Tradi ti onal

Abdomi nopl asty

Alan Matarasso, MD*
The modern history of abdominoplasty can be
traced to the late 1960s and 1970s, and was
marked by acceptance of abdominoplasty as
a bona fide aesthetic procedure with excision of
the pannus, tightening of the underlying muscula-
ture, numerous incision designs, recognition of
complications, and performing it in conjunction
with other cosmetic (eg, breast reduction, breast
augmentation, and so forth) and noncosmetic
procedures (eg, hysterectomy, cholecystectomy,
and so forth).
The introduction of liposuction in the 1980s
dramatically and permanently altered the
landscape of body contour surgery. Liposuction
as a sole contouring procedure or in combination
with excisional procedures represented the
greatest advance in body contour surgery, even
to date. In many instances incisions were short-
ened and patients heretofore not considered
feasible as candidates were able to be treated.
Indeed the abdomen became a group of
contour procedures that were referred to as the
abdominolipoplasty system of classification and
treatment. This group included liposuction alone
(type I), mini abdominoplasty (type II), modified
abdominoplasty (type III) (type II and III are consid-
ered limited abdominoplasties), and a full standard
abdominoplasty (type IV) with or without liposuc-
tion (Fig. 1).
Extensive abdominal liposuction in conjunction
with a full (type IV) abdominoplasty is known as lip-
oabdominoplasty, and is currently receiving re-
newed interest. Lipoabdominoplasty has also
been referred to by various other nomenclatures
such as suction-assisted abdominoplasty, ab-
dominolipoplasty or marriage abdominoplasty.
This article describes a standard abdominoplasty
without or with liposuction (lipoabdominoplasty).
In the 1990s, with the increase in popularity of
laparoscopic and arthroscopic procedures,
attempts were made to perform abdominoplasty
endoscopically. These procedures met with tech-
nical difficulties, a lack of refinement in instrumen-
tation and, more significantly, the inability to
address remaining excess skin, which often
appears greater than anticipated after the rectus
muscle is plicated. If applicable these techniques
are most likely to be useful in males. It is this
excess skin that must be excised that is ultimately
the rate-limiting factor in the surgeons ability to
shorten any abdominal incision. Unlike, for
example, the face, where incisions can success-
fully be shortened while still removing the amount
of skin necessary, in the abdomen as more skin
needs to be removed the incision must be made
longer.
The turn of the twenty-first century heralded the
increase in bariatric surgery and subsequently an
emerging field of bariatric plastic surgery. Abdom-
inal contour surgery is the cornerstone of the
numerous extensive excisional procedures under-
gone by patients with massive weight loss. It is
interesting, then, that plastic surgery has gone
full circle in less than a generation, from small inci-
sional stab wounds for liposuction-dominated
procedures to extensive lengthy incisions now
deemed necessary for these large excisional
procedures. In terms of abdominal liposuction,
Department of Surgery (Plastic Surgery), Albert Einstein College of Medicine, 1009 Park Avenue, New York,
NY 10028, USA
* 1009 Park Avenue, New York, NY 10028.
E-mail address: matarasso@aol.com
KEYWORDS

Lipoabdominoplasty

Liposuction

Abdominoplasty

Body contour surgery

Mini abdominoplasty

Secondary abdominoplasty

Massive weight loss
Clin Plastic Surg 37 (2010) 415437
doi:10.1016/j.cps.2010.03.006
0094-1298/10/$ see front matter 2010 Elsevier Inc. All rights reserved.
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recent interest is now focusing on the benefits of
laser-assisted liposuction (and the various wave-
lengths), and its role in facilitating fat removal
and the unknown potential for skin tightening.
This article focuses on the most commonly
encountered abdominoplasty scenario of the post-
partum abdomen that manifests itself as loose,
damaged, excess skin; widening (bony) pelvic
girth; rectus muscle diastasis and stretching; alter-
ation in the location of fatty deposits, umbilical
hernias, and altered appearance of the mons pubis
(with distortion, widening, and ptosis) (Fig. 2).
Emphasis is on technique. In addition 10 special
situations encountered in the abdominoplasty
population (eg, the scarred abdomen) are dis-
cussed. These often inevitable and irreversible
changes of pregnancy continue to plague the
physically fit, health-conscious baby-boomer
generation accustomed to obtaining optimal goals,
personally, professionally, and physically. Main-
taining their youthful physique, fashions, and
appeal, particularly in an environment that more
Fig. 1. The abdominolipoplasty system of classification and treatment. This system includes liposuction alone
(type I), mini abdominoplasty (type II), modified abdominoplasty (type III) (types II and III are considered limited
abdominoplasties), and a full standard abdominoplasty (type IV) with or without liposuction. SAL, suction-assis-
ted lipectomy. Pink arrows, liposuction; yellow, undermining; green, excision; cross-hatching, fascial plication.
Matarasso 416
than ever idealizes slimness, youthfulness, and
vitality, along with the current trend of low-cut
clothing (creating the ubiquitous muffin top
appearance in pants) is a priority for these patients.
Indeed people have a tendency to perceive their
level of fitness or ideal weight (and the necessity
to diet or exercise) by the appearance of their
abdomen and flanks. In some it even acts as
a surrogate marker for the aging process.
MARKINGS
The patient is marked wearing preferred undergar-
ments to confine the incision to within the bound-
aries of her clothing, and the undergarments also
serve as a useful guide to symmetry when planning
the incision. An ellipse (undermining wound
contraction, healing, and so forth can alter the final
location of the scar) of tissue to be excised is
Fig. 2. (AD) A 43-year-old gravida 5 para 5 woman complaining of a large diastasis of the rectus muscle and hy-
pomastia. Pre- and postoperative lateral and frontal views following breast augmentation and abdominoplasty.
Traditional Abdominoplasty 417
fashioned by determining the ease in which the
lower abdominal skin (from umbilicus to hairline)
can be excised after grasping the pannus with
both hands in an attempt for the fingers to touch
the thumbs. While holding the pannus slightly
upward, the lower incision is designed to traverse
the natural lower skin crease, slightly below its
normal position extending in length to just beyond
the lateral skin folds (noted in a sitting position) and
approximately 5 to 7 cm above the vulva cleft. The
upper incision is demarcated passing over the
umbilicus to encompass the old umbilical site
and only higher if there is extensive loose skin,
thereby forming an ellipse when joining the upper
and lower incisions. The elliptical excision is
drawn. Bisecting perpendicular lines are marked
through it (Fig. 3) to line up the skin edges for
subsequent closure. The incision for umbilical
circumscription and 4 quadrants on it are marked,
and the abdomen is infiltrated with approximately
1 liter of superwet anesthesia (1 L Ringer lactate,
1 mL 1:1000 epinephrine, 20 mL 1% lidocaine).
This action is desirable because it allows addi-
tional local anesthesia to safely be used in adja-
cent liposuction areas without concerns about
excess lidocaine or epinephrine; moreover, addi-
tional superwet fluid only interferes with
subsequent electrocoagulation. Liposuction is
then performed in the aesthetic units of the
abdomen as indicated (Fig. 4) in the suction areas
and on the entire upper flap, mons pubis, and
flanks. Patient risk is stratified as low to high ac-
cording to previously published guidelines. Candi-
dates for lipoabdominoplasty should be relatively
low risk, American Society of Anesthesiologists
class I, nonobese, nonsmokers, and without co-
morbid medical conditions. Furthermore, one
should keep in mind that liposuction, wound
tension, and undermining will influence flap
ischemia (Fig. 5). Alternatively, intraoperative de-
fatting of the flap below Scarpas fascia can also
be performed with scissors, which some investiga-
tors have claimed actually enhances flap perfu-
sion. After completing liposuction the symmetry
of the proposed incision is verified by placing 0-
silk sutures in the midline at the xiphoid and the
mons below the lower incision. The sutures are
left long, crisscrossed (overlapped), and grasped
with a clamp; these are then rotated to either
side of the midline at various points on the upper
and lower skin incision lines to ascertain symmetry
between sides. The surgical team then changes
gloves as they prepare for the open portion of
the procedure.
OPERATIVE PREPARATION
Before surgery the operating room table is
checked to be certain that it can be placed in
a maximal beach chair position. The symmetry
and angle of arm boards is also verified, and the
arms are secured by wrapping them with gauze.
A Foley catheter is inserted. Thromboembolic-
deterrent stockings and sequential pneumatic
compression devices and are placed prior to the
induction of anesthesia, and if indicated anticoag-
ulants are used. The abdomen is usually the final
procedure if multiple operations are performed.
OPERATIVE TECHNIQUE
The abdominoplasty proceeds by incising and
freeing the umbilicus. The pannus is then prepared
for preexcision in a vest-over-pants fashion (Pla-
nas). This maneuver is accomplished by incising
the upper limb of the ellipse to the level of the
rectus fascia while beveling the cut inward at
a 45

angle. The upper abdominal flap is then

completely undermined in a narrow tunnel resem-
bling an inverted v (corresponding to red suction
area 3) (see Fig. 5) or zone of complete undermin-
ing (Fig. 6A), maintaining the intercostal blood
supply sufficiently to achieve rectus muscle repair
and anterior sheath plication. Preservation of the
Fig. 3. Typical markings for abdominoplasty with
concomitant liposuction. The red, yellow, and green
zones indicate safety according to the suction areas
for simultaneous liposuction of the flap.
Matarasso 418
blood supply in this manner allows for appropriate
liposuction of the flap. Dissection is done by
scalpel, electrocautery, or harmonic scalpel.
An intact zone surrounding this tunnel (yellow
area in Fig. 5, corresponding to suction area 2
or zone of selective undermining [Fig. 6A]) is
undermined as needed to diminish the inevitable
skin bunching that occurs after muscle closure.
This action maintains a broad intact subcostal
perforator blood supply (green area in Fig. 5 or
zone of discontinuous undermining [Fig. 6A], of
axial blood supply corresponding to suction
Fig. 4. Aesthetic units of the abdomen in males (A) and females (B). When discussing the abdomen with females
they often also inquire about the back rolls.
Traditional Abdominoplasty 419
area 1). This intact area has been discontinuously
undermined by the liposuction. Consequently the
entire flap can be suctioned when performing
a full abdominoplasty, hence the term lipoabdomi-
noplasty. This operative technique is standard
unless patients do not require liposuction (Fig. 6).
The operating roomtable is flexed and the upper
skin flap is then pulled over the pannus to the
proposed lower skin marking to verify that it
reaches. Adjustments in the lower incision can
be made at this point if necessary. Vest-over-
pants preexcision has the following advantages:
leaving the pannus that will later be resected in
place preserves heat and blood, it is faster than
elevating a flap that will ultimately be excised,
and it avoids the tendency of wide upper flap
undermining ensuring flap tunneling, thereby
maintaining the lateral blood supply. Once it is
Fig. 5. (A) Blood supply to the abdomen before (left) and after (right) surgery. (B) Suction areas (SA) 1 to 4 are
based on the pre- (left) and postoperative (right) blood supplies. SA 4 is not actually on area it is excised. Note
how these correspond to zones in Fig. 6.
Fig. 6. (A, B) The lipoabdominoplasty procedure. Zone of complete undermining to the extent necessary for
rectus repair is shown. In the zone of selective undermining tethering points are released to allow flap redraping.
Zone of discontinuous undermining results from liposuction. Note how these zones also correspond to suction
areas (SA) 1 to 3 in Fig. 5B.
Matarasso 420
determined that the upper flap reaches the lower
incision, it is committed to and an incision is
made to the level of the fascia. It has been sug-
gested that leaving a thin layer of fibrofatty tissue
on top of the fascia (and/or quilting sutures when
closing) reduces the incidence of seromas. In
patients with massive weight loss, a large pannus
can distort the anatomy and bring the spermato-
chord and so forth into the field; therefore care
must be taken as the incision proceeds down to
the rectus fascia. The pannus is then grasped
with Allis clamps and excised en bloc, from the
right to left side. A plastic button (ocular
conformer) is sutured to the umbilicus to be used
for subsequent identification and removed when
the umbilicus is later exteriorized. At each step
the surgeon and assistants achieve hemostasis
with electrocautery. The rectus muscle diastasis
is marked with ink in a long vertical ellipse from xy-
phoid to pubis. The section above and then below
the umbilicus is closed in layers with running 0-
loop nylon sutures and then a second layer of
buried interrupted 2-0 Neurolon sutures. In thin
patients with minimal intra-abdominal adiposity,
additional waistline narrowing can be performed
by placing 1 or 2 2-0 Neurolon sutures horizontal
to the umbilicus. No further fascial muscle tight-
ening is necessary or desirable. Once appropri-
ately closed, the amount of flattening achieved
with rectus plication cannot be predicted or
increased. Furthermore, some relaxation and
stretching of the fascial repair is likely to occur
over time. Puckering that develops in the upper
skin flap where it is still adherent to the underlying
muscle subsequent to fascial closure is gently
freed by blunt and sharp selective dissection
(zone of discontinuous undermining). Small
amounts of bunching are tolerated and indeed
desirable, as intact skin maintains lateral inter-
costal blood supply. This condition resolves in
the early postoperative period. Ten milliliters of
1/4% marcaine with epinephrine is injected into
various points in the rectus sheath for analgesia
and on occasion pain pumps are tunneled below
the fascia. The cavity is irrigated with lidocaine
and epinephrine solution, and final inspection
and hemostasis is performed. The table is returned
to the degree of beach chair position required to
achieve wound closure, which begins by placing
a 2-0 Vicryl suture in the midline. The wound edges
are aligned with staples, minimizing dog-ear
formation. A 2-0 PDO bidirectional barbed suture
(Quill SRS, Angiotech, Vancouver, Canada) is
used in the deep layers from Scarpas fascia to
the dermis on either side of the midline in a running
fashion. While in the flexed position and with most
of the wound closed, the umbilical button is
palpated below the flap and marked on the skin
in the midline slightly higher than its natural posi-
tion. The dimensions of the abdomenvertical,
horizontal, and so forthcan be expected to
change after an abdominoplasty (Fig. 7). A second
layer of 3-0 monoderm Quill sutures is used in the
subcuticular layer. The drains exit the wound and
are sewn in place with 3-0 nylon sutures. Drains
remain in place for several days until wound
drainage subsides.
When preparing to exteriorize the umbilicus, the
patients midline is verified with the silk marking
sutures and by observing the position of the vulva
cleft. The marked umbilical site is determined and
a 2.5-cm inverted V-type incision is made in the
midline. The upper and (more so) lower skin edges
of the umbilical opening are defatted. The author
no longer tacks the umbilicus to the fascia. The
umbilicus is exteriorized and the button removed.
Deep absorbable sutures are placed from umbi-
licus to skin flap, and the umbilical skin is then
closed with 3-0 nylon sutures. The umbilicus is
packed with a strip of 26-cm xeroform gauze.
Antibiotic ointment is placed on the wound and it
is covered with a Telfa dressing. A binder can be
Fig. 7. The reduction in dimensions from xiphoid to
umbilicus (2.8 cm; XU), change in waistline (7.9 cm;
W) and umbilicus to vulva (5.09 cm; UV) 6 months
following an abdominoplasty. Note that all dimen-
sions are shorter or narrower following an abdomino-
plasty, regardless of whether liposuction was
performed.
Traditional Abdominoplasty 421
used. The patient is transferred to a stretcher in the
same maximally flexed position. Patients should
ambulate that day as if they are using a walker,
and over the next few days progressively begin
to fully straighten out.
In most cases, the skin between umbilicus and
pubis is excised including the old umbilicus site,
which is a significant patient preference. This
maneuver necessitates maximal flexion (Fig. 8) of
the operating room table and can result in tension
of the undermined flap. Concerns about the
appearance of a circumscribed umbilicus have
been among the reasons that have motivated
patients and surgeons to perform alternative
procedures such as lower abdominoplasty or pan-
niculectomy with extensive liposuction. These
procedures yield different results than a full ab-
dominoplasty, with a similar length of incision
albeit without an umbilical scar (Fig. 9). This cosm-
esis is part of the discussion and decision-making
process between patient and surgeon (see section
Special considerations).
COMPLICATIONS
A full abdominoplasty with or without liposuction,
and potentially additional aesthetic or nonaes-
thetic procedures, are extensive operations that
can be associated with a wide array of local or
systematic complications that can range from
a trivial nuisance to a lethal condition. Tables 13
review local and systemic complications in
abdominal contour surgery and in a full abdomino-
plasty, by comparing major case series.
Untoward sequels of abdominoplasty are those
issues that tend to resolve spontaneously, such as
hypesthesias, edema, ecchymosis, induration,
and erythema.
TISSUE ISCHEMIA
Plastic surgery has long been regarded as a battle
between beauty and blood supply (patients
consider it a battle between beauty and a scar).
The abdomen, which involves a large surface
area, wide undermining, concomitant liposuction,
andtensiononwoundclosure only serves tounder-
score the importance of this relationship. Ameticu-
lous technique, awareness of the bloodsupply, and
reconciliation between the extent of liposuction,
tension on wound closure, and the method and
extent of undermining are critical components to
safety. Ischemia noted intraoperatively has been
addressed by delayed wound closure or even by
waitingtoexteriorize theumbilicus until thepostop-
erative period to preserve blood supply.
All wounds are examinedthe night of surgery and
thenext morning. If ischemiais notedany reversible
causes such as fluidcollection, cellulitis, infections,
or wound tension (that can be relieved by suture
removal) are addressed. Should ischemia prog-
ress, the author has used a regime of calcium
chemical blockers (nifedipine), nitropaste (NTP),
and solumedrol. At present, the author prefers
a protocol using dimethyl sulfoxide (Spectrum
Chemical Mfg. Corp, Gardena, CA, USA). Ischemia
that progresses tonecrosis most oftenmanifests it-
self in the terrible abdominoplasty triangle with
the apex located at the umbilicus and the base at
the top of the mons pubis. The flap is most vulner-
able to lack of blood supply here, as this represents
the cross-over watershed blood supply zones from
Huger zones II and III (see Fig. 5). Umbilical
ischemia/necrosis is most often due to torsion,
skeletalization, or entering the stalk to repair
a hernia (which devitalizes the second blood
supply; the first is via the skin). Aprior umbilical float
(transection) that is later circumscribed could also
similarly result in umbilical ischemia.
Standard conservative wound management
protocols are followed for necrotic tissue, and one
should avoid early, unnecessary debridement, as it
has been postulated that this can lead to retrograde
thrombosis. Suction areas (14) have been estab-
lished to reconcile the location, extent, and degrees
of liposuction of the undermined flap and
surroundingareas. Combiningthiswithundermining
in an inverted V to the extent necessary to close
the diastasis and achieve wound closure with oper-
ating room table maximally flexed are important in
safely achieving an optimal aesthetic outcome.
SPECIAL CONSIDERATIONS
Certain circumstances in situations of a full
abdominoplasty merit further discussion.
Fig. 8. The operating room table should be maximally
beach chaired to allow sufficient removal of skin and
excision of the old umbilical site.
Matarasso 422
Preexisting Upper Abdominal Scars
Conflicting reports in the literature suggest that
scars (eg, Chevron incision) may or may not
increase complications. Non-midline upper
abdominal scars that limit the crossover blood
supply to the abdominal wall rendering patients
at risk for wound ischemia require considering an
alteration in approach. One alternative is a fleur-
de-lis excision that incorporates the old scar in
the excision and tightens tissue laterally. The exci-
sion of the old scar avoids issues of it blocking the
blood supply. If a fleur-de-lis is not indicated in
patients with scars, another alternative is limited
flap undermining to the level of the scar, but this
may limit the extent the diastasis can be repaired
or the amount of skin removed (Fig. 10). A reverse
abdominoplasty is another option that rejuvenates
the upper abdomen. This procedure is ideally
Fig. 9. Pre- (A) and postoperative (B) frontal view of a 39-year-old woman who was downstaged to a lower ab-
dominoplasty rather than a full abdominoplasty at her request. Lateral view of the same patient before (C) and
after (D) lower abdominoplasty with 2175 mL of abdominal and flank liposuction, secondary breast reduction,
and lower lid blepharoplasty. No incision is necessary around the umbilicus.
Traditional Abdominoplasty 423
performed in patients with 2 preexisting inframam-
mary scars, or it can be done through one gull-
wing incision. Finally, delaying the flap by incising
the deep and superficial epigastric arteries is
possible. The author does not find that
unconventionally designed excisions are good
alternatives in scarred abdomens. Consequently,
an in-depth discussion about the specific risks
associated with upper abdominal scars is
appropriate.
Table 1
Local abdominal contour surgery complications
Complications Liposuction
Limited
Abdominoplasties
Full
Abdominoplasties
Contour irregularity 9.20% 4.90% 5%
Major skin necrosis (requiring
reoperation)
0% 1% 1%
Minor skin necrosis (healed
spontaneously)
0% 4% 4.40%
Scar revision 0.03% 2.40% 4.90%
Hematoma 0.04% 0.08% 1.40%
Wound infection 1% 0.02% 1.10%
Wound dehiscence 0% 1% 1%
Umbilical abnormality
(requiring reoperation)
0% 0.05% 1.20%
Dissatisfied patients
(unfulfilled expectations)
3.30% 2.90% 2.20%
Need for second surgery 3.50% 2.40% 3.40%
From Matarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a National Plastic Surgery Survey.
Plastic Reconstr Surg 2006;117(6):1797808; with permission.
Table 2
Systemic abdominal contour surgery complications
Complications Liposuction
Limited
Abdominoplasties
Full
Abdominoplasties
Local anesthesia (ie,
wetting solution)
0% 0% 0%
Major anesthesia 0% 0% 0%
Malpractice action 0% 0% 0.01%
Blood transfusion 0% 0% 0.04%
Deep vein
thrombophlebitis
0% 0.01% 0.04%
Pulmonary embolism 0% 0% 0.02%
Pulmonary fat
embolism
0% 0% 0%
Intra-abdominal
perforation
0% 0% 0%
Death 0% 0% 0%
Readmission to
hospital
0.01% 0.01% 0.05%
From Matarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a National Plastic Surgery Survey.
Plastic Reconstr Surg 2006;117(6):1797808; with permission.
Matarasso 424
Achieving a Narrower Waistline
Narrowing the waistline is a common request of
patients seeking abdominal contour surgery, but
in general it is not a result that can be predicted
or assured. The author finds that often when dis-
cussing this, these patients state that they have
always had a disparity between their hips and
waistline (narrow hips), and as intra-abdominal
fat increases and the pelvis widens with age, this
problem is exacerbated. Rectus fascial plication
does not dictate the extent of abdominal flat-
tening. When rectus closure is done appropriately,
no further flattening or waistline narrowing can be
achieved. Selective liposuction in the area of the
waistline may add slight improvement, though by
virtue of the abdominoplasty waistline measure-
ments do change (see Fig. 6). In the individuals
with minimal visceral fat, waistline sutures, as
described by Jackson, can be useful (Fig. 11).
Downstaging to Less Invasive Alternatives
Downstaging is a term used for candidates for ab-
dominoplasty who want less invasive surgery.
These patients may not want the scar or the
Table 3
Comparison of results of abdominoplasty complications
Matarasso
et al
Hester
et al
1,a
Grazer and
Goldwyn
2,b
Pitanguy
3,c
Teimourian
and Rogers
4,d
No. of procedures 11,016 563 10,490 539 25,562
Local, %
Necrosis minor 4.4 0.9% (minimal
slough)
5.4 (wound
dehiscence)
1.4
Necrosis major 1.0 0.3
Seroma 2.5% 5.8 8.58
Infection 1.1 1.1 7.3
Blood loss <1.0 14.2
Hypertrophic scars <1.0 3.7
Hematoma 1.4 6
Wound infection 1%
Dehiscence 1% 0.3
Umbilical abnormality 1.2 0.3
Dissatisfied patient 2.2
Need for second operation 3.4
Scar revision 4.9
Contour irregularity 5.0
Systemic, %
Deep vein thrombosis 0.04 1.1 0.29
Pulmonary embolism 0.02 1.1 0.8 0.25
Pulmonary fat embolism 0 0.02
Blood transfusion 0.04 0.04
Death 0 0.16 0.04
Anesthesia complications 0 0.01
Readmission to hospital 0.05
Malpractice action 0.01 0.18
a
Abdominoplasty versus abdominoplasty and intra-abdominal/pelvic abdo2minoplasty with other aesthetic procedures.
b
Abdominoplasty by survey.
c
Abdominoplasty alone.
d
Abdominoplasty versus suction-assisted lipectomy versus dermolipectomy by survey.
Data from Matarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a National Plastic Surgery
Survey. Plastic Reconstr Surg 2006;117(6):1797808.
Traditional Abdominoplasty 425
recovery period of an abdominoplasty. For
example, downstaging from a full (open) abdomi-
noplasty to a less invasive procedure such as lipo-
suction alone is feasible when reconciling the
patients anatomy with their goals. However,
different and less invasive procedures will not yield
the same results, and this must be emphasized to
the patient (Figs. 9 and 12).
Liposuction as an Adjunct to a Full
Abdominoplasty or Lipoabdominoplasty
Liposuction as an adjunct to a full abdomino-
plasty is routinely incorporated according to
the published guidelines of the suction areas
(14) and in accordance with stratifying risk
factors and balancing the extent of liposuction
Fig. 10. (A) Preoperative front view of a 43-year-old gravida 1 para 1 woman with a subcostal scar on the left side.
(B) Postoperative appearance. Lateral view before (C) and after (D) surgery. Undermining was performed to the
level of the scar.
Matarasso 426
with the amount of tension on wound closure,
and the degree of wound undermining. This
procedure is previously described in the
section operative technique. If deemed inap-
propriate, liposuction and abdominoplasty can
be separated and performed as staged proce-
dures. Some surgeons prefer defatting the
undermined flap with scissors. Studies on
combining liposuction of surrounding areas or
the flap itself have suggested a higher seroma
rate; however those patients requiring defatting
by definition are having more surgery, and
might be expected to have a higher seroma
rate.
Lipoabdominoplasty has recently became
a popular term; however, the exact meaning
varies according to who is using it. The author
describes an abdominoplasty with limited upper
abdominal undermining (or inverted V fashion),
thereby preserving lateral intercostal blood
supply, and then performing liposuction more
aggressively on the upper flap (Fig. 13) as ab-
dominoplasty with liposuction or lipoabdomino-
plasty (see Fig. 6).
Fig. 11. (A, B) The patient is shown before and after abdominoplasty, demonstrating a narrower waistline. (C, D)
Frontal view of another patient with a narrower waistline after a full abdominoplasty.
Traditional Abdominoplasty 427
Panniculectomy with Extensive Suction-
Assisted Lipectomy or Liposuction with Lower
Skin Resection or Lower Abdominoplasty
Essentially these terms describe similar tech-
niques that combine extensive liposuction with
en bloc resection of approximately the lower
25% of abdominal skin (half of tissue from umbi-
licus to the mons pubis) without direct flap under-
mining, just discontinuous undermining of the
upper flap by liposuction, with or without umbilicus
Fig. 12. Downstaging. The patient who is shown here preoperatively (A) and preoperatively (B) would be an
appropriate candidate for abdominoplasty but requested liposuction only. A different patient who did not
want an abdominoplasty and was downstaged to liposuction is shown before (C) and 1 week after (D) 4200
mL of abdominal and flank liposuction.
Matarasso 428
circumscription, and with or without lower rectus
tightening. If the umbilicus is circumscribed
enough, partial undermining should be done to
ensure old umbilicus site removal with the pannus
of excised skin (Fig. 14). If the umbilicus is not cir-
cumscribed, the excision should be designed with
enough skin below the umbilicus to reach the
mons pubis and to be aesthetically pleasing.
Patients may prefer this because there is not an
incision around the umbilicus, although the lower
incision is nearly the same as a full abdomino-
plasty but it does not fully address supraumbilical
skin laxity if present (see Fig. 9).
As mentioned, concern for the appearance of
a circumscribed umbilicus, preference for a less
invasive option, the desire to do more liposuction,
and potentially less risky procedure are among the
reasons that have led some patients and surgeons
to consider these procedures. Other purported
advantages of lower abdominoplasty include less
fluid drainage, being a good option for smokers,
those with scarred abdomens, or obese patients.
These procedures yield different results than
a full abdominoplasty, with a similar length of
incision albeit potentially without an umbilical
scar. This cosmesis forms part of the discussion
Fig. 13. An example of a 39 year old gravida 2 para 2 woman pre (A, C) and post (B, D) abdominoplasty with 2750
mL of liposuction of the abdomen, thighs, and backrolls. (E, F) same patient frontal view.
Traditional Abdominoplasty 429
and decision-making process between patient
and surgeon. These or other alternatives are indi-
cated based on the patients anatomy and goals.
Fig. 14 demonstrates various alternative excisions
and incisions; the lower 3 choices do not create
umbilical scars. Just as in other situations of
downstaging whereby less invasive alternatives
are selected, lower abdominoplasty will not neces-
sarily yield the same outcome as a standard full
abdominoplasty. Lower abdominoplasty is essen-
tially the most recent reincarnation of a procedure
somewhere between a mini and a modified
abdominoplasty with (Fig. 15) or without (Fig. 9)
transection or floating of the umbilicus.
If one chooses to operate on obese patients
(Fig. 15), who are generally at a higher risk for
complications from a full abdominoplasty and
present with significant visceral and subcutaneous
fat, and possibly umbilical hernias, then they may
also be better suited for this procedure than a full
abdominoplasty. In addition to the advantages
mentioned: (1) less flap undermining makes lipo-
suction safer and reduces wound complications;
(2) if the umbilicus is not circumscribed, then
umbilical hernias can potentially be repaired; (3)
not repairing the entire rectus muscle diastasis
avoids the discomfort and pulmonary complica-
tions associated with this operation. It prevents
increased pressure in the abdomen (abdominal
compartment syndrome), which may contribute
to deep vein thrombosis/pulmonary embolism,
and it avoids technical complications associated
with muscle repair such as inadequate plication
or recurrent defect. Moreover, rectus muscle
closure has little benefit in those patients with
abundant visceral fat. In fact the author often
avoids rectus repair in males, nulliparous females
(or those anticipating a pregnancy), patients with
massive weight loss, or other patients who might
not benefit from the repair. Overall this alternative
should be associated with fewer complications
than a full abdominoplasty, including those prob-
lems associated with maintaining a flexed position
or achieving early ambulation.
Abdominoplasty in Patients who Previously
had Liposuction
Several observations can be made about these
patients, who will now accept an abdominoplasty
incision to address loose skin or diastasis of the
rectus muscle when they might not have required
it before. Changes that earlier liposuction can
cause include small pseudo-bursas or scars and
the fact that the upper flap will have less laxity/
elasticity due to the prior surgery, so it is tighter
Fig. 14. Drawing of excision for various abdominal contour alternatives. Note the mini is a drawing of the inci-
sion. Note that a mini abdominoplasty, lower abdominoplasty, or panniculectomy without umbilical circumscrip-
tion avoids umbilical scars.
Matarasso 430
and unfurls less than in an unoperated abdomen.
Consequently, the planned excision should be
more conservative than would have been antici-
pated. Scoring the undersurface of the flap
similar to what is done on the galea of the scalp
releases some of the tension. Also, because it is
essentially a delayed flap, wider undermining can
also be safely performed. The operating room
team should be prepared to maximally flex the
patient and drains should be left in place for an
extended period of time, as these patients can
have longer postoperative drainage. These
patients may also have concerns with laxity of
the flank areas, and extending the incision to
incorporate a flankplasty can be discussed
(Fig. 16).
Fig. 15. An obese patient is shown before (A) and after (B) lower abdominoplasty (panniculectomy) with exten-
sive, unrestricted liposuction and circumscription of the umbilicus (and breast reduction).
Fig. 16. (A, B) Example of a patient who had prior liposuction (left) and then a full abdominoplasty (right).
Traditional Abdominoplasty 431
Secondary Full Abdominoplasty
Secondary full abdominoplasty is an uncommon
event unless there have been additional preg-
nancies, a long time interval from the first
surgery, or issues related to the outcome of
the primary surgery including failed diastasis
repair. These patients are often concerned with
many of the same problems as primary patients,
including excess loose skin, rectus muscle dia-
stasis, and adipose tissue that may or may not
have been treated at the time of the first opera-
tion. The second abdominoplasty design is
Fig. 17. (A) Lateral view of a 59-year-old woman complaining of loose skin and rectus diastasis years after an
earlier abdominoplasty. (B) The patient is shown following a secondary abdominoplasty. Frontal view of the
same patient before (C) and after (D) a secondary abdominoplasty. Note the second incision is somewhat dictated
by the location of the first abdominoplasty incision.
Matarasso 432
somewhat committed to the location of the
previous incision. At the time of secondary
surgery, improvements in appearance can be
made by liposuction, excising skin, excising
a closed prior umbilical site, improving the
scar, or additional muscle tightening (Fig. 17).
Removing the Old Umbilical Site
Designing and performing the procedure to re-
move the old umbilical site is an important concern
of patients who, despite pleasing results, will
complain that a retained umbilical site looks
unsightly or like a second umbilicus. Enough
upper abdominal skin should be recruited to
excise the old umbilical site. Therefore, the incision
design should be appropriate and the operating
table maximally flexed (see Fig. 8) to ensure
removal of the umbilical site. This removal can
lead to more wound tension than the surgeon is
accustomed to, so other factors such as liposuc-
tion and the nature of flap undermining must be
reconciled to account for this (Figs. 18 and 19).
Performing the Wrong Operation
This scenario occurs most frequently when
substituting a mini abdominoplasty for a full
abdominoplasty but anticipating the same
outcome. In postpartum patients a limited
abdominoplasty is often not adequate to achieve
their goals; it is most appropriate in nulliparous
females. The prospect of a mini procedure
with a smaller scar, shorter recovery, and less
complications is appealing to the patient and the
surgeon; but should only be performed with the
understanding of what can be achieved. Indeed
the most common error in this group of patients
is performing this procedure that does not
adequately address the patients concerns. In
those patients that have had a modified or limited
abdominoplasty and are unsatisfied if the umbi-
licus has been transected and they now require
a full abdominoplasty, 2 main problems will be
encountered: (a) harvesting enough skin to excise
the old umbilical site and reaching the full extent of
the rectus diastasis, and (b) devitalizing a previ-
ously transected umbilicus by now circumscribing
it (Fig. 20).
Bariatric Plastic Surgery
Bariatric plastic surgery is performed in the patient
with massive weight loss, whether surgically
induced or resulting from lifestyle changes. The
abdomen is one of the primary concerns in this
patient population, who have a variety of options
based on their concerns. These options include
panniculectomy with extensive liposuction (as
previously described), abdominoplasty (Fig. 21),
extended abdominoplasty (which extends the
Fig. 18. (A) Preoperative view 45-year-old woman marked for an abdominoplasty by another surgeon. (B) Post-
operatively after first abdominoplasty. Not the vertical slit closure of old umbilical site (arrow), which was not
removed at surgery. (C) Following secondary abdominoplasty with removal of old umbilical site. Again the inci-
sion is not optimal but based on the previous abdominoplasty incision.
Traditional Abdominoplasty 433
resection to include the flanks), or a circumferential
abdominoplasty. Metabolic changes associated
with massive weight loss should be addressed
preoperatively. If there is a port from a lap band,
this must be accounted for during dissection and
muscle plication, taking care not to disturb it. If
the lap band requires adjustment postoperatively,
the bariatric surgeon must also be made aware
Fig. 19. (A) 31-year-old gravida 2 para 2 long-waisted patient who was a concerned about the ability to excise the
old umbilical site. (B) Frontal view postoperatively, following abdominoplasty and breast augmentation. Lateral
view of the same patient before (C) and after (D) surgery.
Matarasso 434
Fig. 20. (A) The frontal appearance of 39 year old gravida 2 para 2 woman who had previously undergone a mini
abdominoplasty with an umbilical float. (B) The patient is shown after a secondary procedure, with a full abdom-
inoplasty and umbilical circumscription, excision of lower skin with old umbilical site, and complete rectus muscle
repair. (C) Lateral view of the same patient after mini abdominoplasty. (D) Following a full abdominoplasty.
Traditional Abdominoplasty 435
that the scars used to place the port have been
moved. Finally, in these patients one must be
prepared for the unexpected, such as incisional
or umbilical hernias.
MALES
Males have some different considerations than
females that are beyond the scope of this article.
In general males benefit from circumferential lipo-
suction of the abdomen and flanks, or a full ab-
dominoplasty without rectus muscle plication.
These are the preferred techniques in males.
SUMMARY
Abdominal contour surgery represents a spectrum
of treatment options available to improve the
appearance of the abdomen. Abdominoplasty is
a successful operative procedure that excises
excessabdominal skin, closesrectusmusclediasta-
sis, and improves lipodystrophy. Abdominoplasty
has proven to be an effective and safe treatment
for rejuvenating the postpartum patient alone or in
conjunction with breast, body surgery, or other
procedures.
Fig. 21. Frontal view of a 45-year-old massive weight loss (125 pounds) patient before (A) and after (B) an abdom-
inoplasty and mastopexy. Lateral view of the same patient before (C) and after (D) surgery.
Matarasso 436
SUGGESTED READING
See the Suggested Reading list (available online
at http://www.plasticsurgery.theclinics.com/) for
further reading.
REFERENCES
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2. Grazer FM, Goldwyn RM. Abdominoplasty assessed
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constr Surg 1977;59:513.
3. Pitanguy I. Abdominal lipectomy. Clin Plast Surg
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4. Teimourian B, Rogers WB III. A national survey of
complications associated with suction lipectomy:
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Traditional Abdominoplasty 437