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23 Secondary Abdominoplasty
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In all cases the defect can be addressed through a reintervention with controlled dissection of the Xiphoid—pubic
midline and appropriate correction of the existing diastasis.
23.3.12 The Navel [11–13]
It is the only scar on the body that should be reconstructed
after surgery. The resulting scar may be due to a reintegration
technique or a neoumbilicoplasty technique.
The absent umbilical scar is usually seen when primary
surgery has not been performed by a qualied plastic surgeon.
The creation of a neoumbilicus, with a skin graft that can be
obtained from one end of the horizontal scar, should be used.
The defect may be because of the quality of the scar, which
can be hypertrophic, atrophic, keloidal in addition to hyper or
hypopigmented (Figs.23.37 and 23.38). Each of these problems should be addressed and solved with specic treatments
combining inltrations of 5FU, laser, and CO2 laser.
As for the size of the navel, if it is very large you should
choose the reduction technique by excising skin from inside
the navel. There is a tendency for it to relapse due to tensions
that exist in the center of the abdomen or due to a tennis
racket closure that leaves a small vertical scar that becomes
very constricted in a few months.
Whether the navel is very small or even if it has been
completely closed, the technique will depend on whether it is
a neoumbilicus or a reposition. If it is a neoumbilicus it
should be redone again from scratch, but often leaving a
gauze embedded in 5 FU for 3min before completing the
suture to reduce the risk of a new scar formation or constricted healing [9].
If it is a reinserted navel you can use the Murillos [1]
technique that leaves the central umbilical stump as if it were
a neonate and breakdown is expected with subsequent healing by secondary intention.
If the navel is poorly placed, the complete resection and
vertical or horizontal closure and the formation of a neoumbilicus or the mobilization of the scar should be performed
by a technique that we have described to correct the sad
looking navel. The technique consists of a cross incision at
the bottom of the navel, elevation of four triangular aps
(Fig.23.39a, b), dissection in the plane of the anterior fascia
of the abdomen of 5–10cm around the navel, and the reintegration of the four aps into the proper position (Figs.23.39c
and 23.40). Many of these displacements can be due to posture problems or scoliosis that causes varying of the location
of the midline of the abdomen.
When the navel is very shallow, the problem may or may
not have a solution. In very thin patients, with twin pregnancies or very large fetuses, signicant atrophy of the subcutaneous tissue and skin is often seen so it is often very difcult
to give it greater depth. If the problem arises from liposuction or excessive resection of fat at the peri umbilical level
the solution includes lipotransfer to the area in the form of a
doughnut.
Intraoperative photo showing the Scarpa fascia
Figs. 23.37–23.38 5-FU Inltration into the keloid scar
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G. Blugerman et al.
Fig. 23.39 The approach is from a cross incision at the
bottom of the navel. Elevation of four triangular aps (a),
dissection in the plane of the anterior fascia of the abdomen
of 5–10cm around the navel (b), and the reintegration of the
four aps into the proper position (c)
a
b
c
Fig. 23.40 The approach is
shown in the inferior picture:
four aps made from the
umbilical scar. In the upper
picture at the left: pre op and
post-op at the right, of the
correction of the position of
the umbilical scar
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23.4 Conclusion
Secondary procedures after body contouring surgeries are
mostly due to unsatisfactory results. Patients undergoing
body contouring surgeries should be warned at the time of
their informed consent of the possibility of additional procedures. While most problems could be preventable with adequate patient selection and careful completion of primary
procedures, we should make efforts to prevent patient dissatisfaction due to poor results in body contouring surgeries.
References
1. Villegas FJ.A novel approach to abdominoplasty: TULUA modications (transverse plication, no undermining, full liposuction,
neoumbilicoplasty, and low transverse abdominal scar). Aesthetic
Plast Surg. 2014;38(3):511–20.
2. Blugerman G, Schavelzon D, Martinez B, Wexler G, Markowsky
A, etal. New concepts on safer abdominoplasty. In: Serdev N, editor. Body contouring and sculpting. London: Intech Open; 2016.
p.93–108.
3. Khan S, Teotia SS, Mullis WF, Jacobs WE, Beasley ME, Smith KL,
etal. Do progressive tension sutures really decrease complications
in abdominoplasty? Ann Plast Surg. 2006;56(1):14–20.
4. Costa-Ferreira A, Rebelo M, Vásconez LO, Amarante J.Scarpa fascia preservation during abdominoplasty: a prospective study. Plast
Reconstr Surg. 2010;125(4):1232–9.
5. Shiffman MA, Blugerman G.Chapter 55: Fat shifting for the treatment of skin indentations. In: Liposuction principles and practice.
Berlin: Springer; 2006.
6. Blugerman G, Schavelzon D, Zocchi M, Crichlow G, Mussi
M, Schavelzon V, etal. Pneumodissection and external vacuum
with CO2 for preparation of the receiving bed of autologous fat
graft in reconstructive and aesthetic surgery. Rev Arg Cir Plast.
2017;23(1):27–31.
7. Blugerman G, Schavelzon D, Dreszman R. Intralesional
use of 5-FU in subcutaneous brosis. J Drugs Dermatol.
2003;2(2):169–71.
8. Davison SP, Dayan JH, Clemens MW, Sonni S, Wang A, Crane
A.Efcacy of intralesional 5-uorouracil and triamcinolone in the
treatment of keloids. Aesthet Surg J. 2009;29(1):40–6. https://doi.
org/10.1016/j.asj.2008.11.006.
9. Uppal RS, Khan U, Kakar S, Talas G, Chapman P, McGrouther
AD.The effects of a single dose of 5-uorouracil on keloid scars: a
clinical trial of timed wound irrigation after extralesional excision.
Plast Reconstr Surg. 2001;108(5):1218–24.
10. Baroudi R, Keppke EM, Netto FT.Abdominoplasty. Plast Reconstr
Surg. 1974;54:161–8.
11. Blugerman G, Schavelzon D, Wexler G, Lotocky M.
“Umbilicosliding” or repositioning of the navel during or after
abdominal liposuction to prevent or correct the “sad umbilicus”
appearance. Am J Cosmet Surg. 2015;32(3):165–71.
12. Hazani R, Israeli R, Feingold RS. Reconstructing a natural looking umbilicus: a new technique. Ann Plast Surg.
2009;63(4):358–60.
13. Murine W. Navelneo formation. Personal communication at the XVI
international course of aesthetic plastic surgery. Cali: International
Society of Aesthetic Plastic Surgery; 2010.
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ReneCalderon
24
24.1 Introduction
Abdominoplasty is particularly common in people who
have undergone pregnancy as well as in people having massive weight loss so much so that it is now among the 5 most
commonly performed cosmetic procedures in the United
States [1]. Abdominoplasty is undertaken to improve body
contours and it has progressed from being purely skin
removal to now being a combination of lipocontouring followed by skin removal and breast surgery for the best aesthetic result [2]. Abdominoplasty is an increasing popular
procedure that has expanded by 79% over the past 13years.
The selection of the abdominoplasty technique depends on
the presence, location, and extent of skin excess (whether
upper or lower abdomen or both). If there is skin excess
only in the lower abdomen then use of short scar procedures is recommended [3].
Breast augmentation is one of the most commonly performed aesthetic procedures worldwide and over 333,000
breast enlargements were performed in the United States
alone in 2017 [4]. Moreover, according to the Aesthetic
Society, there has been a year-on-year increase of 15% in
patients undergoing enlargement of the breasts in the United
States from 2014 to 2018 [5].
Single stage correction of a drooping ptotic and hypoplastic breast can be a daunting procedure, even for an experienced plastic surgeon. The act of balancing skin stretch
forces secondary to breast augmentation and tissue tightening during and after the procedure, requires a complete analysis of the breast and a thorough understanding of the
procedure in order to achieve sustainable results [6].
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_24].
Breast augmentation and mastopexy as part of a single
stage can be undertaken using various techniques which are
based on the degree of breast ptosis, amount of breast volume present, and the breast volume that the patient expects.
When the augmentation-mastopexy is performed in the
appropriate candidate, we can create a full, attractive breast
with minimal visible breast scar [7].
24.2 History [8]
The surgery modern era of body contouring started in 1870
with a limited skin resection.
In 1890, Demars and Marx reported the rst dermolipectomy in France.
In 1899 Kelly made the rst report of dermolipectomy in
the United States. This author named this procedure “transverse abdominal lipectomy.”
In 1905in France, Gaudet and Morestin reported umbilicus preservation after dermolipectomy.
In 1909 Weinhold reported clover incision. He combined
the oblique and vertical incision.
In 1916 Babcock reported a vertical elliptical abdominal
incision.
In 1924 Thorek began with a transversal incision below
umbilicus.
In 1940 Somalo introduced belt lipectomy.
In 1957 Vernon reported a low transversal incision and
umbilicus transposition.
In 1964 Gonzalez-Ulloa reported circular
abdominoplasty.
In1967 Pitanguy reported more than 500 cases of abdominoplasty with mammoplasty.
In 1983 Illouz popularized lipectomy assisted by
liposuction.
R. Calderon (*)
Universidad Autonoma de Baja California (UABC),
Tijuana, Mexico
© 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_24
375
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R. Calderon
24.3 Classication [9]
24.3.1 Abdominoplasty Classication System
(Matarasso)
Type I—Skin with minimum laxity, fat variable, musculo-
aponeurotic system minimum accidity. Treatment would
include a suction-assisted lipectomy alone.
Type II—Skin having mild laxity, fat variable, musculoapo-
neurotic system showing accidity in the lower abdomen,
treatment partial abdominoplasty.
Type III—Skin moderate laxity, fat variable, musculoapo-
neurotic system moderate superior and/or inferior abdominal accidity, treatment-modied abdominoplasty.
Type IV—Skin severe laxity, fat variable, musculoaponeu-
rotic system signicant superior and/or inferior abdominal accidity, treatment abdominoplasty with
suction-assisted lipectomy.
24.3.2 Breast Ptosis Classication (Regnault)
Regnault classication (Fig. 24.1) is the most commonly
used classication to assess and record breast ptosis. The
relation of the nipple to the inframammary crease is the basis
for this classication.
Grade I ptosis—when the nipple is at or below the level of
IMF by 1cm.
Grade II ptosis—when the nipple is below the level of IMF
by 1–3cm.
Grade III ptosis—is a clinical condition when the nipple is
below the IMF by more than 3cm or lies at the inferior
pole of the breast.
“Pseudoptosis”—is a condition of the breast when the nipple
is at the correct level but the breast tissue is below the
level of the IMF.
The inferior pole nipple-areolar complex (NAC) (GRADE
III) is designated as an end point of ptosis, although the same
anatomic conguration may occur in a tubular breast deformity with a high IMF and hypotrophy of the lower pole
parenchyma [10].
24.4 Abdominal Wall Anatomy [11]
It is very important to have a thorough knowledge of the surgical anatomy of the abdominal wall when planning abdominal wall reconstruction. The various layers of the abdominal
wall include:
1. Skin and subcutaneous tissue—The extent of fat deposits
and the abdominal skin condition depends on the
weight, age, previous surgical intervention, and the
body habitus. The supercial layer of the abdomen can
be grossly divided into skin, subcutaneous fat which is
divided by the Camper’s fascia, and the fascia of
Scarpa. These layers become very important when lipocontouring of the abdominal wall and also when considering closure after an abdominoplasty and wound
care options.
2. Musculofascial layer—It is important to know about the
different muscle layers and the direction of their bers
when undertaking any form of abdominal wall repair.
The paired rectus abdominalis and pyramidalis are anterior muscles which run craniocaudally and the rectus
sheath over the muscle fuses in the midline to form linea
Normal Grade 1 Ptosis:
Mild sagging
Fig. 24.1 Breast ptosis classication
Grade 2 Ptosis:
Moderate
sagging
Grade 3 Ptosis:
Significant
sagging
Pseudoptosis:
Lower breast
sagging
Parenchymal
Maldistribution:
Unusual shape
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alba. The external oblique, internal oblique, and the
transversus abdominis muscles originate supero laterally
and fuse at the lateral border of the rectus abdominis to
form the rectus sheath. This sheath on both side splits to
envelope the rectus abdominis muscle and then the two
slips fuse with each other and with rectus sheath of the
opposite side in the midline called the linea alba. The
posterior rectus sheath is absent above the level of the
arcuate line below which the abdominal contents are
separated from the muscular layer by only the transversalis fascia.
24.4.1 Blood Supply
Huger has lucidly explained by creating a vascular model for
the blood supply of the anterior abdominal wall. He has
Fig. 24.2 Circulation pre and
postoperative abdominoplasty
divided the abdominal tissue into 3 zones based on their vascular anatomy.
Zone I is the area present in the located in the anterior mid-
line of the abdomen which is supplied by the superior and
inferior deep epigastric arteries through their muscular
perforating branches to the skin and subcutaneous tissue.
Zone II includes the caudal aspect of the anterior abdominal
wall which gets its blood supply from the supercial epigastric and supercial external pudendal arteries which
are branches of the femoral artery. The deeper aspect and
the musculoaponeurotic system are supplied by the deep
inferior epigastric and the deep circumex iliac arteries.
Zone III is present in the most lateral aspect and is supplied
by the branches from the intercostal and lumbar arteries
derived from the abdominal and thoracic aorta (Figs.24.2
and 24.3).
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Fig. 24.3 Huger zones
24.5 Breast Anatomy
Breasts in a grown-up mature female are usually conical in
shape or are shaped like a tear-drop shaped located on the
anterolateral chest wall in the subcutaneous layer.
Anatomic location of the breast:
Extends from below the clavicle superiorly to the sixth rib
inferiorly.
The horizontal extension of the breast is from the lateral
border of the sternum to the anterior border of the latissimus
dorsi (midaxillary line).
The breast tissue extends laterally through the axillary
fascia into the axilla called the “Axillary Tail of Spence.”
The breast is bisected into the upper and the lower pole
through a plane that extends through the nipple which lies at
the most projecting point of the breast normally. The drooping of the breast is assessed based on the level of the NAC in
relation to the inframammary crease. In the non-ptotic breast,
the NAC is located above the inframammary fold (IMF) and
the breast mound.
The breast borders, along with the present location of the
NAC, are landmarks which are important and dene the aesthetics of the breast. Some important measurements and
ideal dimensions which dene the breast include:
1. Distance from sternal notch to the nipple should be
19–21cm.
R. Calderon
2. Midclavicular point to nipple distance of 18–21cm.
3. Nipple to IMF distance should be 5–6cm.
4. Nipple to midline in most cases will be 9–11cm.
5. The ideal symmetry, projection, and proportionality of
the breast are represented by an equilateral triangle
formed between the sternal notch and the nipples on both
sides.
Any cosmetic surgery of the breast which may include
breast enlargement, reduction, or lift is individualized for the
patient and is based on the patient’s chest width, present
breast volume and their preference, proportions of the breasts
and their symmetry, and nally posture and body weight of
the patient (Fig.24.4).
24.5.1 Preoperative Assessment [12]
A comprehensive analysis of the patient has to be undertaken
anytime a patient is considered for a combination procedure.
This includes a detailed medical history, a complete physical
examination of the surgery sites and any concerns with previous surgery should be noted. History taking should specically focus on smoking history, history of deep vein
thrombosis (DVT), obesity, diabetes, and associated risk factors. Details about diet, bowel function, activity level, regularity of exercise, medication, surgical history highlighting
any previous postoperative complications including postoperative nausea and vomiting, infections including MRSA,
bleeding tendencies, and cardio-pulmonary health history
must be carefully sought for.
24.5.2 Inuence ofPreoperative Intervention
onPostoperative Surgical Wounds [13]
Poor wound healing remains a critical problem in daily
surgical practice, concerning either impaired healing or
excessive scarring (Athieh 2002). This happens due to the
inability of the various stages of wound healing to initiate
and fail to progress. The stages which can cause delayed
and abnormal healing include abnormal hemostasis,
inammation and abnormal markers, abnormal deposition
of connective tissue, and scarring due to contraction (Geers
2018).
Excessive smoking, use of corticosteroids, diabetes, and
advancing age cause poor wound healing (Powers 2016).
There is much awareness of the positive effects of intra
and postoperative interventions on wound healing, such as
antimicrobial agents, antiseptic dressings, and negative pressure wound therapy (NPWT). Nevertheless, impaired wound
healing remains a common complication of the surgery
(Veno 2006).
Surgical site infection (SSI) and excessive scar formation
can be prevented by using antibiotic prophylaxis (30–60min
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Fig. 24.4 Ideal breast
dimension demonstrating
symmetry, projection, and
proportionality
379
before the incision), maintaining the sterility of the surgeon’s
hands as well as preventing complications of the surgical
eld.
Lewandowsky etal. postulated that higher levels of anxiety can cause increased levels of SSI hence they advocated
the use of diazepam which could modulate the immune system and therefore reduce the risk of infection. Stress has a
signicant effect on wound healing through its stimulation of
release of glucocorticoids and proinammatory cytokines
(McGhee 2009). Flores etal. state that prevention of hypothermia during surgery reduces the risk of SSI.Reduced temperature of the surgical site causes vasoconstriction thus
reducing the oxygen supply and nutrients to the surgical
wound increasing SSI.This hypothermia can be countered
through three ways:
1. Local water ltered infrared and irradiation
2. Forced air warming blankets
3. Local noncontact radiant heat dressing
24.5.3 Examination [9]
Examination of the patient for body contouring is undertaken
starting with the standing position, front bending and sitting,
supine and lateral lying down position and with the legs
raised with exion at the hips to check for muscle weakness.
The anatomy of the body with the bony prominences, body
proportions, umbilicus shape, presence of hernias, scars and
muscle weakness along with the quality of skin and extent of
deposition of subcutaneous fat is assessed. Finally,
assessment is made with regards to possible medical issues,
concerns of the patient regarding the extent of surgery
including possible complications, duration of recovery, and
location of incisions factor into the decision-making
process.
After considering the abovementioned factors, staging of
the patients is undertaken according to the abdominoplasty
system of classication and treatment given by Matarasso
(Table24.1).
Type I, suction-assisted lipectomy.
Type II, mini-abdominoplasty.
Type II, modied abdominoplasty.
Type IV, full abdominoplasty.
24.5.4 Markings (Abdominoplasty) [14]
Preoperative surgery markings are undertaken in the standing position (Fig.24.5). A line is drawn in the midline of the
abdomen extending from the xiphoid process to the pubic
symphysis. The position of the umbilicus is checked with
relation to the midline and if it is not in midline, then it is
brought to the notice of the patient. The lower skin excision
incision is rst marked starting in the midline with the skin
of the lower abdomen being held in an upward traction so as
to lift the pelvic tissues. The incision is marked as a horizontal line in such a way that it is 6–7cm above the clitoral hood
or base of the penis. This will prevent a high riding scar as
well as address the laxity of the mons pubis. The incision is
marked laterally parallel to the inguinal ligament and curved
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Table 24.1 Abdominoplasty system classication and treatment (Matarasso)
R. Calderon
Category
Type I
Type II
Type II
Type IV
Skin Fat Musculofascial system Treatment
Minimal laxity Variable Minimal flaccidity Suction-assisted lipectomy
Mild laxity
Moderate laxity
Severe laxity
Variable
Variable
Variable
Mild lower abdominal flaccidity Mini-abdominoplasty
flaccidity
Significant lower and/or upper abdominal
flaccidity
Modified abdominoplastyModerate lower and/or upper abdominal
Standard abdominoplasty with
suction lipectomy
Fig. 24.5 Marking patient in standing position
superiorly toward a point, typically 2–3cm, inferior to the
anterior superior iliac spine with the skin in maximal stretch
(Fig.24.6). The nal scar should be positioned in such a way
that it is very low and can be hidden while using most styles
of underwear and bathing suits. In cases when it is not
possible to excise the skin up to the umbilicus, we decide on
closing the old umbilicus as a vertical midline scar thus giving a nal inverted T-shaped scar in the lower abdomen.
Fig. 24.6 Marking the inferior abdominal incision
The extent of abdominal skin removal superiorly is estimated by moving the skin inferiorly and marking a symmetrical nal scar. This marks as a reference line for the excision
of the abdominal pannus and if crosshatching is marked, it
helps in aligning the closure too. The estimated superior incision is usually located just superior to the umbilicus in the
midline and gently curved inferiorly to meet the inferior
abdominal markings.
The inferior incision is marked longer than the estimated
skin excision so that per operatively it may be extended if
required to correct a “dog ear.” All areas for liposuction
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should be marked topographically and areas not requiring
liposuction are also marked.
24.5.5 Marking (Breast)
Marking for the breast surgery is undertaken with the patient
standing (Fig.24.7). The rst to be marked is the midline of
the chest which extends from the suprasternal notch to the
xiphisternum. The breast meridian is now marked as a line
extending from the mid clavicle to the mid inguinal point.
The inframammary crease is marked and transposed as a
point on the breast meridian which will serve as the upper
edge of the new NAC.The same marking is now duplicated
a
on the other side so as to prevent asymmetry in the nal outcome which may be due to pre-surgery asymmetries of the
breast.
The footprint of the breast is now marked so as to limit the
extent of pocket dissection for placement of the implant
which has to be centered on the new NAC.Superomedially,
the marking is curved so as to protect the anterior branches
of the second and third intercostal nerves from injury.
Superolaterally, the marking is extended toward the insertion
of the pectoralis major muscle to help recruit skin to cover
the implant by releasing the adhesions to the pectoral fascia.
The access for implant placement in the subglandular plane
is through a 4.5–5cm incision placed in the IMF starting just
lateral to the medial border of the new areola [7].
b
c
Fig. 24.7 (a–c) Preoperative breast markings
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