The surgery is usually performed under general anaesthesia. If multiple operations are performed like facial procedures or breast interventions, the authors usually perform the abdominal surgery as first procedure except of liposuction.

In the OR, the operating table is checked to insure that it can be flexed prior to induction of anaesthesia. The patient is placed in a supine position with silicone pillows under the knees to prevent nerve compressions during the surgery.

Afterwards, the symmetry of the body and the arms is verified, a rolled towel of 5–10 cm diameter is positioned behind the back of the patient at the level of the scapulae in order to decrease the unnatural backwards leaning of the thorax on the operating table and the arms are loosely secured by wrapping them with gauze. A Foley catheter is inserted, sequential pneumatic compression devices are placed and if indicated anticoagulants are used.

To ensure symmetry a 2-0 silk suture is placed in the midline at the level of the xiphoid. Vertical parallel lines at 5, 10 and 15 cm are drawn and a symmetrical upper incision line with a seagull shape is obtained at the crossing of the vertical lines using the silk suture. The same drawing is performed for the lower planned incision (Fig. 5.3a, b).

Preoperative preparations end by infiltrating 0.5 ml of 1:1000 epinephrine and 10 ml of 2 % lidocaine solution in 100 ml saline solution directly through the incision lines.

First, the upper incision above the umbilicus is made. A slightly bevelled incision through the cutis is made through the superior seagull shape marking, while pulling the skin only downwards in order to achieve proper cutting angle (Fig. 5.4).

Then, the blade bevels more to lie at 30° to the surface of the flap, so the Scarpa’s fascia portion of the flap is about 1 cm shorter than the skin portion. This manoeuvre will ensure the scar-edge elevation and an optimal skin closure with good scar healing at the end of the surgery. The bilateral upwards curves of the incision are designed to create a relative paramedian skin gap and median skin excess.

The supra- and subscarpal fat is transversed until the surgeon reaches the abdominal wall. The large vessels are suture-ligated and the rest of the dissection is done by electrocautery or harmonic scalpel, leaving the fine areolar tissue and their lymphatics over the fascia. This is thought to diminish the rate of seroma formation [12].

The upper abdominal flap is undermined up to the xiphoid, resembling a narrow midline tunnel, maintaining the intercostal blood supply sufficiently to achieve rectus muscle repair and anterior sheath plication (Fig. 5.5).

The lack of the lateral dissection and the minimal dissection of costal margins creates a lateral tension at the closure of the skin. This, in conjunction with the tension created by the paramedian skin gap due to the seagull incision will pull the waist towards the midline and help the surgeon create a coke bottle appearance [13].

The median convexity of the seagull incision helps also to create a relative median skin excess from the start of the operation. This tissue excess will later be used to fashion the rectus muscles illusion.

Once the upper flap is elevated, a cold towel is placed into the dissected tunnel and around the flap in order to decrease capillary bleeding (Fig. 5.6). An upside-down heart-shape is drawn around the umbilicus with a diameter of 1–1.5 cm, and then it is freed from the lower skin flap with 15 blade scalpel (Fig. 5.7a–c).

Once the navel is separated, the surgeon changes his position from the right side of the patient to the left side, which will make the lower dissection much easier for right-handed surgeons (Fig. 5.8). The lower flap dissection is performed in the same way downwards to the inguinal region. Extra attention is paid to the haemostasis for perforators around the umbilicus, which are numerous and one of the most important sources of postoperative haematoma (Fig. 5.9). The inferior dissection is continued past the planned level of the final closure in order to lift the thigh region and to rejuvenate the inguinal area as well (Fig. 5.10).

In this fashion, the dissection of both flaps is completed very fast and easy because of short flap length superiorly and inferiorly as well as the excellent control over the surgical area. It is also comfortable for the assistant to retract the flaps and to control the haemostasis (Fig. 5.11).

It is important to note that the expansion of the abdomen due to the “musculofascial” laxity is a three-dimensional deformation, which happens in the horizontal as well as the vertical plane. A definitive treatment of this condition necessitates a horizontal-vertical plication of the abdominal wall. The authors use a triple continuous over-and-over suture, which resembles a spring, or a helical coil, in order to tighten the fascia in horizontal as well as the vertical plane. The horizontal-vertical plication serves two purposes. First of all it is curing the three dimensional abdominal laxity in an anatomical way. Second, it shortens the abdominal wall vertically and elongates the median part of the superior flap.

To do this, the diastasis is noted and an ellipse is marked on the anterior rectus sheath from the xiphoid to the pubis. The widest portion of the ellipse is located at the level of the navel, with a width of around 6–10 cm according to the laxity (Fig. 5.12).

Starting from the upper end of the superior midline tunnel, a triple helix is created with 1-0 polypropylene. These buried sutures start with taking a bite at the left lateral edge of the diastasis, then the right side, repeating three times to create a triple helical loop around the tread itself, fashioning a spring of Prolene (Fig. 5.13a–e). As the knot is tied, the fascia is fastened in the horizontal as well as the vertical plane (Fig. 5.14a, b). These separate triple helical spring sutures are used as many as needed above and then below the umbilicus down to the pubis all along the midline. This will ensure a three-dimensional tightening of the fascia but also shorten the vertical height of the abdominal wall, which in turn will elongate the median part of the superior flap. This will increase the tissue excess which was initially created by the median convexity of the seagul incision. This tissue eminence will later be used to fashion the rectus muscle folds illusion (Fig. 5.15a, b).