Introduction

Fleur-de-lis abdominoplasty is a full abdominoplasty coupled with a vertical scar component to also address transverse tissue excess. Good candidates for fleur-de-lis abdominoplasty have excess lower abdominal skin in vertical and transverse vectors. Patients with existing abdominal scars, especially in the midline, are particularly good candidates as there is already a vertical scar and these patients are often more willing to accept re-excision of this scar in order to eliminate excess skin in the transverse dimension. Many massive weight loss patients simply lack the dermal elasticity for abdominal skin to shrink as the subcutaneous fat is lost. For patients without a vertical scar, a preoperative discussion must be had to make sure the patient is willing to accept extra scarring to obtain a maximum result. This result can be achieved predictably with good preoperative surgical planning and appropriate management of patient expectations.

Preoperative Preparation

For all excisional body contouring procedures, we check a preoperative coagulation profile, complete blood count, comprehensive metabolic profile and Factor V Leiden. Risk factors for thromboembolism are ascertained, including hormone or birth control use, which we ask to be discontinued for at least two weeks preoperatively. We also discontinue aspirin and herbal medications. We ask our patients to wear a tight abdominal binder day and night for two weeks preoperatively to simulate the myofascial plication. This theoretically allows the body to adapt to the higher intra-abdominal pressure so the effect on venous return and ventilation is minimized. Lastly, we recommend a liquid diet for two days preoperatively to help reduce intra-luminal volume.

Patient Evaluation

Patients with complaints of abdominal tissue excess are evaluated for skin quality, stretch marks, subcutaneous adiposity, intertrigo, lymphedema and hanging skin. A careful evaluation of the entire abdomen, flanks, back and buttocks is carried out, noting previous surgical scars. Bimanual palpation is used to gauge redundant tissues and demonstrate to patients the degree of transverse skin tightening possible with the vertical resection (Fig. 26.1). Care is taken to diagnose hernias, particularly in patients with a history of open bariatric procedures. Repairing these hernias at the same time as body contouring is discussed with the patient, as well as the possibility of needing mesh (Fig. 26.2).

FIG. 26.1 (A) Strong bimanual palpation is used to demonstrate the amount of transverse tissue excess. (B) The width of the planned vertical resection is 21 cm. A previous midline scar is marked in red. Note the planned resection tapers toward the midline inferiorly. This is important to take tension off the final closure.

FIG. 26.2 Typical preoperative patient presenting for body contouring. The patient is marked for fleur-de-lis abdominoplasty. Note the hernia marked in red as a result of a prior open bariatric procedure. Frequently the hernia can be repaired and reinforced with midline muscle plication at the time of surgery. Postoperative results are shown in Fig. 26.10.

Using physical exam findings and patient wishes, a surgical plan is formulated. Patients found to have an excess of abdominal tissue in the vertical and transverse dimensions are offered a fleur-de-lis abdominoplasty. Often there is associated ptosis of the flanks and buttocks, and the patient may be best served with a circumferential body lift and fleur-de-lis abdominoplasty. Any regions of excess adiposity can be addressed with concurrent liposuction. All three procedures can be performed safely during one anesthetic.

The mons should be evaluated independently. Excess skin, adiposity and ptosis frequently remain after massive weight loss. If the patient perceives the region as unacceptably full, treatment options include liposuction and direct skin excision. Ptosis is corrected as part of the abdominoplasty closure and will be addressed later in the chapter.

Preoperative photographs are taken in five standard views for the fleur-de-lis abdominoplasty, with an additional three views for a circumferential procedure.

The patient is asked to strongly lift their abdominal skin while in a standing position (Fig. 26.3). The low transverse marking is made at the level of the pubic symphisis, which ends up removing one third of the hair-bearing mons. This mons reduction coupled with the lift achieved during closure is typically the extent of mons contouring required. The low transverse incision is extended bilaterally to the level of the anterior superior iliac crest. The incision is measured to make sure each side is of equal length. If a body lift is planned, the markings are continued circumferentially.

FIG. 26.3 The standing patient is asked to strongly lift excess abdominal skin, and the lower incision is marked at the level of the pubis. This results in the upper third of the hair-bearing mons being within the planned resection.

The superior portion of the abdominoplasty incision is usually judged to be just above the umbilicus. The excess tissue in the transverse dimension is then marked using strong bimanual palpation (Fig. 26.1A). The planned vertical resection is elliptical, tapered at the xyphoid process superiorly and near the planned horizontal incision inferiorly (Fig. 26.1B). All markings should be double-checked intraoperatively prior to incision. Adjunctive liposuction marks are made along with existing scars and hernias. Midline scars are simply incorporated into the planned resection, but off-centered ones such as open cholecystectomy scars may require modification of the vertical resection to incorporate the previous surgical scar and bring the final planned closure off midline (Fig. 26.9).