Joseph P. Hunstad

Remus Repta

The American history of abdominoplasty begins with Kelly’s first report in 1899, in which he coined the term ‘abdominal lipectomy.’ During this first procedure, lower abdominal tissue was excised much as one ‘takes a slice lengthwise of a watermelon.’ This visually understandable description set the stage for many modifications and enhancements of this procedure. The tissue resection was quite substantial, weighing 7450 g and measuring 90 × 31 × 7 cm! In 1910 he reported his eight-patient experience at the Johns Hopkins Hospital, where the incision extended across the central abdomen onto the flanks. This transverse wedge excision of skin and subcutaneous tissue, with possible hernia repair, was performed without undermining. He was the first to note ‘cosmetic benefit’ from this procedure.

Prior to that, in 1890, the French surgeons Demars and Marx had performed significant skin and fat resection from the abdomen. In 1905 Gaudet and Morestin performed a resection of significant excess skin and underlying fat, repair of a large umbilical hernia, and umbilical preservation. In 1931, Passot included undermining with the resection.

German contributions included the transverse elliptic incision in abdominoplasty as described by Morestin, who also published notably on the correction of prominent ears, breast lift, and breast reduction. Weinhold, in 1909, combined a vertical and transverse cloverleaf resection, and in 1911 Jolly first reported the low transverse incision for abdominal tissue resection. A vertical resection was championed by Babcock in 1916.

Thorek’s textbook Plastic Surgery of the Breast and Abdominal Wall in 1924 described umbilical preservation. In 1939, Thorek coined the term ‘plastic adipectomy’ for the resection of ‘fat aprons.’ He described his resection technique as a wedge resection eliminating dead space when the skin edges were closed. He removed the umbilicus with the tissue specimen and then replanted it as a graft in a new, fitting location. He also postulated on alternative methods of circumscribing the umbilicus and leaving it attached by its stalk to the abdominal wall, bringing it through the skin at the end of the procedure.

Foged, in 1949, emphasized the importance of hemostasis. Gillies and Millard, in their 1957 textbook Principles and Art of Plastic Surgery, were the first to describe the ‘Jack-knife’ position, and recommended postoperative knee flexion to reduce the tension on the transverse closure.

Barsky, in 1964, was the first to describe the use of a postoperative abdominal binder. The standard abdominoplasty incision was lengthened circumferentially by two notable surgeons, namely Somalo in 1941 and Gonzalez-Ulloa in 1960. Gonzalez-Ulloa coined the term ‘belt lipectomy.’ This was subsequently expanded upon by Kamper et al., who in 1972 recognized the value of circumferential resection after massive weight loss. These concepts are current today and widely used for the treatment of massive weight loss.

Vernon, an American surgeon, was the first to publish umbilical transposition and relocation with extensive undermining in 1957. Also during the 1950s, dermolipectomy procedures were being performed on the abdomen with increased frequency, notably in South America. Pitanguy’s landmark article in 1967 described 300 abdominal lipectomies and attracted considerable interest. This technique used a transverse incision which curved down at both ends.

The W technique was described by Regnault, from Montréal, Canada, in 1972. This involved resection of the upper hair-bearing mons with lateral incisions along the inguinal folds.

Baroudi published his significant experience in 1974 and 1975, drawing particular attention to the importance of an aesthetic appearance of the umbilicus. His many significant contributions to all techniques in body contouring are well known. The use of quilting sutures was championed by Baroudi as well, and is used extensively to minimize or eliminate seroma and to lessen or eliminate the need for drains in reverse abdominoplasties ( Chapter 10 ) and lipoabdominoplasty ( Chapter 6 ).

During this time Grazer first described rectus plication, which he first learned from Pitanguy (personal discussion, 2001) and which is still in routine use today. His contributions to body contouring are numerous, including gull-wing modification of the Pitanguy abdominoplasty and dermatolipectomies of the extremities, liposuction, and body contouring for the massive weight loss patient. He also performed critical reviews of the American history of abdominoplasty, and by using survey techniques established frequently cited risks and complications.

In 1977 Illouz first performed blunt-tipped liposuction, which ushered in a completely new concept for body contouring. Previous techniques used sharp cutting devices which resulted in significant tissue trauma and scarring. Illouz’s technique has certainly stood the test of time. The simple brilliance of a blunt-tipped cannula protecting important neurovascular structures is now one of the most popular cosmetic plastic surgery procedures worldwide. Illouz states that ‘It is now rare that an abdominoplasty be performed without the assistance of adipoaspiration. Not only is adipoaspiration a useful complement, but it also allows undisputedly good refinements.’ This concept will be described in detail throughout this text as an important adjunctive procedure.

Also in 1977, Rebello described the reverse abdominoplasty, a useful technique for selected patients that have a small amount of soft-tissue laxity primarily located in the supraumbilical abdomen.

Converse (personal communication 2008) was the first to use the concept of hydrodissection which was further expanded by Illouz and Hetter. The process of injecting so-called ‘wetting’ solutions was again greatly expanded upon by Klein, who coined the term ‘tumescent’ for large-volume infiltrations. These concepts resulted in a substantial reduction in blood loss during liposuction procedures, allowing much greater volumes of liposuction to be performed without the need for transfusion. These concepts are equally appropriate for both local and general anesthesia and are used concurrently with the majority of abdominoplasty procedures.

Toranto, in 1988, expanded on Pitanguy’s and Grazer’s concepts for rectus plication by bringing together not only the medial borders of the rectus muscle anterior rectus sheath but often the lateral borders as well. This was noted to dramatically improve the waistline and posture of the abdominoplasty patient.

A very important concept in body contouring was set forth by Lockwood in 1991, with his emphasis on the superficial fascial system (SFS). Wounds closure by maximum tension at the level of the superficial fascia allowed the skin closure to be performed under minimal tension, which helps to achieve a fine-line high-quality scar. Lockwood further described a high-lateral tension abdominoplasty which was designed to improve the waistline.

In the mid-1990s endoscopic techniques were being applied to aesthetic procedures of the face, breast and body. The concept of an endoscopic abdominoplasty was introduced, which consisted of abdominal liposuction with endoscopically assisted muscle plication. This is a useful technique for patients with only a small amount of soft tissue laxity and whose abdominal contour irregularity is largely a result of myofascial laxity.

In the recent years, Hunstad has used many of the above concepts in a combined fashion, including high-lateral tension, SFS closure, wide rectus abdominis plication, subscarpal fat resection, and thorough concurrent tumescent liposuction, to achieve desirable and predictable results.

Continuous improvement in body contouring procedures in general, and in abdominoplasty techniques in particular, has been observed since the very first procedures were performed more than 100 years ago. Future improvements and innovation will undoubtedly be introduced as the current and future generations of plastic surgeons continue to refine the practice of body contouring surgery.