The first stage of the abdominal exam is inspection, with the patient standing and in frontal view: assessment of shape, ratio between subcutaneous and deep fat, symmetry, masses, fat distribution, striae, extent and site of dermatochalasis, and shape and position of the umbilicus. Careful attention must be paid to scars, as previous abdominal surgery may have impaired skin vascular supply. Specifically, scar position, length, width, and retraction are accurately analyzed.

The lateral view, in the upright position, allows evaluation of the lateral extent of the abdominal folds (Fig. 13.1). An easy way to assess musculoaponeurotic system laxity is to have the patient bend over (diver’s test) (Fig. 13.2). Standardized photographic documentation is an integral part of the preoperative evaluation [12].

The patient is then examined in the supine position for palpation. Guarding, rigidity, or pain is noted and intra-abdominal organs are evaluated. As far as the abdominal wall is concerned, attention is paid to thickness and distribution of the subcutaneous tissue, masses, hernias, and rectus abdominis muscle diastasis. Useful maneuvers to assess hernias are to have the patient cough or hold his/her nose and mouth closed and blow forcibly. Muscle diastasis is better palpated by asking the patient to lift his/her head off the pillow and look at his toes. Skin redundancy is assessed by pinching the abdominal wall horizontally and vertically with the patient standing (Fig. 13.3).

Percussion is the next step of the abdominal examination and is used to evaluate masses and to determine if abdominal distention is due to gas-filled bowels or accumulation of fluid.

Auscultation for bowel sounds and bruits is the last step of the abdominal clinical examination.

Preoperative laboratory tests are routinely performed when selecting candidates for abdominoplasty, in particular serum proteins and hydroelectrolytic balance must be tested in patients who previously underwent bariatric procedures, especially if malabsorptive. Adequate vitamin and mineral supplementation must be ascertained in order to prevent nutritional deficiencies [13].

ECG and chest X-ray are routine preoperative investigations. A computed tomographic scan or magnetic resonance imaging of the abdominal wall is carried out in all patients with primary or incisional hernias at rest and during straining. Pulmonary function studies are obtained in patients with primary or recurrent abdominal hernias or chronic obstructive pulmonary disease.

This articulate selection allows identification of candidates for abdominoplasty and, based on the specific abdominal wall deformities, the most appropriate surgical approach. Key points are:

The anchor-line abdominoplasty offers the opportunity to overcome all these concerns:

It is noteworthy that the vertical and horizontal approach is also advantageous whenever concomitant abdominal or gynecological operations are needed, as it allows easier access to the abdominal cavity. This holds true also in case of recurrent incisional hernias.