Introduction

The treatment of the abdominal contour, in general, is managed by procedures at two extremes, liposuction and classic abdominoplasty. Patients with excess abdominal adiposity without flaccidity undergo liposuction, and those with accentuated abdominal laxity have traditionally been treated with the classic abdominoplasty, which corrects the excess skin and fat in the abdominal wall, and is usually performed in association with the correction of abdominal diastasis recti. In most patients the outcome of the latter procedure is favorable, but at the expense of extensive scarring, which is not always well accepted by patients. However, a range of intermediary cases exist which are not a perfect match for either simple liposuction or classic abdominoplasty.

Basic Science

Diastasis of the rectus abdominis muscles requires correction, regardless of whether there is enough excess skin for classic abdominoplasty. Many cases requiring correction of diastasis are contraindicated for classic abdominoplasty.

In cases where the navel is high, leaving little skin expanse above the umbilicus, or even in cases where the supraumbilical skin has little flaccidity, a classic abdominoplasty is difficult. Patients with post-pregnancy diastasis but with plans for further pregnancies are also a relative contraindication for the classic tummy tuck.

The correction of the diastasis can be accomplished via a small video-assisted suprapubic incision, without skin resection, or by a mini-abdominoplasty in a technique described since 1971 by Callia, with a small infraumbilical skin resection. Other authors have already described, with variations, an infraumbilical plication only and no detachment of the umbilicus.^1–7 There are also descriptions of a small incision in the umbilicus to facilitate the supraumbilical detachment² and another approach that detached the umbilicus from the m. rectus.^8,9 Since the introduction of video-endoscopy, indications for the correction of diastasis without skin resection can be extended to include, primarily, congenital diastasis and diastasis in men.¹⁰

Indications for video-assisted mini-abdominoplasty are limited. This option must be precisely discussed with the patient because, on the one hand, there is the advantage of less scarring, but on the other hand, resection of skin is limited and there may be mild residual laxity both above and below the umbilicus. Another factor that should be considered in female patients is the possibility of pregnancy after surgery. In nulliparous patients who have abdominal flaccidity following weight loss (Figs 24.1 and 24.2), or in patients who have post-pregnancy abdominal flaccidity but are planning another pregnancy, this technique would be well indicated, because it doesn’t present the same limitations as classical abdominoplasty for postoperative pregnancy.

FIG. 24.1 Pre- and postoperative young patient, post weight loss, frontal view.

FIG 24.2 Appears ONLINE ONLY

FIG. 24.2 Pre- and postoperative young patient, post weight loss, half profile view.

Diagnosis/Patient Presentation

It is essential that candidates for this procedure have a high navel; this allows correction of the flaccidity that occurs right above the umbilicus, by reinserting the navel a few centimeters lower (1.5 to 2 cm), while still maintaining an adequate distance between the umbilical scar and pubic region.

Proper physical examination of the patient is of paramount importance, both in the seated position, to measure if the supraumbilical fold is correctable with mini-abdominoplasty, as well as lying down with effort, to assess the degree of diastasis. In patients with thick adipose tissue, moderate liposuction can also be performed, being sure to maintain a sufficient thickness of the panniculus to avoid surface irregularities and increased skin flaccidity above the umbilicus.

Patient Selection

The selection of patients is subject to strict criteria:

• Patients with mild supra- and/or infraumbilical skin laxity, with diastasis of the rectus abdominis.

• High navel position, more than 14 cm above the pubis.

• Firm or minimally flaccid supraumbilical skin that will not allow the descent of the supraumbilical region to the suprapubic region.

• The possibility of post-abdominoplasty pregnancy, provided that the flaccidity is not excessive. These patients fall into Types III and IV of the Bozola and Psillakis classifications,¹ and Type I in the Nahas classification system.⁴

• Diastasis of the rectus abdominis muscle, which can either be acquired (post-pregnancy or following weight loss), or congenital, which can occur in both women and men (Figs 24.1–24.7).

FIG. 24.3 Correction of congenital diastasis – male patient, frontal view.

FIG. 24.5 Correction of congenital diastasis – male patient, profile view.

FIG. 24.6 Correction of diastasis of the rectus abdominis, half profile view.

FIG. 24.7 Correction of diastasis of the rectus abdominis, profile view.

FIG 24.4 Appears ONLINE ONLY

• Abdominal hernias (especially umbilical hernia) associated with lipodystrophy and skin flaccidity (Figs 24.8 and 24.9).

• Lipodystrophy and moderate skin flaccidity, where liposuction would offer limited results (Figs 24.10 and 24.11). Younger patients who have undergone massive weight loss resulting in abdominal flaccidity fall into this category, and also those with post-pregnancy flaccidity but who may become pregnant in the future (Figs 24.12 and 24.13).

FIG. 24.8 Abdominal hernias (especially supraumbilical hernia) associated with lipodystrophy and sagging skin, frontal view.

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