skin and subcutaneous tissue and a laxity of the abdominal wall musculature. Increasing demand of these specific patients for abdominal wall restoration has extended the abdominal surgery to lower circumferential procedures. These problems are reviewed in Chapter 27 and 30.

Fat accumulation occurs in a distribution pattern that varies according to the gender. With weight gain, women tend to add local adiposity in the lower trunk and hip region, while men see an increase in abdominal girth. In women, fat accumulation commonly in the posterior thigh region can result in cellulite, induced by fibrous septa within the subcutaneous tissue.²⁴

Diastasis recti results from a hyperextension of the rectus sheath with a widening of the aponeurosis at the linea alba, presenting as a supra- and/or infraumbilical protrusion. This abdominal wall weakness can occur in conjunction with ventral hernias, including postoperative incisional, congenital epigastric, and umbilical hernias. Preoperative diagnosis of hernias is crucial to avoid intraoperative bowel injury.

Infections in the abdominal wall have to be treated meticulously, since they can escalate to a bacterial gangrene and necrotizing fasciitis with life-threatening conditions. Benign and malignant tumors in the abdominal area are quite uncommon. Possible wide resections can lead to larger substantial defects with the requirement of microsurgical tissue transfer.

Congenital abdominal wall defects distant to the umbilicus are relatively uncommon and based on structural defects of the abdominal wall. Omphalocele, a defect in the group of persistent fetal ducts, resolve spontaneously in 80% of children within the first 12 months.²⁵ Gastroschisis, one of the more common congenital abdominal wall defects, results in herniation of fetal abdominal viscera into the amniotic cavity, which has to be surgically corrected in most cases by primary closure or staged silo repair. A discussion of abdominal wall reconstruction appears in Volume IV, Chapter 12.

Classification of problems

In 1988, Bozola and colleagues published a classification including five different groups of aesthetic deformities of the abdomen with assigned operative procedures.^26,²⁷ Group I comprised younger nulliparous women with normal elastic skin and good muscle tone but excess adipose tissue in the subcutaneous layer in the abdominal area. Group II patients usually had at least one pregnancy, mild lower abdominal skin laxity, diastasis recti, and excess adipose tissue most often present inferior to the umbilicus. Group III includes patients with significant infraumbilical skin, excess adiposity, and abdominal muscle laxity with diastasis of the rectus and oblique muscles. In addition, patients often have striae after multiple pregnancies. Patients in group IV and V have severe skin and fat excess superior and inferior to the umbilicus, accompanied by mild to severe diastasis of the rectus and oblique muscles. Group V patients present with an umbilicus which is below the ideal height.

To attempt the correlation of appearance and physical examination findings to appropriate surgical interventions in patients after massive weight loss, Song et al. designed the “Pittsburgh Rating Scale”, a classification system that addresses the full range of post-weight loss deformities found in this unique population (Fig. 25.6).²⁸

Fig. 25.6 Pittsburgh rating scale for abdominal deformities.

Patient selection and indication

The preoperative evaluation of intra-abdominal content and the resulting pressure is important to avoid a postoperative pressure increase or abdominal compartment syndrome. In cases of elevated intra-abdominal pressure, in the supine position, the abdominal wall elevates above the costal margin and the level of the iliac crest (Fig. 25.7). Abdominoplasty procedures with or without rectus plication, have to be performed cautiously in such cases.

Fig. 25.7 Assessment of intra-abdominal pressure in the supine position. The nonscaphoid abdomen will be prone to pressure increase after abdominoplasty.

History and physical examination

During the first consultation, a review of the patient’s medical history and a physical examination is done. The evaluation of medical history should include the weight history with the current BMI, weight fluctuations and constancy, possible bariatric procedures, nutritional disorders, medication, the number of pregnancies and children, history of caesarean section, abdominal surgeries and abdominal hernias, the frequency of exercise, gastrointestinal, cardiac and pulmonary history, and a smoking history. Previous liposuction in the abdominal area has to be documented. Women wishing to become pregnant should be advised to postpone abdominal contouring, however. Future pregnancy does not demonstrate a contraindication.

The physical examination covers the entire abdominal wall, including the skin and fat layer, the musculoaponeurotic layer and the intra-abdominal volume. Examination of the skin and fat tissue is done by pinching and measurement of the subcutaneous layer thickness. Skin quality and the presence of striae are assessed, noting that supraumbilical striae commonly are not resected in abdominoplasties. Studies on skin quality in post-bariatric patients have demonstrated damage to collagen structures.^29,³⁰

The lower and occasionally upper abdominal pannus have to be evaluated and measured, with the fold areas examined for eczema and consequent hyperpigmentation. The skin excess in the areas below the lower abdominal fold, in the area of the lateral and upper abdomen, the waist, hips and thighs as well as the lower chest have to be included into the preoperative assessment, during upright standing, supine as well as sitting positions.

Any scar in the abdominal area can impair the blood supply, especially subcostal and midline scars. Horizontal upper abdominal scars will limit the choice of procedure, perhaps leaving reverse abdominoplasty as the only viable option. Vertical midline scars can be included into the fleur-de-lis technique.

The knowledge of abdominal zones of adherences in the supraumbilical midline and the inguinal area is crucial for the surgical planning. Upper abdominal rolls arise from a zone of adherence at the waist level.

Lastly, the abdominal wall has to be critically examined for bulging due to a rectus diastasis or due to incisional, epigastric or umbilical hernias. In cases of diagnostic uncertainty, a computed tomography (CT) or magnetic resonance imaging (MRI) can be helpful.

The following documentation is recommended:

• Quality of skin

• Thickness of adipose tissue

• Number and location of folds

• Location of abdominal wall defects

• Patient’s favored clothing

• Pre-existing scars

• Status of abdominal musculature

The following measurements are recommended:

• Distance from umbilicus to top of mons

• Distance from umbilicus to sternal notch

• Distance from anterior vulva commissure to top of mons

• Waist and hip measurement, waist-to-hip ratio

• Thickness of abdominal adipose tissue by pinching.

• Due to an increased risk of thromboembolism and seroma formation, indication for abdominal surgery should be made critical in cases of a BMI higher than 30 or an estimated weight of resection above 1500 g. Further, a higher preoperative BMI restricts the postoperative aesthetic results.

Photographic documentation

It is important to ensure complete photographic documentation pre- and postoperatively, consisting of at least five and if possible eight views, including: anterior, oblique anterior, side, oblique posterior and posterior views. Additional photographic documentation should include the patient in a forward bending position from side and front views as well as the patient in sitting position. Commonly accepted postoperative time points for photography are at 3, 9, and 12 months.

The area to be photographed should extend from the submammary fold down to the symphysis pubis; adjoining areas can be included in additional photographs. Also helpful are views with abdominal muscles contracted and relaxed. One photo-set is made in the upright position with the patient’s arms down and another with raised arms. Furthermore, patients can be photographed in the sitting position to demonstrate redundant upper abdominal laxity and tissue excess. Supplementary images can be obtained with patients grasping and holding up excess abdominal tissue in the central and waist region, as well as pinching of excess tissue in the central abdominal area with front and side views in a bent forward position.

Informed consent

Patient education and consultation on the operative procedure, possible alternative techniques, as well as the risks and benefits are a crucial part of preoperative management. Besides regularly available standard consent forms, which have to be reviewed with the patient, an audio-visual demonstration is useful for improved understanding and recollection later. As with any cosmetic procedure, patients have to be informed ruthlessly about any imaginable complication; this can include seeing photographs of major wound complications such as flap necrosis with subsequent skin grafting. Additionally, standard and individual consent forms have to be explained and documented. Ideally, the informed consent should be signed by the patient and the consulting surgeon at the earliest opportunity, followed by a second consent shortly before surgery. Patients have to be informed about their postoperative care, including their expected level of activity. Patients must clearly understand the limitations of the surgical result in cases of existing variables of bone structure, intra-abdominal fat, and existing scars. Lastly, patients must be aware that like any aesthetic or reconstructive procedure, their abdominoplasty may require an operative revision at a later date.

Patients’ preoperative instructions

Patients are required to stabilize weight for at least 12 months preoperatively; any desired weight loss should be implemented prior to the surgery. Patients are strongly advised to stop smoking 6 weeks prior to the surgery, and at a minimum, at latest 2 weeks prior and for at least 2 weeks postoperative. Patients should take antiseptic showers in the evening and morning prior to the surgery, the abdominal folds and the umbilicus should be cleaned thoroughly with cotton sticks and antiseptic solutions.

If perioperative blood transfusion is a possibility, patients are informed preoperatively, as this will require blood typing and an informed consent.

Anticoagulant drugs must be avoided 10 days prior to surgery. The patient should also avoid perioperative use of various homeopathic drugs and nutritional supplements, which can induce bleeding.

Due to an expected increase of intra-abdominal pressure, surgery is generally performed with bowel purgation the night before surgery. In severe cases, patients can be restricted to a fluid diet for 24 h prior to surgery.

Patients should be well informed about the intraoperative procedures, including any adjunct activities such as positioning, antithrombotic arrangements, Foley catheter, drain and garment placement, and patient-controlled analgesia.

Patients must be instructed about the postoperative course, regarding thromboembolism prevention, respiratory exercises, early mobilization, avoidance of high abdominal pressure, the schedule for drain and suture removal and the minimum time required off work and away from exercise.

Preoperative markings

The expected markings should be demonstrated and discussed with the patient during the initial consultation, to allow enough time for patients to be concerned with the future scar course. Preoperative markings should be carried out as close as possible to the time of surgery. We recommend the photographic documentation of operative markings for reference later in cases of the patient’s discontent. Reviewing the preoperative markings after the surgery will also aid the surgeon in a personal program of quality improvement.

The scar course in male patients should generally run flatter and lower than in female patients with respect to a reduced waist tightening.

Aesthetic procedures

Markings and scar-position – measurements

We commence the marking with a partially dressed patient in the upright position in order to mark the borders of the underwear. The future scars should then be evaluated and discussed with the patient. In this context, it is important to inform the patient that tractive forces and tissue excess may cause asymmetric results and aberrant scar positions. We mark the future scar line with a different coloured felt pen. This procedure has proved its value, since the patient gets involved in the preoperative planning, and thus feels jointly responsible for the future scar course (Fig. 25.8).

Fig. 25.8 Markings are to be performed with respect to the anterior vulva commissure and the umbilicus.

The expected resection is then evaluated by careful pinching of the tissue (Fig. 25.9). According to the physical equilibrium of forces, we mark the lower incision line about one to two finger-breadths below the expected scar line. The patient is asked to evaluate the redundant tissue for precise positioning.