The abdomen is one of the most frequently affected regions when body contour shows aesthetic and functional deformities of the abdominal wall caused by genetics, obesity, weight loss, or pregnancy.
Fat accumulation occurs in a distribution pattern that varies according to gender. With weight gain, women tend to add local adiposity in the peripheral stores, such as the lower trunk and hip region. Men see an increase in central store (intra-abdominal) increasing abdominal girth.
Pregnancy is the commonest cause of abdominal wall deformities because the skin and muscles are stretched beyond their capability to retract. Consequently, there is thinning and loss of elasticity of the skin with striae and diastasis of the rectus muscles. Separation of abdomen muscles results from stretching their covers, presenting as abdominal protrusion
Lipo-abdominoplasty was developed as a safe aesthetic and functional option combining complete abdominal liposuction and full abdominoplasty in the same surgical procedure, promoting the benefits of both techniques.
Indication and Patient Selection
Healthy patients with excess fatty tissue, skin and soft-tissue laxity, and musculature laxity are ideal candidates for lipoadminoplasty.
Patients with significant health risks, unrealistic surgical goals, and body dysmorphic disorder are primary contraindications.
Patients with the disposition to keloids or hypertrophic scars must be informed and accept postoperative scarring. Relative contraindications include abdominal scars, uncontrolled diabetes, morbid obesity, cigarette smoking, bladder or bowel dysfunction, and a history of thromboembolic disease. Patients who eventually plan for pregnancy are also not a candidate.
History and Physical Examination
The patient’s medical history and physical examination are reviewed during the first consultation.
The evaluation of medical history should include the weight history, current body mass index (BMI), weight fluctuations and constancy, possible bariatric procedures, nutritional disorders, medications, the number of pregnancies and children, history of cesarean section, abdominal surgeries, and abdominal hernias, the frequency of exercise, gastrointestinal, cardiac, and pulmonary history, and smoking history.
It is essential to know which possible bariatric procedure has been used. Dislocation of the stomach band will cause strangulation of the stomach. It is preferable to have the band deflated before abdominoplasty.
The physical examination covers the entire abdominal wall, including the skin and fat layer, the musculoaponeurotic layer, and the intra-abdominal volume.
Gender differences (Men vs. Women) Patients
We must differentiate between male and female regarding scar position and the shape of the abdomen and flanks. The beautiful normal in the female is a more curved silhouette with an inward belly button and central midline groove with no muscular appearance.
In most male patients with a history of weight loss, we find a drum-like appearance with a combined diastasis of the rectus and oblique muscles, giving them a flattering waistline. A straighter contour course is desired in the male with no central groove nor belly retraction. If oversized love handles are present, a circumferential abdominoplasty or a body lift procedure combined with liposuction must be considered. A flat and straight scar in the low position is vital for the final appearance
The skin and fat tissue are examined by pinching and measuring the subcutaneous layer thickness. Skin quality and the presence of striae are assessed. The skin excess in the areas below the lower abdominal fold, around the lateral and upper abdomen, the waist, hips, and thighs, as well as the lower chest, must be included in the assessment during upright standing spreads and sitting positions.
Abdominal scars from previous operations should be carefully examined. Horizontal upper abdominal scars will limit the choice of procedure, leaving reverse abdominoplasty as the only viable option. A right gall bladder surgery scar should be treated with great care. A vertical midline incision is not a contraindication to surgery and can often be improved with scar revision.
Lastly, the abdominal wall must be critically examined for bulging due to muscle diastasis or hernia. These hernias are easy to deal with intraoperatively but should be kept in mind during liposuction and soft-tissue elevation. In cases of diagnostic uncertainty, a computed tomography (CT) or magnetic resonance imaging (MRI) scan can be helpful
To identify too much intra-abdominal content and pressure. Increasing pressure can also be dangerous regarding deep vein thrombosis (DVT) and abdominal compartment syndrome. We lay the patient flat and see if the abdomen stays above the costal margin.
The following documentation is recommended:
- Quality of skin
- The thickness of adipose tissue
- Number and location of folds
- Location of abdominal wall defects
- Patient’s favored clothing
- Pre-existing scars
- Status of the abdominal musculature.
The following measurements are recommended:
- Distance from the umbilicus to the top of mons
- Distance from the umbilicus to sternal notch
- Distance from anterior vulva commissure to top of mons
- Waist and hip measurement, waist-to-hip ratio
- The thickness of abdominal adipose tissue by pinching.
Smoking is of great concern for all abdominoplasty procedures. Active smokers are at increased risk of ischemia and necrosis of their wounds. We suggest complete smoking cessation for six weeks preoperatively; or a drastic reduction of smoking for at least two weeks before the operation.
Diabetes may be a relative contraindication to this procedure, especially in poorly controlled patients. Furthermore, excluding any skin infection or inflammation in the abdominal folds and umbilicus area is essential. An inspection of these areas immediately before the operation is strongly advised. People with diabetes should receive a single-shot antibiotic immediately before surgery. However, careful planning, limited liposuction, and attention to detail can achieve a safe and successful result.
Prophylaxis for pulmonary embolism (PE) and deep vein thrombosis (DVT) is an important consideration. Patients taking birth control medications or hormone replacement therapy are at an increased risk for DVT and PE, which should be discussed preoperatively. Discontinuing such medications for two weeks preoperatively is advised. Previous history and laboratory analysis are recommended to evaluate the patient’s coagulation profile or refer to the hematologist.
The abdominal wall plication performed with full abdominoplasty can increase intra-abdominal pressure and potential interference with venous return and pulmonary ventilation volumes. We recommend placing all patients in a tight abdominal binder. Together with breathing exercises starting two weeks before lipoadminoplasty..
A cold, dry cough, or any respiratory infection should postpone surgery since coughing fits may provoke a rupture of the fascial sutures with consequent secondary bleeding.
Patients with respiratory difficulties are of increased concern because muscle tightening results in a transient increase in intra-abdominal pressure, which may be a source of postoperative respiratory difficulties.
After bariatric surgery, the routine blood tests are hemoglobin, hematocrit, electrolytes, vitamin B1, B12, folic acid, iron/ ferritin, vitamin D3, glucose, transaminases, and albumin. Total protein, total cholesterol, parathyroid hormone (PTH), and A1C (only if the patient had diabetes before surgery).
- Patients must stabilize weight for at least 12 months preoperatively; any desired weight loss should be implemented before the surgery.
- Patients with stretch marks should avoid ultraviolet exposure at least 14 days before the operation.
- Patients are strongly advised to stop smoking at least two weeks prior and at least two weeks postoperatively.
- Two days before surgery, patients are advised to use antiseptic lotions for body wash, focusing on regions of surplus skin and the umbilicus area.
- Anticoagulant drugs must be avoided ten days before surgery. The patient should also avoid the perioperative use of various homeopathic drugs and nutritional supplements, which can induce bleeding.
- Due to an expected increase in intra-abdominal pressure, surgery is performed with bowel purgation the night before surgery. In severe cases, patients can be restricted to a liquid diet 24 hours before surgery.
- Patients must be instructed about the postoperative course regarding thromboembolism prevention, respiratory exercises, early mobilization, avoidance of high abdominal pressure, the schedule for drain and suture removal, and the minimum time required off work and away from exercise.
The usual markings should be demonstrated and discussed with the patient during the initial consultation. We commence the marking with a partially dressed patient in the upright position to mark the borders of the underwear.
The patient is asked to evaluate the redundant tissue for precise positioning. The expected resection is then evaluated by careful pinching of the tissue.
We mark the lower incision line about one to two fingerbreadths below the expected scar line. The lower incision line must be adapted in mons pubis hypertrophy or ptosis cases. The lower incision line will run parallel to the scar line and usually is 1–2 cm below the abdominal fold. Respecting a minimum distance of 6–7 cm above the anterior vulva commissure is essential.
Subsequently, we estimate the upper incision line, which will be checked intraoperatively before the abdominal flap resection to ensure wound closure.
To ensure symmetry, we measure and document the length of the scar line bilaterally, starting from the midline.
The scar course may individually be matched to the age and fashion style of the patient. For example, a high-cut bikini approach may cause problems for the fashion-conscious patient wearing hipsters or a bare midriff T-shirt.
Finally, all areas for liposuction are marked at this time, including the central abdomen, lateral axilla and flanks, hip rolls, and mons.
The area to be photographed should extend from the submammary fold down to the symphysis pubis. One photo set is upright with the patient’s arms down and another with raised arms.
Pre-and postoperatively, consisting of at least five and, if possible, eight views, including anterior, oblique anterior, side, oblique posterior, and posterior views. Additional photographic documentation should include the patient in a forward bending position, sitting position, abdominal muscles contracted and relaxed, grasping and holding up excess abdominal tissue in the central and waist region, and pinching excess tissue in the central abdominal area.
Patients must clearly understand the limitations of the surgical result in cases of existing variables of bone structure, intra-abdominal fat, and existing scars. Patients must know they may require an operative revision later, like any aesthetic or reconstructive procedure.
Ideally, the informed consent should be signed by the patient and the consulting surgeon at the earliest opportunity, followed by a second consent shortly before surgery.
Perioperatively, patients should always be pre-warmed by using convective warming devices immediately before surgery, and active warming should be used in surgeries longer than one hour. Anti-embolic devices or stockings should be implemented in all abdominal wall surgery patients.
General anesthesia is administered. Intravenous antibiotics (Ancef 1 g) and steroids (Decadron 4 mg) are routinely administered unless the patient’s medical history is contraindicated.
All incision lines are injected with a solution of lidocaine and epinephrine. The regions to be liposuctioned are then infiltrated with a tumescent solution. Usually, the central abdomen, upper abdomen, lateral abdomen, flanks, hip rolls, and mons are infiltrated. It is standard practice to infiltrate between 4 and 6 L of fluid for a complete abdominoplasty.
Infiltration is performed before full prepping and draping for efficient use of time and sufficient time for vasoconstriction. Entry sites are prepared with Betadine, and the cannula is frequently wiped with Betadine during the infiltration process.
Liposuction is performed on all infiltrated areas. Suctioning of the lateral axilla and fullness above the breast is best performed through an axillary entry site. Occasionally an inframammary entry site is used, which provides efficient access to the lateral breast, flank, and upper abdomen.
The umbilical entry site is ideal for access to the central abdomen. In the area of proposed undermining, liposuction is performed on the fat superficial to Scarpa’s fascia because deep fat resection will be performed.
Liposuction is started in the supraumbilical region with a 3- and 4-mm cannula, removing the fat of the deep and superficial layers and going out to the flank.
A change of intraoperative positioning to the “beach-chair” position should be reviewed at the start of the procedure because it will be used to reduce wound tension at the time of wound closure.
Before the patient awakens from anesthesia, a compression girdle should be fitted to avoid rupture of fascial sutures on awakening. Coughing and increased abdominal pressure should be avoided during extubating, a process that should be handled gently and with great care.
In previously operated patients, identifying the appropriate dissection layer may be difficult. The lower incision line is cut utilizing an electrocoagulation needle. The surgical assistant must ensure a careful upward pull of the abdominal flap to facilitate a clear layer definition to preserve Scarpa’s fascia. By staying above Scarpa’s fascia, the subjacent lymphatic vessels are preserved.
Dissection to Scarpa’s fascia continues cranially up to a level two to three fingerbreadths below the umbilicus. Scarpa’s fascia is incised at that point, and dissection continues along the anterior rectus sheath. The umbilical stalk is then circularly transected from the abdominal flap and may be temporarily sutured closed for asepsis. Dissection continues above the umbilicus along the rectus fascia up to the xiphoid.
Plication of the anterior rectus sheath from the xiphoid to the symphysis is accomplished using a non-absorbable suture. Paramedian plication of the anterior rectus sheath may accentuate an hourglass figure with further waist tightening.
The abdominal flap is then pulled down, and several progressive tension sutures are placed, followed by an incision of the flap in the midline. The upper incision line is then marked, and the resection of skin and tissue excess is performed obliquely to the wound edge at a 45° angle to adapt different layer thicknesses for optimal wound closure. After meticulous coagulation, the wound is closed temporarily.
The new umbilical position is estimated and marked. Several umbilical incision patterns have been described (we prefer the inverted “V” incision). Drains should be inserted before starting with progressive sutures and deep closure. We usually prefer to insert one drain on each side.
Wound closure is performed by reapproximation of each layer. For optimal wound closure, the patient must be intraoperatively flexed at the level of the hips.
Continuity of the Scarpa’s fascia is achieved with slowly absorbable sutures in a single knot or running technique. The subdermal layer is closed using slow-absorbable sutures in a single-knot or running technique. Nevertheless, an intracuticular absorbable barbed suture can be used for wound security.
The vascularity of the abdominal flap is checked by evaluating the capillary refill just above the scar in the midline. An excellent capillary refill is a sign of flap viability.
Abdominoplasty Surgical Options
Due to the number of variations and modifications of abdominoplasties, selecting the appropriate technique in every individual case is vital, determining the best procedure by minimizing morbidity and postoperative disability for desirable and predictable results.
The whole or complete abdominoplasty is the most performed as it offers the most significant correction for most patients seeking abdominal contouring. A complete abdominoplasty scar usually extends across the abdomen.
This length is necessary to achieve the best results by facilitating complete removal of the below the umbilicus skin and soft-tissue laxity that bothers these patients. This procedure can improve lifetime, particularly for patients who maintain weight afterward.
Modified Brazilian Abdominoplasty (MBA)
Significant refinements have been introduced in abdominoplasty techniques to meet the growing perception of aesthetics among the general population and deal with the new challenges recognized by surgeons. Eventually, a new concept evolved—truncal rejuvenation. This truncal rejuvenation 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 standard waistline definition and mons elevation.
Mini Abdominoplasty (Short Scar Abdominoplasty)
The term mini-abdominoplasty is often used to refer to any procedure where the length of the transverse incision is smaller than that typically used in a full abdominoplasty, as well as avoiding the use of umbilical translocation. The mini-abdominoplasty represents a spectrum of surgical procedures depending on the deformity.
The ideal patient for a mini-abdominoplasty is a young woman between 25 and 50 who has had several children but never suffered from significant weight gain. These patients often have mild to moderate excess adiposity, mild to moderate skin laxity, and striae. They are thin, and their abdominal skin is usually in good condition
The extended abdominoplasty procedure occupies a unique niche between full and circumferential abdominoplasty. This extended modification of abdominoplasty procedures treats the abdomen, hips, and lateral thighs. This technique represents a helpful solution for patients with insufficient abdominoplasty, and a lower body lift is beyond their needs.
Circumferential abdominoplasty is an ideal procedure for patients who have experienced massive weight loss and who have circumferential tissue laxity of the trunk. Furthermore, those patients present with buttock ptosis and lateral and posterior thigh laxity.
Circumferential abdominoplasty allows for complete correction of buttock ptosis, lateral and anterior thigh laxity, abdominal tissue redundancy, and mons ptosis.
It can be combined with autologous buttock augmentation, vertical abdominal tissue resection, and mons reduction. Patients are consistently some of the happiest body contouring population and most grateful patients.
Reverse abdominoplasty is offered to massive weight loss (MWL) patients suffering from persistent skin and soft tissue excess in the upper abdomen. The procedure can be combined with breast augmentation, mastopexy/reduction, or upper and middle back contouring procedures such as a bra-line back lift. Since most patients are female, positioning the scar in the inframammary fold is achievable, although patients must be aware of a visible scar between the breasts. The indication for male patients is limited because the scar in this region cannot be concealed.
Vertical abdominoplasty refers to a purely vertical incision with lateral mobilization of abdominal soft tissue. This procedure is primarily indicated in patients with a pre-existing scar in the abdominal midline who seek an improvement of the abdominal contour without additional transverse scars. This procedure may improve abdominal contouring, especially in patients requesting vertical fascial tightening due to pre-existing diastasis recti or scar hernia.
- The patient is warmed with a warming blanket and monitored in the recovery room until stable.
- Care should be taken to minimize the risk of postoperative nausea and vomiting, as this will cause great anxiety to the patient, with significant abdominal wall discomfort, increased blood pressure, abdominal swelling, and hematoma formation.
- Careful inspection in the recovery room is vital to ensure no kinking or folding of the binder, which could result in ischemia or necrosis. It should be worn only snugly, not tight, during the early postoperative period. The caregivers should be instructed to release the binder if it feels too tight for the patient. It should also be released, smoothed, and repositioned every few hours.
- Frequent movement of the lower extremities while in bed and regular walking is encouraged to help reduce the chance of DVT/PE.
- Drains are removed when drainage is less than 30–50 mL over 24 hours. Instructions regarding drain care are provided to the patient and their caregiver.
- The patient is instructed to maintain a flexed position and can usually straighten up between 7 and 10 days postoperatively.
- Patients with pre-existing umbilical scars should be observed for the blood supply of their skin
- . A slight postoperative discoloration of the umbilicus is usually not precarious. Complete necrosis of the umbilical stalk is uncommon and may be treated conservatively, satisfying results.
- Patients can go home and usually see the next day or so. Upon discharge, patients are sent home with oral antibiotics, pain medication, and vitamins, starting preoperatively. They are instructed to keep their waist slightly flexed and refrain from heavy lifting or vigorous activity.
- Patients are instructed to stay well hydrated by drinking plenty of fluids.
- The abdominal binder is always worn except for showering, which is allowed after one to two days.
- Vigorous activity and heavy lifting are restricted for the first three weeks. Most patients will slowly increase their activity reasonably as they recover.
- We usually see all our body contouring patients the following day and frequently during the first postoperative week. Doing so will allow more diligent monitoring of fluid status, better pain management, and assurance that the patient is walking periodically and using the incentive spirometer frequently.
Complications of Abdominoplasty
Patients can expect postoperative pain or soreness, numbness of the abdominal flap, bruising, general fatigue, and discomfort due to increased abdominal tension for many weeks.
Local complications may include hematoma, seroma, wound infection, fat necrosis, dehiscence, paresthesia, and persisting numbness. If liposuction has been done simultaneously, issues with that procedure include contour irregularities and dermal tethering.
Other local problems include scar or umbilical esthetic in nature. Most of these problems can be avoided with proper preoperative planning and attention to surgical detail.
- Seromas are the most common problem and are usually handled with serial punctures and drainage. Persistent seromas may require an indwelling drain or a secondary surgical procedure in the case of a late encapsulated seroma.
- Cellulitis If suspected, a simple aspiration may prevent a deteriorating course if seromas are detected in time.
- Minor wound dehiscence is common and is typically a self-limiting problem. Significant dehiscence may be due to excess tension or marginal wound necrosis. If necrosis occurs, it is usually in the distal portion of the abdominoplasty flap near the midline, where tension is most significant.
- Appropriate treatment is conservative wound care, although once a significant area of necrosis has been restricted, it should be surgically debrided. A skin graft may be necessary for wound closure if secondary wound healing is ineffective. It is seldom possible and seldom indicated to attempt additional flap advancement to close a postoperative wound healing defect.
Systemic complications include DVT, pulmonary embolism, respiratory compromise due to increased intra-abdominal pressure, and systemic infections, including toxic shock syndrome. All these complications are potentially lethal and must be dealt with expeditiously.
Surgeons should know that abdominoplasty, especially when combined with other procedures, has a higher systemic complication rate than any other routine cosmetic surgical procedure.
Medicine-Based Evidence on abdominoplasty
- Smokers significantly increase wound healing problems and infections (50% vs. 15% in non-smokers): evidence level (EV level) II.
- Obese patients with a BMI >30 and those with significant soft-tissue resection of more than 1500 g have an increased risk of developing pulmonary embolus: EV level II.
- Wound healing complications are more common in patients after bariatric surgery than natural weight loss before abdominoplasty: EV level II.
- Operation times of about two h have been identified to increase the risk of pulmonary embolism intensively: EV level II.
- Single-dose antibiotic prophylaxis can be recommended to all patients undergoing abdominoplasty to reduce the incidence of wound infection: EV level II.
- Patients with a BMI >30 have an exponential risk of DVT: EV level II.
Outcomes and Results
The Lipoadminoplasty procedure is the most performed abdominoplasty method recently as it addresses most abdominal wall deformities in most patients. The legacy of a long scar with limited treatment effects on the hips and the back region is an unfortunate aspect of this procedure.
Techniques with Previous scars
Abdominal scars restrict the choice of abdominoplasty technique, especially horizontal scars near the costal margin. As a rough guide to avoid complications from scar presence, the surgeon will avoid any undermining in the scar area. The pre-existing scar should be integrated into the proposed incision course, regardless of a impaired aesthetic appearance.
Management of the Mons Pubis
Secondary findings in patients with abdominal wall laxity and tissue excess are often hypertrophy or mild to severe ptosis of the mons pubis, especially in MWL patients. Patients may complain about a pseudo-hypertrophy of the mons pubis, created by an imbalance between abdominal flattening and mons pubis laxity accentuated by the disruption of lymphatic drainage to the mons.
Additive liposuction of the mons pubis is sufficient in most abdominoplasty cases without local skin excess. In patients, particularly after MWL with hypertrophy and surplus skin in the mons pubis region, we routinely perform a horizontal monsplasty, which is integrated into the lower abdominal incision.
In cases of severe hypertrophy and ptosis of the mons pubis, a combined horizontal and vertical monsplasty is indicated. An additional V-shaped excision at the midline can be conducted in this context.
Minor complications that do not affect the outcome. All surgical procedures have some degree of risk. I can determine the specific risks and the suitability of this procedure for a given individual only at the time of consultation.