Introduction

The abdominal wall is one of the regions that most frequently presents with a wide range of anatomical variations. This is due to several factors, which include inadequate diet, pregnancy, sedentary lifestyle, weight loss, and loss of skin elasticity. These can be challenging deformities to address.

Traditional abdominoplasty and mini-abdominoplasty procedures with or without liposuction, usually address most of these problems. However, skin with or without fat excess, especially in the supraumbilical abdominal region, still remains a challenge to most plastic surgeons.

The first description of skin and adipose tissue resection in the upper abdomen was made by Thorek in 1942.¹ However, in 1977 Rebello & Franco described and systematized the approach through the inframammary sulcus for abdominal plastic surgery.² After this period, reverse abdominoplasty was practically forgotten about for many years. This was primarily because it was said to result in poor esthetic results with regards to the inframammary scars.³

However, TRA should be considered a therapeutic option by plastic surgeons, as it is possible, through inframammary incisions, to correct abdominal deformities in the supraumbilical portion.

This chapter proposes a modification of the original technique, based on the upper traction of the flap and its strong fixation to the abdominal aponeurosis, resulting in a tension-free inframammary scar.⁴ The inframammary scar extension and the dissection amplitude are determined by the intensity of the supraumbilical deformities.

This technique should be primarily indicated for patients complaining of skin laxity mainly in the upper abdomen and patients prone to have such excess after liposuction. In these cases, it should be always considered that there is insufficient skin excess for indicating a suprapubic abdominoplasty, and that mini-abdominoplasty would render less than optimal results.

Patients with previous inframammary scars favor this technique, especially if the scars are extensive and are unifying or almost unifying at the midline. Similarly, breasts with wide bases, even without previous incisions, favor the utilization of this technique, as they tend to better hide the resulting scar. On the other hand, this technique is contraindicated to patients with previous history of keloids or hypertrophic scars, especially in cases that require scar unification at the midline.

This technique can also be indicated to patients who had abdominoplasty procedures in the past, but show unsatisfactory results, such as dermal-fat residues or skin excess in the supraumbilical portion.

Preoperative Preparation

Preoperative marking is done preferably in the orthostatic position, by exerting upper traction on the flap towards the breasts and determining the amount of skin to be resected. At this moment, the required extension of the inframammary scar and the eventual need to unify the scars at the midline are defined. This step is extremely important, as the patients are divided into two groups.

FIG. 23.1 Incision (dotted red line) and dissection (grey area) in Group 1.

FIG. 23.2 Incision (dotted red line) and dissection (grey area) in Group 2.

Surgical Technique

The flap to be dissected should be infiltrated with saline solution and epinephrine, at a concentration of 1 : 500 000. Epinephrine (1 mg) is used for each 500 ml of saline. The amount varies depending on the extension of the area to be treated and the patient’s measurements. One liter is needed for the entire abdominal surface, and about 500 ml for just the superior half are usually used. In cases of excessive fat, the procedure begins with a liposuction, which can be limited to the flap region or include the entire abdominal wall.⁵ In both groups, dissection is performed with electrocautery at the anterior aponeurotic plane, resulting in one or two dermal-fat flaps (Fig. 23.3).

FIG. 23.3 Dissected flap showing traction lines and the midline fascia plication markings in methylene blue.