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Abdominoplasty Principles
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AldoPerez
19
The abdomen is a very important area when considering the
aesthetics of the human body, which may be due to multiple
factors such as overweight, pregnancy, previous surgeries,
muscle disorders, triggers deformities causing personal frustration, and low self-esteem.
Traditional abdominoplasty techniques can successfully
achieve a at appearance, but sometimes these results may
lack the subtle anatomical features that we appreciate in a
youthful, attractive abdomen, giving it a board-like appearance [1].
Several methods that have been published before do not
place emphasis on reestablishing the continuity of the various anatomical features of the abdominal wall. In addition,
the technical tools required to attain the anatomical details
present on the ideal aesthetic abdomen were limited prior to
the publication of the progressive tension suture (PTS) technique [2].
19.1 Historical Background
oftheProcedure
The origins of plastic surgery on the abdominal wall go back
to the end of the eighteenth century in 1890 with Demars and
Marx in France, and, in 1899 with Kelly whose treatment
consisted of giant hernia correction of the abdominal wall
plus skin and abdominal fat resection.
In 1967 Pitanguy described the horizontal incision a bit
above the pubis and transposition of the umbilicus. In 1975
through analysis of an extensive clinical research, he emphasized the importance of the reinforcement and plication of
the abdominal fascia, which was demonstrated by the good
aesthetic results and a low complication rate.
In 1992, Matarasso [3, 4] performed liposuction of the
abdominal ap with wide dissection, which he called an
abdominolipoplasty. He also presented the classication of
abdominoplasty, based on the evaluation of the skin, fat, and
facial muscle system [5].
In 2001, Saldanha [6] published the rst work on complete abdominal liposuction associated with classic abdominoplasty, with selective dissection of the abdominal ap
preserving the Fascia of Scarpa and transposition of the
umbilicus. Since then, the safest way of combining the two
techniques has been studied and published.
19.2 Classication
Abdominoplasty, and treatment for other abdominal contouring surgeries, is based on the quality of the skin, volume
of intra and extra-abdominal fat, muscle tone, and other
treatable soft tissues (Table19.1).
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_19].
A. Perez (*)
Department of Plastic Surgery, Universidad de Ciencias Medicas
de la Habana, Cuba
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_19
301
302
Skin Fat System TreatmentType
Transverso del abdomen
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Table 19.1 Abdominoplasty system of classication and treatment for abdominal contour surgery
A. Perez
I
II
III
IV Variable Complete diastasis Standard abdominoplasty
This is based on the treatable soft tissue layers of skin, fat, and muscle [5]
Fig. 19.1 Layers of the
abdominal wall. It is clearly
seen that the rectus sheath is
an aponeurosis formed by the
ve muscles of the abdomen.
Various parts of the rectus
sheath are seen in the (a)
upper abdomen (b) lower
abdomen
Minimal laxity Variable Minimal diastasis Suction-assisted lipectomy
Mild laxity Variable Lower diastasis Mini abdominoplasty
Moderate laxity Variable Lower +– upper diastasis Modified abdominoplasty
Severe laxity
a
b
Linea alba Recto del abdomen
Fascia transversal
Peritoneo parietal
Linea alba Recto del abdomen
with or without suction
lipectomy
Oblicuo externo
Oblicuo interno
Transverso del abdomen
Oblicuo externo
Fascia transversal
Peritoneo parietal
19.3 Anatomy oftheAbdominal Wall
The anterior and lateral part of the abdominal cavity is bound
by the muscular abdominal wall providing exible coverage
and protection for internal organs. This complex structure
consists of numerous layers of the abdomen.
From supercial to deep: (Fig.19.1)
1. Skin.
2. Supercial fascia (above the navel, it is a thin, single
layer of subcutaneous tissue). It is divided below the
umbilicus, a fatty supercial layer called Camper’s fascia, and a deeper one called Scarpa’s fascia (blood vessels
and nerves run between them).
Oblicuo interno
3. Muscles.
4. Fascia.
5. Parietal peritoneum.
19.3.1 Structure andFunction
The main functions of the abdominal wall are:
• Trunk stability and rotation.
• Increased intra-abdominal pressure.
• Protection of the internal abdominal organs.
• By increasing the intra-abdominal pressure and thus moving the abdominal organs toward the diaphragm, it assists
in expiration.
L
Segmental
Perforators
DCIA
R
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Fig. 19.2 (Left) The “Huger
zone”—Zone I to Zone III of
the abdominal wall and its
blood supply. In the virgin
abdomen without scars and
undermining, Zone I is
supplied predominantly by
the deep superior epigastric
artery and collaterals from the
deep inferior epigastric artery.
(Right) After the skin ap has
been elevated for
abdominoplasty zone III
(segmental or lateral
intercostal perforators) and a
minor contribution from zone
II perfuses the ap [3]. DCIA
deep circumex iliac artery,
DIEA deep inferior epigastric
artery, DSEA deep superior
epigastric artery, MPA main
pulmonary artery, SCIA
supercial circumex iliac
artery, SEPA supercial
external pudendal artery, SIEA
supercial inferior epigastric
artery, SSEA supercial
superior epigastric artery
DCIA
SCIA
SIEA
DIEA
SEPA
Asc.Br..
DCIA
MPA
DSEA
SSEA
II
303
III
Segmental
Perforators
I
SCIA
• Providing strong muscular covering and preventing the
abdominal organs from moving out of the abdominal
cavity.
19.3.2 Blood Supply andLymphatics [7–11]
The blood supply of the anterior abdominal wall is as
follows:
• Superior epigastric artery.
• Inferior epigastric artery.
• Deep circumex iliac.
• Supercial epigastric vessels.
• Supercial circumex iliac.
Thoracoepigastric veins are running longitudinally,
which connect the lateral and superficial epigastric
veins [12].
This anatomical knowledge can help us evaluate the
abdominal wall and delineate the safe surgical areas known
as “The Huger Zones” [3, 13] (Fig.19.2). The blood supply
in zone I is predominantly given by the superior epigastric
artery. Zones II and III are responsible to perfuse the ap
after the skin ap is elevated.
19.3.3 Nerves
The anterior abdominal wall is innervated:
• Subcostal nerves.
• Iliohypogastric.
• Ilioinguinal.
The muscles of the abdominal wall are divided into two
groups:
1. Two vertical muscles are located near the midline, the
rectus abdominis, and the pyramidalis.
2. Three at muscles are located laterally, the external oblique,
the internal oblique, and the transversus abdominis.
Flat muscles ex and rotate the torso. The bers of all the
muscles criss-cross and connect to strengthen the abdominal
wall, this reduces the risk of hernias [7, 12].
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A. Perez
19.4 Patient Evaluation andPreparation
During the evaluation of an abdominoplasty candidate, there
are three elements that require evaluation: the most important is the skin laxity, the presence of diastasis, and an excess
of subcutaneous fat.
Preoperative preparation begins from the time, the patient
has its rst consultation, and it is a process including the surgeon, the anesthesiologist, staff, and the patient [1].
Before surgery, the patient receives a detailed list of products to avoid or suspend if necessary, such as aspirin, vita-
a
b
mins, contraceptives, and some specic food. For all
contouring procedures, patients need to cease nicotinecontaining products at least 3weeks before their procedure.
All patients undergo a series of studies, including complete
blood count, urinalysis, basic metabolic panel, comprehensive metabolic panel, lipid panel, coagulation panel, HIV,
syphilis, and C-reactive protein test.
Abdominoplasty has the highest incidence of venous
thromboembolism of all cosmetic procedures, and a half or
more of abdominal deaths are due to thromboembolism.
c
d
g
Fig. 19.3 The lower transverse and the midline incision is marked
(a–d). This horizontal incision mark is placed approximately at the
level of or slightly superior to the symphysis of the pubis. The lateral
height and length of the incision are measured to ensure symmetry. (c)
The incision mark is then extended laterally in a natural skin fold if skin
e
h
f
i
has to be excised laterally (e). The upper line, which serves as an estimate of the amount of tissue to be resected, is then drawn. (f, g). The
midline upper abdomen, lateral breast, anks, and hip rolls are also
marked for liposuction, which will be performed concurrently (h, i)
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305
We recommend the use of TED stockings or a calf compression device, for at least 24h after the surgery, and the use
of enoxaparin sodium 40mg subcutaneously every 24h for
5days, including one dose 12h prior.
The surgical markings (Fig.19.3a–i) are made in conjunction with the patient. Abdominal resection is essentially the removal of an ellipse of tissue between the
umbilicus and the pubis. The length of the abdominoplasty
incision is determined by locating the end of the pannus
skin excess when the patient is in a Fowler’s position.
Above 6–8cm above the vulvar cleft, the surgeon connects
these lateral markings to the midline. The upper incision is
then marked from one anterior superior iliac spine to the
upper part of the umbilicus, and then to the contralateral
anterior superior iliac spine, connecting the lower
marking.
Ideally, the old umbilicus site must be removed in an
abdominoplasty.
a
b
19.5 Surgical Procedure ofFull
Abdominoplasty withSaldanha’s
Technique
It is the combination of massive abdominal liposuction and
closure of the supraumbilical area, once the skin of the infraumbilical portion is removed.
The advantage of this technique is the preservation of the
vascular and lymphatic tissue, or the detachment of these
being minimal.
All procedures are undertaken with systemic anesthesia
(spontaneous ventilation general anesthesia, or spinal/epidural) administered by an anesthesiologist. The operative
eld is injected with approximately 1 Lt of superwet anesthesia (Fig.19.4a–e) (1 Lt of Hartmann, 20mL of 1% lido-
caine, 1mL of 1:1000 epinephrine). Limiting the volume of
wetting solution to the abdomen provides a margin of safety
to allow inltration of additional operative sites (Fig.19.5).
c
d
Fig. 19.4 (a–e) Several entry sites, including the superior portion of the umbilicus, are used to perform tumescent inltration
e
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A. Perez
a
SA 2 SA 2
ARC
SA 3
SA 1
SA 4
SA 1
SUCTION AREA (SA)
Safe areas of SAL SA 1
Limited areas of SAL
Cautious area of SAL
Unrestricted SAL
Fig. 19.5 Image shows the safe and unsafe area for liposuction based
on its blood supply after abdominoplasty incision has been made. SA 4
is the area to be excised. In a traditional abdominoplasty, SA 2 and SA 3
are the areas that will be undermined. SA 3 is the area called as “Terrible
abdominoplasty triangle” where, if ischemia occurs, is most likely
SA 2
SA 3
SA 4
SA 1
Modied Klein’s solution greatly hydrates the tissue,
allowing the cannulas to pass with minimal trauma, and protects the blood vessels by compressing them, making them
targets for less trauma.
The operation begins by making the surgical access points
and liposuctioning in the indicated areas (Fig.19.6).
In the area of proposed undermining, liposuction is performed on the fat supercial to Scarpa’s fascia, because
subscarpal fat resection will be performed which will remove
the fat deep to Scarpa’s fascia throughout the entire area.
After the liposuction is done, the lower transversal incision, which was previously marked, is made with the number
10 scalpel, (Fig.19.7a) just through the dermis; combining
electrocautery (Fig.19.7b, c) to seal the blood vessels within
the subdermal plexus. Electrocautery is also used to reach
the subcutaneous tissue while making hemostasis of the
superior and inferior epigastric vessels when identied
(Fig.19.7d). This is of most importance since these can bleed
and lead to a hematoma postoperatively.
Then, soft-tissue dissection is performed superiorly to the
level of the umbilicus, going through the deep fat to reach
Scarpa’s fascia (Fig.19.8).
The umbilicus is incised and dissected free with scissors;
at this point, the inferior ap is split to facilitate subsequent
upward dissection. After the umbilicus is freed, the dissection continues superiorly to the costal margins and the
xiphoid, and the inferior ap dissection is also performed
until the pubis symphysis is reached (Fig. 19.9a). Always
b
c
Fig. 19.6 (a) Liposuction of the anks. (b, c) Liposuction of the
abdominal ap
trying to leave a small amount of subcutaneous fat to maintain vascularity.
At this point, the stage is set to perform myofascial
plication.
We begin by outlining the medial borders of the rectus
abdominis muscle (Fig.19.9b) to dene the diastasis. The
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Fig. 19.7 (a) Incision is rst
made along the inferior line at
the suprapubic area and
extending to the iliac region.
(b, c) Cautery is now used to
make the incision deeper. (d)
The inferior epigastric vessels
are separately dissected and
cauterized
a
c
b
d
a
Fig. 19.8 (a, b) Soft-tissue dissection is performed superiorly to the level of the umbilicus, going through the deep fat to reach the abdominal wall
at a point midway between the symphysis and the umbilicus
b
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A. Perez
a
c
b
d
e
Fig. 19.9 (a) The dissection continues superiorly to the costal margins
and the xiphoid using electrocautery to seal all perforating vessels. (b)
Medial borders of the rectus abdominis muscle have been outlined, pre-
f
g
paring for plication. The abdominal wall plication is performed with
barbed suture (c–g)
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309
a
d
b
e
c
Fig. 19.10 (a–e) Myofascial plication is performed with a single line
of barbed sutures. At the upper edge of the umbilicus, the suture continues down on one side of the rectus sheath, exiting only at the inferior
most inferior point of the plication is the pubic symphysis
and the most superior is the xiphoid process. At this point,
myofascial plication is performed with a single line of barbed
suture.
At the upper edge of the umbilicus, the suture continues
in a running fashion down one side of the rectus sheath only
exiting at the inferior edge (Fig.19.10).
It is important to remember the vascularity of the soft tissue through connections between the abdominal wall and the
skin ap of the costal margins.
Discontinuous undermining is recommended and is very
effective at eliminating the soft-tissue ridge, mobilizing the
tissues, and preserving tissue vascularity.
edge. At this point, the plication process is resumed. The plication process should allow sufcient space around the umbilicus to prevent
potential ischemia
Tissue demarcation and resection are performed next
(Fig.19.11a–d).
An inverted T incision closure may be necessary if the
umbilicus does not incorporate with the resected area, usually
in patients with long waists and limited abdominal laxity.
Demarcation of the excess tissue is accomplished by the
patient exing the waist in a semi-Fowler’s position. Towel
clamps are placed over the tip of the ap of the separated tissue and a single suture point with Vicryl 2–0 is placed at the
midline. The excess of tissue is determined by the demarcation line, and we continue to perform a full-thickness excision
using a scalpel, and additional division of the ap in the midline is performed if necessary, depending on tissue tension.
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A. Perez
a
c
b
d
Fig. 19.11 Final skin ap dissection is performed (a–c) with (d) showing the excised specimen
Once these points of demarcation are made, the area for
resection is identied. A full- thickness resection is then performed using a scalpel.
To get the desired nal aesthetic result, the creation of a
new umbilicus is critical, performing a vertical incision
along with the subcutaneous tissue beneath the surface surrounding the new umbilicus site, which is placed ideally
2–3cm above an imaginary line from both anterior superior
iliac spines, in the midline.
At this point, resection of a sub-scarpal fat portion is
resected throughout the entire area of undermining.
Preserving Scarpa’s fascia is important to maintain ap
viability as well as to allow proper three-layer closure of the
transverse incision.
After the sub-Scarpal fat dissection is completed, we
proceeded to place a single Drenovac along the midline
and securing it at the entrance point to prevent
displacement.
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