The evolution of the modern abdominoplasty

The abdominoplasty technique has evolved significantly in the last 4 decades. The modern abdominoplasty technique was developed in South America in the 1960s. The basic surgical tenets have always been to conduct a rectus plication, with maximal excision of the central skin excess by extensive undermining of the entire abdominal wall. The closure is often under some tension and is therefore, per force, conducted with the patient in significant flexion. When liposuction was introduced in the 1980s, it soon became apparent that blithely and aggressively adding this modality to abdominoplasty was fraught with an unacceptable incidence of flap ischemia and skin necrosis. Liposuction then evolved into a more conservative adjuvant treatment. Although there were indeed less physiologic problems with this technique, the aesthetic results were also, once again, more constrained.

Then, in the early 1990s Lockwood published a series of seminal articles that single handedly changed the tack of the abdominoplasty technique. Based on his extensive experience with body-contouring surgery, he decisively demonstrated and definitively modified the surgical principles of abdominoplasty and reported greater safety and improved aesthetics. He enumerated several surgical tenets that were in many ways diametrically opposed to those of the classic or traditional abdominoplasty: the undermining of only the central skin flap to facilitate plication with discontinuous dissection elsewhere (to enhance vascularity and allow for judicious concomitant liposuction) and the initial resection of the lateral excess skin, with more conservative resection of the central skin flap (to accomplish a more complete and natural repair) by using a planned and controlled high-tension closure (with the diligent use of the underlying superficial fascial system). And so HLTA was borne.

HLTA: a 2.0 version

In the past 12 years, I have become a diligent student of these Lockwood principles and applied them to a large series of several hundred patients. The application of these principles and the critical analysis of the results have driven a successful evolution of the HLTA procedure. For a result to be called truly successful, strict standards were balanced equally: the case had to demonstrate the greatest degree of safety (zero tolerance for complications), with the maximal aesthetic result (correction of all deformities) and with a consistent reliability of the technique (regardless of patient presentation). Several important expanded principles of the HLTA may be distilled from this experience to define a true 2.0 advancement in technique.

• 1.
  

  The abdominal procedure should not be a slave to the otherwise arbitrary mandate that all the skin between the pubis and the umbilicus must be excised. This approach only truly works in the patient with an enormous pannus. Otherwise, the excisional marking must be, per force, placed above the pubic hairline to accomplish wound closure, that despite the harnessing of the excess pubis, remains overly tight. That result may be an excessively high scar and superiorly retracted pubis, an unnaturally flat hypogastrium and more seriously, an exaggerated rate of wound dehiscense and skin necrosis. Instead, any redundant pubis should be excised, rather than aid in the closure of harnessed. The pubis is then closed under no tension and rests in a lower, more inconspicuous location. However, except for the most “redundant” cases, this approach often deliberately leaves some of the skin between the pubis and umbilicus intact. This necessitates that the original umbilical site be closed. The surgeon must resist the temptation to remove even a few centimeters of intervening abdominal skin for fear of recreating the usual overly tight closure.

  
  
• 2.
  

  Any abdominoplasty should consider not only what is above the future incision (the traditional pannus) but also what is below: that is, the excess pubis, anterolateral and medial thigh redundancy, as well as buttocks laxity. Otherwise, the tissues below the incision may be distractingly untreated postoperatively and the full effect of the HLTA may not be realized. This tenet underlines one of the greatest benefits to HLTA not normally considered possible with traditional abdominoplasty: one can realize a true body lift effect through an anterior incision only. In essence this approach is actually a “global” tension abdominoplasty, with sequential tension placed fully from lateral to medial.

  
  
• 3.
  

  It is has always been important to evaluate the magnitude of excess skin to be excised. But to actually design the most efficient length and direction of the incision, it is critical that the extent and orientation of the skin left behind is also assessed. The surgeon must ensure that the remaining skin is both sufficient to close the defect and efficiently relieved of its own redundancy. This principle may be applied equally to the central and lateral closure. Specifically, laterally, the excess skin at the hip and thigh is often neglected by traditional abdominoplasty. This primarily obliquely oriented excess tissue is efficiently removed through the oblique incision/vector of the HLTA. Centrally the superfluous skin at the epigastrium constitutes primarily horizontal excess (that has migrated from the chest), that can neither be efficiently removed nor should be used to close a lower abdominal defect, through the horizontal incision. Therein lies the essence of the potential flaw in traditional abdominoplasty and the efficacy of the high lateral tension technique. That is, an incongruent consequence may occur: the wound closure may be too tight despite the apparent epigastric redundancy, which can, in turn, be left behind and the lateral excess cannot be effectively treated because the remaining abdominal flap has been primarily used for the central closure. Instead to reconcile this paradox, less skin should be excised centrally but more laterally, through an HTLA-oriented incision and repair. These concepts are illustrated in Figs. 1 and 2 . Using vector analysis, the lateral tissue above and below the incision is redundant in a more oblique vector and so should be removed through an opposing oblique incision. Serendipitously, this matches the relative direction of the desired HTLA lateral scar placement. In addition, this oblique vector also treats the predominantly horizontal excess in the epigastrium. Applying this vector of excess principle, the necessary direction of the most desirable HTLA central and lateral incision placement is easily understood and defined. Thus, the more a procedure follows the vectors of excess of both what is taken and what will remain, the more efficient the treatment of redundant skin.

  
  

  
  

  
  

  
  

  
  

  The more a procedure follows the vectors of excess of both what is taken and what will remain, the more efficient the treatment of redundant skin.

  
  

  
  

  
  

  
  

  
  

  Applying this vector of excess principle, the necessary direction of the most desirable HTLA central and lateral incision placement is easily understood and defined.

  
  
  
  
• 4.
  

  As a corollary of this aforementioned principle, it may be stated that, as long as there is excess tissue, the longer the scar, the more far-reaching the tension effect and the more dramatic the results. In fact, as will be shown in this chapter, a “virtual” lower body lift can be accomplished, when indicated from this entirely “supine” operation. Clearly, the most posterior buttocks and thighs cannot be addressed, but this approach can and does satisfy the majority of properly selected patients who, in fact see this effect as a significant bonus. And inherently, this, albeit, “conservative” body lift does reduce the surgical time and operative risks as compared to a full truncal lift procedure.

  
  
• 5.
  

  Lockwood, originally, and rightfully so, emphasized the “lateral” tension nature of this technique. That is, that the surgeon, contrary to the traditional approach, must begin the resection from lateral and work medially. This admonition emanated from his original observation that there was actually more redundancy laterally at the hip, thigh and buttock than centrally. Indeed, if the surgeon respects and executes this principal, they will indeed realize a superior correction beyond the central abdomen. Hence the “lateral” tension eponym. However, it is more instructive and indeed more efficacious to instead, consider the entire length of the wound as tension. That is, it is also possible to accomplish as much correction centrally, at the redundant pubic and inner and anterior thighs, if the tension principle is honored here as well.

  
  
• 6.
  

  The goal of the design and placement of the future scar should primarily be to hide it. Lockwood originally described a very high (French cut) lateral closure, probably because that style of clothing was more fashionable at the time and a more oblique vector of pull does more efficiently treat the upper abdominal excess as described earlier. However, considering how fashion changes, and that a hidden scar will usually trump some residual excess skin, the surgeon should mark the patient within their preferred clothing. This philosophy becomes particularly relevant when working with the low-cut jean fashion.

  
  
• 7.
  

  The location and extent of the remaining subcutaneous fat must also be evaluated and respected. This assessment represents an age-old plastic surgical battle between beauty and blood. That is, at what cost to the blood supply does the surgeon attempt to remove all remaining excess subcutaneous fat? Lockwood originally described a reasonable detente: liposuction should only be conducted beneath tissues that have not been undermined. However, most recently, the proverbial pendulum has swung backward: more recent publications are giving permission once again to conduct more aggressive full truncal liposuction at the time of the abdominoplasty. This recommendation is predicated on the notion that if one follows the original Lockwood admonition to restrain the flap dissection only as much as needed to conduct a fascial plication, then enough perforators are preserved to allow for this aggressive liposuction. However, as has been stated earlier, Lockwood did also warn that despite this conservative undermining, liposuction of the remaining central skin flap should not be entertained for fear of skin flap necrosis. (And realistically, some of these same precious perforators are often sacrificed to repair the more protuberant abdomen.) This principle should be respected in light of Lockwood’s prodigious experience.

  
  
• 8.
  

  If the premise is to preserve the central flap’s blood supply by undermining only centrally to allow for fascial plication, it may indeed be self-defeating to then disrupt the very same flap with liposuction. Ironically, the only patients who might be candidates for such an aggressive approach would be those without a significant amount of fat in the first place: that is, the patient with a low body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters). Otherwise, in the usually higher BMI abdominoplasty patient, liposuction should be restricted to the waist and hip rolls with a planned secondary liposuction centrally, some 6 to 12 months later. Only then, can a zero tolerance for skin flap necrosis and dehiscence be honored.

HLTA: a 2.0 version

In the past 12 years, I have become a diligent student of these Lockwood principles and applied them to a large series of several hundred patients. The application of these principles and the critical analysis of the results have driven a successful evolution of the HLTA procedure. For a result to be called truly successful, strict standards were balanced equally: the case had to demonstrate the greatest degree of safety (zero tolerance for complications), with the maximal aesthetic result (correction of all deformities) and with a consistent reliability of the technique (regardless of patient presentation). Several important expanded principles of the HLTA may be distilled from this experience to define a true 2.0 advancement in technique.

• 1.
  

  The abdominal procedure should not be a slave to the otherwise arbitrary mandate that all the skin between the pubis and the umbilicus must be excised. This approach only truly works in the patient with an enormous pannus. Otherwise, the excisional marking must be, per force, placed above the pubic hairline to accomplish wound closure, that despite the harnessing of the excess pubis, remains overly tight. That result may be an excessively high scar and superiorly retracted pubis, an unnaturally flat hypogastrium and more seriously, an exaggerated rate of wound dehiscense and skin necrosis. Instead, any redundant pubis should be excised, rather than aid in the closure of harnessed. The pubis is then closed under no tension and rests in a lower, more inconspicuous location. However, except for the most “redundant” cases, this approach often deliberately leaves some of the skin between the pubis and umbilicus intact. This necessitates that the original umbilical site be closed. The surgeon must resist the temptation to remove even a few centimeters of intervening abdominal skin for fear of recreating the usual overly tight closure.

  
  
• 2.
  

  Any abdominoplasty should consider not only what is above the future incision (the traditional pannus) but also what is below: that is, the excess pubis, anterolateral and medial thigh redundancy, as well as buttocks laxity. Otherwise, the tissues below the incision may be distractingly untreated postoperatively and the full effect of the HLTA may not be realized. This tenet underlines one of the greatest benefits to HLTA not normally considered possible with traditional abdominoplasty: one can realize a true body lift effect through an anterior incision only. In essence this approach is actually a “global” tension abdominoplasty, with sequential tension placed fully from lateral to medial.

  
  
• 3.
  

  It is has always been important to evaluate the magnitude of excess skin to be excised. But to actually design the most efficient length and direction of the incision, it is critical that the extent and orientation of the skin left behind is also assessed. The surgeon must ensure that the remaining skin is both sufficient to close the defect and efficiently relieved of its own redundancy. This principle may be applied equally to the central and lateral closure. Specifically, laterally, the excess skin at the hip and thigh is often neglected by traditional abdominoplasty. This primarily obliquely oriented excess tissue is efficiently removed through the oblique incision/vector of the HLTA. Centrally the superfluous skin at the epigastrium constitutes primarily horizontal excess (that has migrated from the chest), that can neither be efficiently removed nor should be used to close a lower abdominal defect, through the horizontal incision. Therein lies the essence of the potential flaw in traditional abdominoplasty and the efficacy of the high lateral tension technique. That is, an incongruent consequence may occur: the wound closure may be too tight despite the apparent epigastric redundancy, which can, in turn, be left behind and the lateral excess cannot be effectively treated because the remaining abdominal flap has been primarily used for the central closure. Instead to reconcile this paradox, less skin should be excised centrally but more laterally, through an HTLA-oriented incision and repair. These concepts are illustrated in Figs. 1 and 2 . Using vector analysis, the lateral tissue above and below the incision is redundant in a more oblique vector and so should be removed through an opposing oblique incision. Serendipitously, this matches the relative direction of the desired HTLA lateral scar placement. In addition, this oblique vector also treats the predominantly horizontal excess in the epigastrium. Applying this vector of excess principle, the necessary direction of the most desirable HTLA central and lateral incision placement is easily understood and defined. Thus, the more a procedure follows the vectors of excess of both what is taken and what will remain, the more efficient the treatment of redundant skin.

  
  

  
  

  
  

  
  

  
  

  The more a procedure follows the vectors of excess of both what is taken and what will remain, the more efficient the treatment of redundant skin.

  
  

  
  

  
  

  
  

  
  

  Applying this vector of excess principle, the necessary direction of the most desirable HTLA central and lateral incision placement is easily understood and defined.

  
  
  
  
• 4.
  

  As a corollary of this aforementioned principle, it may be stated that, as long as there is excess tissue, the longer the scar, the more far-reaching the tension effect and the more dramatic the results. In fact, as will be shown in this chapter, a “virtual” lower body lift can be accomplished, when indicated from this entirely “supine” operation. Clearly, the most posterior buttocks and thighs cannot be addressed, but this approach can and does satisfy the majority of properly selected patients who, in fact see this effect as a significant bonus. And inherently, this, albeit, “conservative” body lift does reduce the surgical time and operative risks as compared to a full truncal lift procedure.

  
  
• 5.
  

  Lockwood, originally, and rightfully so, emphasized the “lateral” tension nature of this technique. That is, that the surgeon, contrary to the traditional approach, must begin the resection from lateral and work medially. This admonition emanated from his original observation that there was actually more redundancy laterally at the hip, thigh and buttock than centrally. Indeed, if the surgeon respects and executes this principal, they will indeed realize a superior correction beyond the central abdomen. Hence the “lateral” tension eponym. However, it is more instructive and indeed more efficacious to instead, consider the entire length of the wound as tension. That is, it is also possible to accomplish as much correction centrally, at the redundant pubic and inner and anterior thighs, if the tension principle is honored here as well.

  
  
• 6.
  

  The goal of the design and placement of the future scar should primarily be to hide it. Lockwood originally described a very high (French cut) lateral closure, probably because that style of clothing was more fashionable at the time and a more oblique vector of pull does more efficiently treat the upper abdominal excess as described earlier. However, considering how fashion changes, and that a hidden scar will usually trump some residual excess skin, the surgeon should mark the patient within their preferred clothing. This philosophy becomes particularly relevant when working with the low-cut jean fashion.

  
  
• 7.
  

  The location and extent of the remaining subcutaneous fat must also be evaluated and respected. This assessment represents an age-old plastic surgical battle between beauty and blood. That is, at what cost to the blood supply does the surgeon attempt to remove all remaining excess subcutaneous fat? Lockwood originally described a reasonable detente: liposuction should only be conducted beneath tissues that have not been undermined. However, most recently, the proverbial pendulum has swung backward: more recent publications are giving permission once again to conduct more aggressive full truncal liposuction at the time of the abdominoplasty. This recommendation is predicated on the notion that if one follows the original Lockwood admonition to restrain the flap dissection only as much as needed to conduct a fascial plication, then enough perforators are preserved to allow for this aggressive liposuction. However, as has been stated earlier, Lockwood did also warn that despite this conservative undermining, liposuction of the remaining central skin flap should not be entertained for fear of skin flap necrosis. (And realistically, some of these same precious perforators are often sacrificed to repair the more protuberant abdomen.) This principle should be respected in light of Lockwood’s prodigious experience.

  
  
• 8.
  

  If the premise is to preserve the central flap’s blood supply by undermining only centrally to allow for fascial plication, it may indeed be self-defeating to then disrupt the very same flap with liposuction. Ironically, the only patients who might be candidates for such an aggressive approach would be those without a significant amount of fat in the first place: that is, the patient with a low body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters). Otherwise, in the usually higher BMI abdominoplasty patient, liposuction should be restricted to the waist and hip rolls with a planned secondary liposuction centrally, some 6 to 12 months later. Only then, can a zero tolerance for skin flap necrosis and dehiscence be honored.

Patient anatomy

The general abdominal anatomy is well described in this issue by Farzad Nahai. Therefore, the specific anatomy most relevant to the understanding and application of HLTA is highlighted in this article.

There are 3 critical anatomic points that should be understood and respected when planning and performing HLTA:

• 1.
  

  The superficial fascial system: This layer must be identified and used fully to both harness the maximal lift that this technique can proffer and prevent wound dehiscence.

  
  
• 2.
  

  The perforator blood supply: The abdominal flap’s viability is predicated on the preservation of as many fascial perforators as possible.

  
  
• 3.
  

  The zones of adherence: These various points of skin attachment must be released, at least bluntly, to realize the maximum translation of pull of the remaining skin envelope, particularly at the anterolateral thigh region. There is often also what may be called a waist band of adherence at the patient’s midsection that can significantly inhibit the skin’s mobility. (see later discussion).

Patient assessment

A comprehensive examination is mandatory to enable the surgeon to properly prepare the patient and accurately plan the surgery.

Physical

The physical examination should include evaluation of all layers of the abdominal wall: the skin, the subcutaneous fat, and underlying fascia/muscle (with an indirect assessment of the extent of intra-abdominal fat).

Skin

The skin examination should be much more than just the assessment of the classic pannus of excess lower abdominal skin above the pubis.

Striae

Their boundaries are assessed. The extent of the striae that may not be included in the resection should be duly noted and explained to the patient (particularly those above the umbilicus).

Excess skin

The extent of obvious anterior redundant skin (width of the pannus) is noted first. This evaluation most accurately defines the length of the incision. However, a proper assessment must be made beyond the obvious excess lower abdominal pannus if a more complete correction is to be made of the entire anterior trunk aesthetic unit; that is, the extent of redundancy is evaluated not only above the inguinal area but also below the incision, at the hips, thighs, and pubis. If there is particular excess at the lateral thighs, then the incision will, by definition, be appreciably longer, if the HLTA approach is to be properly applied. In fact, in these patients, it may be stated that the longer the incision made, the better the results. On the other hand, if the patient demonstrates minimal excess laterally, then significant tension should not be planned, to avoid making the incision unnecessarily longer. Note should also be made of excess skin at the upper abdomen. Here there may be what I call a secondary roll or wall of cascading skin, which really represents a migration of redundancy from the chest rather than the abdomen. Consequently, all of this upper abdominal skin cannot usually be removed from the suprapubic approach. It is of great value to conduct this examination not only with the patient in the supine and standing positions but also with the patient sitting and bending over. This is often the only posture in which one can see the areas of redundancy in the patient who demonstrates what appears to be primarily abdominal wall protrusion ( Fig. 3 ). Of equal importance, the mobility or what may be called the translation of the skin, is very telling: the looser the skin, the better the potential result.

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