Modern Research in Plastic and Reconstructive Surgery

Our review chapter describes the common abdominoplasty operative techniques including the traditional, lipoabdominoplasty, fleur-de-lis, and mini abdominoplasty. Critical anatomic considerations, patient selection, and discussion of common complications are also discussed in detail. Lastly, our chapter discusses the recent use of progressive tension sutures, their reported value, technique and proposed benefit compared to use of drains.

Keywords: Abdominoplasty, Lipoabdominoplasty, Mini-abdominoplasty, Fleur-de-lis

The history of the abdominoplasty can be traced back to the 1960s and 1970s.¹ From its conception, the procedure involved removal of an abdominal pannus with tightening of the underlying rectus muscles and has been performed with various techniques and planned approaches. According to the 2023 Plastic Surgery Statistics report published yearly by the American Society of Plastic Surgeons (ASPS), abdominoplasty was the third most common cosmetic procedure performed, totaling 170,110 cases, with liposuction and breast augmentation reported as the first and second most popular.² Oftentimes, abdominoplasty will be combined with other procedures for the breast and body.³ Since its introduction, many approaches and modifications have been described in the literature such as the mini-abdominoplasty, fleur-de-lis, and lipoabdominoplasty however the traditional approach remains the most common. The goal of our chapter is to discuss the common surgical techniques used for abdominoplasty in addition to recent data and advancements in surgical techniques aimed at improving patient outcomes and complication rates.

The abdominal contouring procedures are broken down into grouped classifications, with type 1 including liposuction only, type 2 including the mini abdominoplasty, modified abdominoplasty (type 3) and the full traditional abdominoplasty (type 4).¹ Liposuction of the abdomen combined with a type 4 abdominoplasty is considered a lipoabdominoplasty, which has also been gaining popularity as a procedure since 2010. Expert knowledge and awareness of underlying anatomy and blood supply to the area, with use of preoperative markings are crucial to performing safe, successful, and aesthetically desirable abdominoplasty results.¹

Patients undergoing abdominoplasty should be medically optimized and should have maintained a stable weight for 3-6 months. Absolute contraindications include poorly controlled or inadequately managed medical comorbidities, body dysmorphia and unrealistic surgical goals. Relative contraindications include smoking, plans for pregnancy, and subcostal scars.⁴ Lastly, all patients should be checked for any abdominal hernias on physical exam and if suspicion is high, it is appropriate to order Computed Tomography (CT) imaging prior to their operation.

It is recommended that patients are marked in the upright position wearing their undergarments so that scar placement and expectations are discussed and planned in real time. The traditional abdominoplasty markings may vary depending on the surgeon; however it is recommended to mark an elliptical incision pattern with the superior line passing at or above/umbilicus and extending laterally to the anterior superior iliac spines (ASIS) on both sides, and the inferior line of the ellipse following the natural lower skin crease while maintaining a recommended vertical distance of 5-7 cm above the vulvar cleft.^1,5 If a patient has a previous scar from a Cesarean section, the lower incision line should be drawn inferiorly to this. The patient’s midline, xiphoid and any previous scars should be marked and identified as well. Additionally, performing a pinch test can help the surgeon qualitatively determine how much skin can safely be resected while allowing for a proper closure. Other markings may be made if the patient is desiring liposuction to identify targeted areas.

The abdominal wall is composed of skin, fat, fascia and muscle. Underneath the skin, scarpas fascia separates the superficial fat from the deep fat.⁴ Because the deeper fat layer receives blood from the subdermal plexus,⁴ it can be thinned without concern for compromising the overlying skin which happens during lipoabdominoplasty. In contrast, the superficial fat layer is thicker and has a more robust blood supply. The abdominal wall blood supply can be broken down into 3 zones based on arterial supply.⁶ Zone 1 is found midline and is supplied by the superior and inferior epigastric vessels. Zone 2 is found inferior to Zone 1 and is supplied by circumflex iliac and external pudendal vessels. Lastly, Zone 3 is lateral to Zone 1 and is supplied by the intercostal and subcostal vessels.⁶ This becomes incredibly important as prior to abdominoplasty, the abdominal wall receives blood mainly from Zone 1 and afterwards the main supply is from Zone 3.^4,5 For this reason, it is crucial to avoid excessive lateral undermining of the abdominal flap during elevation as to preserve the remaining vascularity to the flap from Zone 3. This is also why it is imperative to check for presence of scars during pre-op evaluation as scars represent areas of compromised vascularity.⁴ Blood supply to the umbilicus is from the subdermal plexus and perforators from the deep inferior epigastric system. Careless dissection in this area may lead to umbilical necrosis.^4,5

Innervation to the abdominal wall comes from lateral cutaneous branches and intercostal nerves which pass in the plane between the transversus abdominis and internal oblique muscles. The nerve commonly at risk for injury is the lateral femoral cutaneous nerve, which is found 2 cm medial to the ASIS necessitating the need for superficial dissection in this area.⁵ If injured, patients experience numbness and burning in the lateral thigh, a sensation known as meralgia paresthetica. Other nerves with potential for injury include the iliohypogastric, ilioinguinal, and intercostal nerves. Respectively, injuries to these structures causes numbness in the inguinal/gluteal region, numbness in the medial thigh/groin, and numbness in the flanks.⁵

Traditional abdominoplasty

The surgical approach for the traditional abdominoplasty often begins with making an incision around the umbilicus and dissecting it with scissors circumferentially down to the rectus sheath. Of note, it is important to leave a generous amount of fat around the umbilical stalk in order to avoid compromising the blood supply leading to umbilical necrosis.¹ The inferior portion of the planned elliptical incision is dissected through scarpas fascia down to the rectus sheath. The upper abdominal flap is then undermined up towards the xiphoid and costal margins, separating it from the rectus sheath with care taken to avoid extensive lateral dissection,⁷ essentially undermining in a narrow “inverted-V” fashion and maintaining the lateral blood supply to the flap.⁷ A small amount of fat should also be left when dissecting bilaterally near the ASIS and dissection should be carried out superficially in order to avoid exposure or injury to the lateral femoral cutaneous nerve which runs in this area.^1,7 Injury to this nerve is associated with post-op paresthesia’s and pain in the lateral thigh region also known as meralgia paresthetica, and was found to have a 10% injury rate in a review of abdominoplasty procedures.⁵

The abdominal flap should be elevated in a loose areolar plane to the xiphoid and costal borders with careful attention to avoid transection of the dissected umbilical stalk. Additionally, when nearing the subcostal region, it is crucial that undermining of the flap remains superficial, as the main blood supply to the flap will now come from this area.⁴ Naturally, many arterial perforators are found near the umbilicus and serve as a warning sign during flap undermining to slow down and take precaution in this area to preserve the stalk and avoid accidental transection.⁴

After the flap is elevated, some may choose to correct rectus diastasis or any umbilical hernias seen on prior CT scans. Diastasis correction is carried out via rectus plication which is done using permanent or long-acting resorbable interrupted sutures.¹ A marking pen can be used to outline the medial borders of the rectus muscles from the xiphoid to the pubic bone forming an ellipse on the rectus sheath outlining areas to for plication. Beginning plication at the level of the xiphoid serves to prevent any post-operative bulges in the epigastric area.⁷

Following plication, it is recommended to inject a solution of 25% Marcaine with epinephrine into the rectus muscle for analgesia1 or administer a transverse abdominis plane (TAP) block. The bed is then flexed to determine the amount of skin to be removed from the abdominal flap to provide an adequate closure, and the excess skin and fat is resected. Following this, the area is irrigated and meticulous hemostasis is achieved.

Before closure of the abdominal incision, the surgeon can choose to leave drains or proceed with a “drainless abdominoplasty” and incorporate progressive tension sutures, essentially alleviating the need for drains. Historically drains were placed in the cavity exiting the wound laterally on either side, remaining in place for several days post op or until output is less than 30 cc in 24 hrs.³ The use of drains serves to reduce incidence of seroma and hematoma formation after creation of significant dead space during creation of the abdominal flap. However, in 2010 a new technique was being implemented into abdominoplasty operations that alleviated the use of drains entirely,⁸ being described in the literature as the “drainless abdominoplasty” which will be discussed in the following section. This novel technique, first described by Pollock and Polluck, incorporated placement of progressive tension sutures (PTS) to eliminate dead space and decrease seroma formation without the use of drains.

The final step involves layered closure of the incision and inset of the umbilicus into the skin of the abdominal wall. The ideal belly button should be placed midline, inverted with superior hooding, and ellipse shaped.⁴ The abdomen is closed along the incision in three layers including the deep fascia, dermis, and subcuticular layer. Scarpas fascia should be closed with interrupted sutures, and the dermis and subcuticular space can be closed in a running fashion or with interrupted sutures in the dermis. To avoid formation of dog ears, the flap should be advanced medially, starting closure on the lateral edges for precise approximation, however if needed, the incision can be extended laterally.⁴ Additionally, some studies have reported on the use of skin glue after closure of the dermis in place of closing the subcuticular space. Results were comparable between use of skin glue vs subcuticular suturing, with the only reported difference being a decrease in operative time when surgeons used glue only.⁹ The patient is then placed in a flexed position and an abdominal binder is applied with instructions for continuous wear for 4 weeks. They are encouraged to ambulate early to minimize risk of VTE and if patient is considered high risk they are given low molecular weight heparin. Finally, they are instructed to take 2 weeks off from work and to avoid heavy lifting for 6 weeks.

Lastly, often times surgeons will combine abdominoplasty with other procedures such as breast augmentation, mastopexy, or breast augmentation-mastopexy, which can be done safely as long as operative time does not exceed 5 hours to avoid complications.

Lipoabdominoplasty

Lipoabdominoplasty combines traditional abdominoplasty with liposuction of the subcutaneous fat. Historically, it was thought that abdominal lipoplasty and abdominoplasty should not be combined due to concern for vascular compromise and “100% seroma rate”,⁸ however it was later stated by many that with liposuction limited to the deep fat layer this can be safely performed. As stated earlier, the fat layers of the abdominal wall consist of the superficial and deep fat, with the superficial fat having a more robust blood supply. The deeper fat layer, separated from the superficial layer by scarpas fascia, can undergo liposuction as it relies on blood supply from the subdermal plexus.⁴ For this reason, the deeper fat layer can be thinned safely and is considered as safe as traditional abdominoplasty.⁴ During lipoabdominoplasty, a superwet^4,5 tumescent solution should be used, and selective undermining of the flap should be limited to the central area¹⁰ so that lateral perforators, nerves, and lymphatics are preserved. Liposuction should be avoided in the upper midline and is preferentially utilized in the lateral parts of the abdominal skin flap.⁸ If liposuction is performed in areas of the flap that are undermined, risk of flap necrosis increases.⁵ Additionally, the use of progressive tension sutures further reduces risk of seroma and distal flap necrosiss.^3,8,11

Fleur-de-Lis

The Fleur-de-Lis abdominoplasty, which is used in patients with excess transverse and vertical skin laxity, was first described in 1967 and popularized in 1985.¹² Due to the recent increases in bariatric weight loss surgery and injection weight loss medication, there has been an increased need. Massive weight loss (MWL) patients typically have lost 70-100 lbs often through surgical weight loss such as a gastric sleeve or bypass, medical weight loss, or diet/excersize. Patients commonly will complain of chronic skin rashes, itching, and breakdown underneath their pannus.¹² Using a traditional abdominoplasty approach in the MWL patient often results in dog ears while combining the horizontal and vertical incisions with a fleur-de-lis technique allows for resection of these components in addition to contouring the hips and flanks.¹² The vertical incision can be taken as high up as the xiphoid process. Of note the main concern for these patients is wound breakdown at the intersection of the vertical and transverse limbs, also known as the T-junction or T-point. Lastly, when talking with patients interested in this approach, it is imperative to discuss the scar burden. While results tend to be better with a fleur-de-lis approach, the scar is much bigger than with traditional abdominoplasty and involves a midline vertical scar.^4,12

Mini abdominoplasty

This abdominoplasty technique is suited for patients with isolated excess infraumbilical skin. While there is no separation of the umbilicus, some sources report that the umbilicus will move 2 cm inferiorly.⁴ The scar is shorter and the operation can be combined with lipoabdominoplasty and/or diastasis correction.

Progressive tension sutures

First described by Pollock and Pollock, progressive tension sutures (PTS) allow for elimination of dead space and transfer of tension from the skin incision to the superficial fascial system.^8,13 In doing so, the use of drains can be avoided without increased risk of seroma formation.^13-16 Sutures should be placed using interrupted 2-0 vicryl suture or running continuous barbed suture from the superficial fascia to the deep fascia as the abdominal flap is advanced. Tension is distributed throughout the abdominal flap rather than on the incision which is the case in the traditional abdominoplasty.^1,14According to Pollock, use of PTS allows for closure with “virtually no tension”. In a study comparing outcomes in 454 abdominoplasty patients receiving drains vs PTS, overall complication rates were significantly lower in the PTS group (31.4% vs 13.8%) in addition to decreased seroma incidence (24.7% vs 0.0%).³ In a separate study by Macias use of PTS had a significant effect on decreased seroma rate in addition to reporting no increase in rate with concomitant use of liposutction.¹⁵ The reported disadvantages of PTS use included increased operative time, difficulty of placement, skin dimpling, significant learning curve, and increased pain for patients. In the study an additional 25-30 min was used to place the sutures at increased cost to the patient. Lastly, it is worthwhile to note that use of PTS has been well documented in the literature and is successfully being used in facelift procedures and breast reconstruction.³

The most common complications associated with abdominoplasty is seroma with an incidence of 7-10%, infection (4%), and skin necrosis (3%).⁶ It is proposed that seroma formation may be caused by lymphatic channel disruption during undermining, shearing forces between the flap and fascia, release of inflammatory mediators and creation of dead space.³ It is therefore unsurprising that efforts targeted at reducing these proposed sources (such as PTS) have associated decreased seroma incidence.^1,14,16,17Other proposed approaches include maintenance of a thin fat layer on the rectus fascia allowing for retainment of the lymphatic channels and minimizing thermal injury during flap elevation and using a scalpel rather than bovie cauterization. Of rare note, one additional complication, the formation of a pseudocyst, has been reported in the literature following abdominoplasty.¹⁸ Pseudocyst formation is thought to be a consequence of an unresolved seroma in which the body then starts to wall off.¹⁸ Nonetheless, use of PTS would also likely decrease incidence of pseudocyst formation.

While seroma is the most common complication,¹⁷ the most significant complication is formation of venous thromboembolism (VTE). It was noted that from the years 2001-2006, abdominoplasty had the highest rate of death due to PE according to the American Association for Accreditation of Ambulatory Surgery Facilities.⁵ However, with proper patient selection criteria and prophylaxis, complication rates can be significantly reduced. Use of sequential compression devices (SCDs) help to further reduce the incidence as well. VTE risk specifically in abdominoplasty is thought to be related to the tightening of the abdominal wall which increases intrabdominal pressure.⁴ Other significant complications include wound dehiscence, flap necrosis, and large hematomas. Flap ischemia risk can be reduced with minimal undermining and with use of PTS. Seromas and hematomas can be drained in the outpatient setting and oftentimes areas of dehiscence are left to heal by secondary intention. If complications become more severe, patients may have to return to the operating room.¹⁹

Abdominoplasty continues to be a safe procedure with proper selection of patients and assessment of risk factors. While many variations of abdominoplasty technique are described in the literature, the traditional approach remains the most common. Liposuction can also safely be combined with abdominoplasty and may continue to provide superior results and patient satisfaction. Lastly, recent use of progressive tension sutures within the last 10 years seem to provide similar if not decreased rates of seroma formation in patients while simultaneously alleviating the need for drain placement.

All authors made substantial contributions to the conception, creation, and editing of this chapter.

Not applicable.

Not applicable.

None.

This Review Article received no external funding.

Regarding the publication of this article, the authors declare that they have no conflict of interest.

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