The Clinical Problem ( Fig. 31.1 )
Abdominoplasty is a surgical procedure designed to rejuvenate truncal aesthetics, in which flattening a protuberant abdomen, removing redundant tissue, and restoring normal waistline definition is a surgical challenge. Advancement in surgical techniques should reduce surgical risk and improve aesthetic outcomes. The term modified Brazilian abdominoplasty (MBA) originated after a presentation by the Brazilian plastic surgeon, Joao Erfon Ramos, at the International Society of Plastic Surgeons Meeting in Australia in 2008. Results are at least as good, but the complications are significantly lower than with a traditional abdominoplasty, where there is wide undermining and excision of Scarpa’s fascia in the lower abdomen. The proven lower complication rates are achieved through minimizing dissection and dead space. Waist definition is improved by a combination of medially advancing lower abdominal Scarpa’s fascia and repairing any divarication of the rectus abdominis muscles. Scarpa’s fascia is an important part of the superficial fascial system (SFS), which helps define waist contour and may also have a role in urogenital dynamics.
Abdominoplasty is a plastic surgery procedure that has been evolving over time. Significant refinements have been introduced in abdominoplasty techniques to meet the growing perception of aesthetics among the general population, as well as dealing with the new challenges that were recognized by surgeons. Eventually, a new concept has evolved—truncal rejuvenation. This truncal rejuvenation, as described by Lockwood in 2004, envisages the trunk and thighs as a circumferential aesthetic unit, extending from the breasts to the knees.
One of the challenging elements of truncal rejuvenation is restoring a normal waistline definition. The combined effects of pregnancy, aging, and fluctuations of obesity on the abdominal wall are characterized by redundant skin, with associated striae, excess subcutaneous fat, and musculoaponeurotic flaccidity. When performing a traditional abdominoplasty, these three fundamental defects of the abdominal wall must always be addressed by the plastic surgeon. The waist, as part of the trunk circumferential aesthetic unit, must also be addressed in the same manner.
Musculoaponeurotic laxity is corrected by midline plication of the rectus sheath from the xiphoid to the pubis ; however, this technique alone is not sufficient to improve the contour deformity of the whole musculofascial layer, especially in the waist area. Skin excess or lipodystrophy encircling the truncal region, especially involving the flank areas, can be extremely problematic for the plastic surgeon. Unfortunately, this cannot be corrected solely by a traditional abdominoplasty operation or liposuction in most cases. In addition, abdominal wall flaccidity and ptosis inevitably cause unwanted bulging of the mons pubis.
The MBA technique was adopted over 8 years ago as a means to excise lower abdominal wall apron, tighten the rectus sheath, provide a more aesthetic waistline, and reduce the prominent bulge of the mons pubis, thus returning the ptotic, bulging, U -shaped mons back to its more youthful V shape. This discussion focuses on the surgical technique whereby flank tightening using medial advancement of Scarpa’s fascia improves waist definition, and mons elevation is achieved using lipocutaneous mobilization and elevation of Scarpa’s fascia in the lower abdomen. It is always combined with the MBA technique.
Surgical Technique
Incisions
The lower elliptic linear incision line is marked at the upper limit of the pubic hair in the natural crease line, where possible. The upper incision line is marked to include the umbilicus. The lateral limit to the scar was determined by assessing the skin redundancy with the patient in the sitting position.
Excess Tissue Excision
Tissue excision is full thickness down to the rectus sheath, only within a subumbilical midline strip 4 cm lateral to the midline on both sides using the harmonic scalpel (Ethicon, Somerville, NJ; Figs. 31.2A,B and 31.3 ). The lateral tissue is excised using a harmonic scalpel down the plane superficial to Scarpa’s fascia using a controlled traction technique. Scarpa’s fascia is preserved together with the underlying fat and left attached to the abdominal wall (see Figs. 31.2C and 31.3B ). There is less damage to the neurovascular and lymphatic channels.
Mobilizing
Upper Abdominal Flap
Unlike the traditional techniques, which require wide undermining of the abdominal flap extending superiorly to the xiphisternum and laterally to the costal margins, the Brazilian abdominoplasty largely involves tissue advancement after lipomobilization, using a standard tumescent liposuction technique. In nonobese patients, the cannulae are not used to remove fat but only to create channels. The dissection is limited to a central tunnel in the midline to allow midline plication of the medial rectus sheath and repositioning of the umbilicus ( Fig. 31.4 ). This technique is similar to that demonstrated by Saldanha et al. in 2003.
Mons Pubis
The mons pubis is also lipomobilized, debulked if necessary, elevated, and fixed by suturing Scarpa’s fascia to the anterior rectus sheath. This changes the ptotic, often bulky, U -shaped mons to a more youthful V shape.
Umbilicus
The umbilicus is then positioned using a single suture through the anterior abdominal wall for later re-siting once the exact position has been determined (usually 9 cm above the pubic hairline).
Improving the Waistline Definition
The preserved Scarpa’s fascia on both sides of the midline of the lower abdomen are then pulled medially, thinning and sliding over the underlying fat before suturing together in the midline and onto the centrally plicated rectus sheath. This pull places medial traction of the whole superficial fascial system of the lower abdomen, causing a tightening effect on the flanks ( Figs. 31.5 and 31.6 ; see Fig. 31.2D ), and also obliterates the lower midline deadspace.
