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23 Secondary Abdominoplasty
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Fig. 23.2 Lowering the scar and neoumbilicoplasty through a transverse plication
ment of an intralesional injection regimen and/or any other
preventive measures.
23.3.4 Atrophic or Dehiscent Scar (Figs.23.4,
ity of tissues around the area with carboxytherapy, ultrasound, and lymphatic drainage.
23.3.5 Scar Attached toDeep Planes
23.5, and23.6)
The most appropriate treatment is the resection of the scar
once a reasonable time of maturation of the scar usually
about 6months has elapsed. In this period of time they can
undertake complementary treatments to improve the elastic-
If the epidermal scar looks adequate and is of normal color
but the scarred area is tethered to the underlying muscle then
the most appropriate treatment is the subcision (subcutane-
(Figs.23.7, 23.8, 23.9, 23.10, 23.11, 23.12,
23.13, 23.14, and23.15)
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Fig. 23.3 Hypertrophic scar. Wider, swollen, and red, worse in the
middle
G. Blugerman et al.
Fig. 23.5 Dehiscent scar 15days postoperatory in a young patient. He
had an abscess, which we drain and treat with antibiotic for 15days
Fig. 23.4 Patient consulting for repair of a scar after dehiscence and
secondary closure, 1 year and a half after abdominal surgery
Fig. 23.7 Front view of a
patient with a cesarean scar
attached to a deep plane,
showing a step in the
continuity of the skin
Fig. 23.6 Patient with dehiscent scar treated with local antibiotic and
a good hygiene regime, almost solved 2months postoperative
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Fig. 23.8 Oblique view of the same patient
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Fig. 23.10 Another patient with a cesarean scar attached to deep
planes, and a McBurney scar also attached to deeper planes
Fig. 23.9 Better seen in the prole, a cesarean scar attached to deeper
planes, and excessive skin hanging over it
Fig. 23.11 Same patient seen from the left side with cesarean scar
showing a stop in the continuity of the abdominal skin
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Fig. 23.12 Right side where we can see the attachment to deeper
planes at the McBurney scar and the cesarean scar
ous incision). To do this you can use a thick needle 18G or
16G or a hooked scalpel that is often found as the instrument
of arthroscopic knee surgery and is quite useful to us since
from a single access point you can release 10–12cm of the
scar. Liposhifting maneuvers at the edges of the scar are
often very useful to allow for better redistribution of subcutaneous tissue below the epidermal scar.
23.3.6 Poorly Compensated Flaps
Two scenarios are usually presented. One is the so-called
Dog Ears. Depending on its size and extent it may be corrected with liposhifting or liposuction [5], localized liposuction or revision surgery could be used to extend the scar to
the anks. When poor compensation involves misalignment
of the dawn line leaving the midline shifted (Figs. 23.16,
23.17, 23.18, 23.19, and 23.20), then there is no other
possibility other than lifting the ap to an extent sufcient to
rectify that deviation and a new compensation correcting that
defect.
Where previous surgery has left an inverted T-scar in the
center (Fig.23.21) for lack of descent of the ap during pri-
mary surgery or by correction of a dehiscence or central
necrosis, the residual elasticity of the skin, the length of the
vertical scar, the distance of the scar to the navel and the scar
G. Blugerman et al.
to the anterior vulvar fork should be evaluated. In the right
candidate the use of the TULUA technique with a transverse
suturing usually gives the possibility of reducing the vertical
part of the scar by up to 4cm. The need for navel mobilization at the same time or as a secondary procedure should be
assessed.
23.3.7 Asymmetry ofAdipose Tissue
(Figs.23.22, 23.23, 23.24, and23.25)
Artistic liposuction should be performed to correct excesses
and highlight anatomical shapes and reliefs that signify a
beautiful and curvaceous abdomen.
If there has been an overaggressive liposuction and the
adipose tissue content is inadequate, the problem is a little
harder to solve. It will begin with treatments that recover the
elasticity of the skin through kinesiological therapies and
carboxytherapy. Selective lipotransfer is the treatment of
choice, if there are adequate fat donor areas.
The asymmetry of adipose tissue may be caused by asymmetrical resections of adipose tissue directly or by liposuction, or due to postoperative retractions that have produced
distortions of the fat layer so the origin of the defect should
be adequately studied (Fig. A and B). When it comes only to
asymmetric liposuction, the use of disruption and liposhifting or liposuction of redundant areas can solve the problem,
but when the distortion is due to the presence of an undiagnosed hematoma or chronic seroma the picture is totally different. In such cases a “medusa” sign, we often refer to as
“jellysh,” occurs, as the undiagnosed hematoma usually has
a central area near the damaged artery, but in addition to the
blood has travelled through the tunnels left by the liposuction cannula (Fig. C and D). At the same time as the centripetal contraction of the scar takes place in the form of sun
rays, the scar present in the tunnels retracts the adipose tissue
attached to it and mobilizes it to the central area producing a
bulge of fat in the center and rays of brosis around it. The
only solution in these cases is complete resection of brous
tissue that is usually present in a laminar or corset fashion on
the anterior fascia of the abdomen.
When there is redundancy of the ap over the deep tissues
it is usually due to the presence of an encapsulated seroma
that also usually deforms the surface of the skin. In these
cases we are in favor of accessing the capsule through the
original incision, and through use of 90% acetic trichloro
acid, destroy the pseudoendothelium or pseudocyst lining
that forms on the inner face of the serous cyst and therefore
facilitating the adhesion of the two surfaces without the need
for resection of the capsule (Fig. 23.26). The adhesion is
guided by Baroudi [10] of resorbable material and a vacuum
drain is left.
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Figs. 23.13–23.15 Patient with a scar attached to deep planes, after secondary closure, 1 year and a half after the abdominoplasty
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Fig. 23.16 Front view of a patient with massive weight loss, and a
wrong plan for compensating aps (wrong marking). Dogears, bigger
at left side
Fig. 23.18 Dog ears at both sides
Fig. 23.19 Dog ears at both sides
Fig. 23.17 Left view. We can see the dog ear and the front defect from
the side: big excess skin from the waist (horizontal excess), and a central infraumbilical hollow
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G. Blugerman et al.
Fig. 23.21 Bad scar quality and placement and bad position of the
umbilicus, probably due to a poor planication
Fig. 23.20 Naturally lateralized umbilicus
Figs. 23.22–23.23 Asymmetric resection of adipose tissue with liposuction, traditional technic on lower abdomen
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Fig. 23.24 Three months postoperative patient, with an undiagnosed
hematoma in the upper abdomen
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Fig. 23.26 Graphic of a seroma intraoperatively and application of
TCA 90% to achieve the adhesion of the capsule walls
23.3.8 Excess Skin Component (Figs.23.27,
23.28, 23.29, 23.30, 23.31, 23.32,
and23.33)
The vector of this excess should be correctly evaluated in
orderto plan additional skin resection surgery for that particular case. If the excess is vertical again the TULUA technique is the nest choice especially because it does not need
the surgeon to know the nature of the previous procedure
performed regarding discoloration and consequent loss of
vascularization of the ap.
If the excess is anteroposterior as is frequently observed
in postbariatric patients, medial resection should be evaluated leaving a scar in the midline with the creation of a neo
navel, or as in the case illustrated, a lateral mirror resection
at the height of the middle axillary line taking advantage of
the presence of pre-existing stretch marks and the use of
cover tattoos that the patient may have or willing to have.
Fig. 23.25 An intraoperatory picture, where we can see the brous
tissue in that area
23.3.9 Decient Skin Component
The case history, and causes of the decit should be adequately studied, whether it was primary or secondary to
necrosis or dehiscence of the sutures. In minor cases associated with brosis complementary treatments such as carboxytherapy, vacuum therapy and external ultrasound
associated with inltrations with diluted 5-FU that can provide one or two extra centimeters of skin, but when the decit is signicant then one must have to resort to the use of
skin expanders.
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Fig. 23.27 Front view of a patient with massive weight loss, and a
wrong plan for compensating aps (wrong marking not contemplating
the anteroposterior excess). Dogears, bigger at left side
G. Blugerman et al.
23.3.10 Adhesions, Post-necrotic Scars,
andStretch Marks [11] (Figs.23.34
and23.35)
If what occurs are scar adhesions from previous surgeries the
option of subcision in and other modalities usually provides
excellent results.
When there are post-ap necrosis and secondary-
intention scarring, in our experience a wait of at least
6months is required before planning a free ap surgery or
even inverted T-closing.
In cases of residual stretch marks that compromise the
aesthetic result, it is essential that the patient knows the
impossible task of the total elimination of post-pregnancy
stretch marks in most cases. Treatment with specific
meso therapy, fractional CO2 laser, and dermaroller may
Figs. 23.28–23.29 Front view of a patient with excess skin on the superior ap. (a) Closer view. (b) Oblique view
Figs. 23.30–23.31 Right and left oblique view
SURGICAL RESECTION OF THE ORGANIZED HEMATOMA
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Figs. 23.32–23.33 Left view prole and oblique
Fig. 23.34 Before and
9months after treatment with
carboxytherapy, vacuum
therapy, and ultrasound
therapy
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Fig. 23.35 Before and after
using the TULUA
abdominoplasty technique
be instituted for improvements that are most often
minimal.
23.3.11 Aponeurotic Muscle Wall Defects
(Fig.23.36)
G. Blugerman et al.
In the postoperative period, herniation and/or abdominal
wall eventrations can be diagnosed or made often secondary
to increased intra-abdominal pressure caused by intestinal
adhesions or strictures. They can be treated with the usual
techniques for such defects and the use of mesh is dependent
on the extent of the damage and the condition of the local
tissues.
In some very thin patients where a suture of nonabsorbable monolament material was used with nylon or
polypropylene for the plication, patients may report discomfort due to transcutaneous knot palpation or even pricking
sensation by the tails of the material that have been left very
long and is in contact with the deep layers of the skin. The
solution involves the removal of the knots by a direct access
or the use of fat grafts that can camouage the presence of
the knot and cover the ends of the thread.
The presence of diastasis of the anterior abdominal wall
may be primary or secondary. Primary diastasis in turn may
have been undiagnosed or unresolved in the original surgery
(Fig.23.3). The non-treatment in the primary instance may
be due to different factors such as the patient not wanting
Fig. 23.36 The picture shows a diastasis post abdominoplasty
more extensive surgery, or the abdomen was protuberant and
high in visceral or intra-abdominal fat and after surgery the
patient lose more weight so the diastasis become more
noticeable.
Secondary diastasis may be due to relaxation or rupture
of sutures, partial wall repairs, or changes in the dynamics of
intra-abdominal pressures after transverse or oblique repairs.
Another case of secondary dehiscence may be observed in
patients who have become pregnant after primary abdominoplasty surgery.
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