Introduction

The high lateral tension abdominoplasty (HLT) accomplishes far more than a flatter anterior abdomen: it is a modified lower body lifting procedure. Lockwood ¹ noted that his body lifting procedure improved the abdomen more than did an abdominoplasty. He attributed this to his observation that the greatest laxity is lateral, and therefore a greater amount of excision should occur in those areas (Table 25.1).

TABLE 25.1 Comparison of HLT to Standard Abdominoplasty

	HLT	Standard
Objective	Rejuvenation of abdomen and trunk	Rejuvenation of central abdomen
Anatomical basis	Greatest laxity is lateral	Greatest laxity is central
Incision	Lower centrally, raising laterally obliquely, usually longer	More superior and horizontal, usually shorter
Umbilicus management	Better to close site vertically than to pull tighter to excise	Better to pull tighter to excise than to close vertically
Areas of improvement	Central abdomen as well as flanks, inguinal region, buttocks	Mostly central abdomen
Simultaneous liposuction	Can be more liberal	Should be more reserved
Location of tension	Greatest tension on lateral limbs of incision along inguinal crease; less tension centrally on the mons	Greatest tension is centrally over mons; progressively looser along inguinal crease
Direction of pull	In two oblique directions, perpendicular to the lateral limbs of the incision	In one superior-inferior direction, perpendicular to the central incision

Two years later Lockwood published his HLT paper,² which was the anterior component of his body lift. He ascribed four key characteristics to the HLT. First, only areas to be excised or necessary for rectus plication would be undermined. Second, simultaneous liposuction would therefore be safe. Third, he used permanent sutures to close the superficial fascial system (SFS) as a means to reduce the widening of scars and to improve skin contour far away from the incision. Finally, he emphasized the importance of putting the greatest tension on the lateral part of the incision.

Though it is the basis for the name of this procedure, the notion of placing high tension laterally remains elusive. That is because it is not something that can be shown in a drawing. Rather, it is a principle that must be understood while marking the patient, and even more so when determining the extent of skin resection intraoperatively.

Instead of being called “high lateral tension” it should have been called “higher lateral tension” because the point is not that the lateral tension is high per se, but that it is merely greater than the central tension.

The higher lateral tension concept also forces us to pay more attention to the scar location. There is a natural tendency to expect the final scar to correspond to the initial incision. But the initial incision has no more to do with the location of the final scar than does the final incision. Both equally determine the amount to be excised, and each needs to be planned carefully (Fig. 25.1).

FIG. 25.1 Origins of the HLT.

Before and after a high lateral tension abdominoplasty (HLT).

Preoperative Preparation

Figure 25.2 shows the preoperative markings. Any abdominoplasty has the potential to correct three separate anatomical structures: skin, fat, and muscle. Each is evaluated separately in order to preoperatively plan the operation and give the patient reasonable expectations.

FIG. 25.2 Preoperative marking.

(A) Make an outline of the patient’s underwear or bikini bottom. (B) Determine the location of the ideal final scar within the underwear. (C) Place vertical force that simulates the tension after excision. The patient should be against a wall so that they are not pushed over. Note that the incision may end up beneath the underwear, but this will rise up with final closure. (D) Make a grid to help make the initial incision and the final line of excision symmetric. It may be helpful to do this before even drawing the intended initial incision.

Skin Excess

One of the signatures of the high lateral tension abdominoplasty is that it requires the greatest tension to be placed on the lateral part of the incision. This means that the umbilical site might not get excised, leaving a vertical scar from its closure. While this usually heals well, and accepting that the presence of this scar may be considered the sine qua non of a true HLT philosophy, this scar does not always heal perfectly, and many patients want to avoid it. If there is any question as to whether the site can be excised, the patient should be warned that there are three choices: proceeding with a classic HLT (Fig. 25.3) and accepting a vertical scar if necessary, placing the incision more superiorly on the abdomen so that there is a greater chance of excising the old umbilical site (though the necessity for elevating the lateral limbs of the flap may make the lateral scar more likely to rise above pants), or abandoning the HLT principles and placing as much central tension as is necessary to remove the site.

FIG. 25.3 Classic vs. HLT.

In the classic abdominoplasty (A), the surgeon is focused on removing the umbilicus and places the greatest tension centrally, potentially elevating and narrowing the mons, exposing the labia, and not maximally tightening the groin and upper anterior thigh. In the high lateral tension shown in (B), the greatest tension is in the groin, enough so that the tissue over the mons is almost approximated once the lateral limbs are closed.

Patients frequently ask for a “mini” tummy tuck, wanting the horizontal extent of the incision to be as short as possible, perhaps even as narrow as their C-section scar. Few individuals have vertical laxity so slight and horizontal laxity so centrally focused that a short scar removes all the troubling laxity and attractively recontours the abdomen (Fig. 25.4). The patient should always be evaluated sitting straight upright or even bending forward, as this demonstrates the amount of vertical excess as well as the extent to which the laxity extends laterally. Placing patients in this most unflattering of positions helps them to see the extent of their laxity (Fig. 25.5). They can understand that if there is laxity at the anterior axillary line, then an incision that stops at the midclavicular line will be inadequate to create a nice contour. It can also be demonstrated that if there is a significant amount of vertical excess to be excised, a significant length of the incision is obligatory to avoid a dog-ear. Given that the HLT has greater lateral tension and seeks removal of lateral skin excess, the incision must go even more laterally. Lockwood’s drawings show the superior and inferior incision joined at a 90° angle, but in his discussion he says that the incision needs to be lengthened to eliminate a dog-ear. (This is a reminder that the highest tension is not at the very lateralmost extent of the incision, but is usually located at about the midclavicular line.) An HLT incision will invariably be at least as wide as the anterior axillary line, and often to the posterior axillary line. The philosophy of the standard tummy tuck is to excise the old umbilical site at whatever tension is necessary. The length of the scar is essentially that which is necessary to recontour the abdomen without a dog-ear. But the HLT concept is that the greatest laxity is more lateral, and that it is essential to excise that to optimally tighten the thighs. Placing more tension centrally raises and distorts the mobile mons, oftentimes shortening the distance from the top of the public hair to the umbilicus. Since the mons is more vertically mobile than the skin along the inguinal crease, high central tension causes the mons to rise, making the incision more flat and horizontal, and it is the angle of the lateral limbs that most helps flatten the epigastrium. The HLT concept is that it is better to have a vertical scar from the old umbilical site, with the mons/pubic hair left lower with a greater distance between it and the umbilicus. That is because the standard tummy tuck is essentially an exercise in “excising the umbilicus”; the width is only that which is necessary to remove that vertical excess without creating a dog-ear. But the HLT considers that lateral excess the most important area for excision. By pulling down and out laterally, a greater degree of flattening of the epigastrium occurs than simply pulling straight inferiorly. The greatest laxity on the trunk of the postpartum or weight loss patient is also laterally, so this area needs the greatest amount of excision (Fig. 25.6).