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C. G. Cabrero and R. C. Nájera
24.8 Postoperative Care
1. Use of a pressure therapy garment: the patient
wears on a corset-like sash during the rst
month of post-operation (Fig. 24.14). They
are not allowed to remove it before the rst
5days, until they are seen in the ofce for the
rst revisions. After rst 5 days, the patient
should only remove the garment to complete
their hygienic routine.
2. Hygiene: during the rst few days of postoperation, the patient cannot remove the compression bandage. It is removed once during
the rst consult, and the wound is treated with
clorhexidine to eliminate the scabs that have
been produced. Then betadine is applied and
the sutures are covered with surgical tape.
After this appointment, the patient can shower
in their home, avoiding getting the tape wet. If
Fig. 24.14 Sash recommended for the rst month
post-operation
the tape does get wet, the patient should dry it
with cold air and soak it with betadine.
3. Massages and lymphatic draining: it is recommended that the patient seeks out manual or
mechanical methods of lymphatic draining
after the rst week of post-operation with professionals who poses understanding of the
subject matter. Additionally, it is recommended to seek massages with radiofrequency
devices such as Indiba Deep Care.
4. Activity: the patient can walk beginning on
the rst day of recovery. Rigorous exercise
can resume after a month of operation. If there
has been a plication of the abdominal rectal
muscles, it is recommended that regular activities do not resume for the rst 3months.
24.9 Outcomes andPrognosis
The patient should be able to see partial results
from the beginning. The inammation should be
progressively reabsorbed until the third month
and can last longer if the intervention is accompanied by liposuction. In this case, the nal
results can be seen in the sixth month of post
operation.
It is recommended that the patient maintains
healthy living so that the results can last longer. If
the patient experiences a change in weight, it is
probable that the distribution of fat falls differently compared to before the intervention, especially if the mini abdominoplasty is accompanied
by liposuction.
In respect to the evolution of the scarring, it is
expected that during the rst year of development
it is colored with a red, garnett, or pinkish hue.
One year after the intervention, the scarring
should present as white, and if there has not been
any complication such as keloids or dehiscent
scarring, it is expected to see the scar hidden by
bikinis or underwear lines.
To assist in the healing process, it is recommended that the patient apply pressure to the scar
(with their underwear already being worn). It is
also recommended that during the rst trimester,
the patient uses silicone patches and applies oil or
cream, such as rosehip oil.
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24.10 Complications [8]
As with any surgical intervention, the miniabdominoplasty is a procedure that can present
itself with complications; the majority of them
are infrequent when the operation is correctly
executed and the preventative measures are
followed.
24.10.1 Seroma
While less frequently occurring then in a conventional abdominoplasty, a seroma has the highest
rate of occurrence within the scope of the miniabdominoplasty. It is caused by a signicant separation that takes place and consists of accumulation
of serous uid between the abdominal wall and
the skin that is normally reabsorbed into the
body. However, there are occasions where it
requires draining. The cavity created can be
closed by some stitches from the supercial fascia to the muscular aponeurosis producing its
obliteration. Personally, we prefer the second
option, and this technique also avoids, in most
cases, the use of drains and the possible appearance of a post-operative seroma.
24.10.2 Hematoma
It is possible to experience an episode of bleeding
during or after surgery. If a post-operational hemorrhage occurs, it could require urgent treatment
to drain the accumulated blood or a blood transfusion. The bleeding frequently comes from epigastric arcade perforators. To prevent this
complication, ensure that the patient stops consumption of anti-inammatory medication
10 days before the surgery. Coagulation mode
electrocautery dissection helps prevent this
condition.
to seek treatment that includes antibiotics or
additional surgery. Antibiotic prolaxis during
the surgical act with third-generation cefalosporins can be taken into consideration to prevent
this situation.
24.10.4 Cutaneous Necrosis
This complication can be caused by the separation of skin aps or excessive pulling of the skin.
Hypertension, diabetes, smoking are risk factors
that must be considered. The absence of smoking
during the 6weeks prior to surgery can help to
prevent this situation.
24.10.5 Changes inSkin Sensitivity
Changes in skin sensitivity can occur in the lower
abdomen and tends to disappear 6months after
the surgery in majority of the cases.
24.10.6 Deep Venous Thrombosis
andPulmonary Embolism
This procedure requires a person to maintain a
position for an extended amount of time which
increases the risk of suffering the complication.
We must be extremely careful with patients that
take oral contraceptives, those with records of
thromboembolism, or those who present vericous
veins in their legs. Following protocol, we always
employ prophylaxis of deep vein thrombosis with
heparin, as well as the use of the intermittent
pneumatic compression system in the lower
extremities. We start the day before the intervention and nish 7days after the surgery.
24.10.7 Hypertrophic Scar
andKeloids
24.10.3 Infection
An infection is an uncommon occurrence in this
type of surgery. If it occurs, it would be necessary
In some cases, the intervention can produce skin
abnormalities. Hypertrophic scarring can occur
due to excessive tension of the skin. At fascial
level, sometimes stiffened sutures may be neces-
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C. G. Cabrero and R. C. Nájera
sary, i.e.,Vicryl 2/0. Multilamentous and interlaced synthetic absorbable sutures that maintain
tensile strength will be used for 3–4weeks. The
adequate approximation of the supercial fascial
system will promote local conditions of zero tension for the skin suture. This is a critical detail if
we want skin scar of the best quality. Keloids
heavily depend on the patient’s genetic
predispositions.
We recommend that once the wound closure is
nished, inltration with PRP (platelet-rich
plasma) of the wound edges to improve healing,
maturation, and nal appearance of the scars.
24.10.8 Intestinal or Intra-
abdominal Perforation
There are some documented cases in the literature of intestinal or intraabdominal perforation
generally associated with consequences of previous abdominal surgeries or important hernias of
the abdominal wall. It is important to understand
the previous diagnostics to avoid this
complication.
24.11 Conclusion
• Adequate assessment of the patient prior to
surgery is necessary. The degree of skin and
musculofascial laxity, the presence of scars,
and the evaluation of abdominal wall defects
are some essential items to know before the
performance or any abdominoplasty.
• Appropriate knowledge of the different treatment modalities is essential to achieve best
results with less complications.
• Prevention of thrombosis, seroma, and tissue
necrosis are largely within our reach.
• Liposuction almost always plays a leading
role in achieving the best result.
References
1. Greminger RF. The mini-abdominoplasty. Plast
Reconstr Surg. 1987;79(3):356–65.
2. Matarasso A, Matarasso DM, Matarasso
EJ.Abdominoplasty: classic principles and technique.
Clin Plast Surg. 2014;41(4):655–72.
3. Ali A, Essam A. Abdominoplasty combined with
cesarean delivery: evaluation of the practice. Aesthet
Plast Surg. 2011;35(1):80–6.
4. Fernandes JW, Damin R, Nasser Holzmann MV, De
Oliveira Ribas GG. Use of an algorithm in choosing abdominoplasty techniques. Rev Col Bras Cir.
2018;45(2):e1394.
5. Walgenbach KJ, Shestak KC. “Marriage” abdominoplasty: body contouring with limited scars combining mini-abdominoplasty and liposuction. Clin Plast
Surg. 2004;31(4):571–81, vi.
6. Wan D, Hubbard BA, Byrd HS.Achieving aesthetic
results in the umbilical oat mini-abdominoplasty:
patient selection and surgical technique. Plast
Reconstr Surg. 2019;143(3):722–32.
7. Mohamed AA.Tumescent local inltration Anesthesia
for mini abdominoplasty with liposuction. Open
Access Maced J Med Sci. 2018;6(11):2073–8.
8. Grella R, Razzano S, Lamberti R, Trojaniello B,
D’Andrea F, Nicoletti GF.Combined epigastric hernia repair and mini-abdominoplasty. Int J Surg Case
Rep. 2015;8C:111–3.
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Take-Home Points
• Right selection of the patient is key to
success.
• Abdominal wall exploration is mandatory.
• Among the variety of techniques described,
every patient needs a customized surgery plan.
• Take time for correct placing of the scar.
• Early mobilization is key to prevent
thrombosis.
25.1 Introduction
Abdominoplasty is one of the most demanded procedures in plastic surgery. Since its introduction,
the evolution of the technique has been widely
modied and completed with different procedures
[1] in order to achieve better results. For years,
plastic surgeons have tried to improve outcomes by
means of different incision patters, planes of dissection, sutures, drains, liposuction, etc. However,
a standard technique has not been adopted.
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_25.
J. B. Pérez (*)
Head of Plastic, Aesthetic and Reconstructive
Surgery Dept. Hospital Clínico San Carlos Madrid,
Universidad Complutense Madrid, Madrid, Spain
MD Anderson Cancer Center, Madrid, Spain
Private Practice, Madrid, Spain
Optimal skin removal with minimal tension
and adequate perfusion of the ap associated
with proper reconstruction of fascia layers are the
main goals of this procedure [2]. Once this is
achieved, the abdominal contour is improved
substantially but there could be some areas that
can be rened by means of associated liposuction
when required [3].
Considering the multiple approaches and
options for this surgery, one should select the
appropriate technique depending on the specic
characteristics of each patient in order to improve
results and avoid complications in a predictable
way.
25.1.1 Anatomy
The abdomen has multiple structure to consider
[4], and its knowledge is crucial for optimal
assessment of the desired surgery [5, 6].
Embryological development of the abdominal
wall is based on the three layers which confer a
very complex anatomy with a number of different structures. The development of these structures is segmental which results in segmental
innervation and irrigation [7]. Different congenital or developmental defects may occur, and they
should be explored before any surgical procedure [8].
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_25
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J. B. Pérez
The core of the abdominal wall is composed
by four muscles and it has nine layers:
Skin
Fat
Deep fascia
Rectus
External oblique
Internal oblique
Transversus
Fascia trasversalis
Peritoneum
Within the functions of the abdominal wall are
vertebral column stabilization, trunk movement,
and containment of abdominal viscera.
Furthermore, it is involved in maintenance of
upstanding position, forced expiration or other
activities that require increase of intra-abdominal
pressure.
25.1.1.1 Blood Supply
The arterial supply comes from the boundaries of
the abdominal wall. Medially, intercostal arteries
arise between transversus and internal oblique
muscles accompanied by intercostal, iliohypogastric, and ilioinguinal nerves. These branches pierce
the rectus muscles and anastomose with the epigastric axis. From the top, the superior epigastric
artery arises behind the rectus and goes down
toward inferior epigastric. It is originated from the
internal mammary after its division in musculophrenic and superior epigastric. From the lower
part, the inferior epigastric artery arises from the
external iliac and ascends behind the rectus muscles conforming to the epigastric axis with the
superior epigastric. Just below the deep inferior
epigastric artery, the iliac circumex arteries arise
from the same origin and contribute to the blood
supply with its ascending branches.
All these arteries provide rich irrigation to
skin via multiple perforator branches which are
powerful tools in reconstructive surgery [9].
Blood drainage veins are the same as the arteries described above. Superior to umbilicus, the
drainage is ultimately via superior vena cava and
inferior to the umbilicus the drainage is via
saphenous-femoral to the inferior vena cava. It is
important to remember the link between the ligaments teres and the venous drainage that can reperfuse during portal hypertension means
resulting in dilation of abdominal veins.
25.1.1.2 Lymphatic Drainage
Parallel to the vein drainage, the lymphatic vessels course in the abdominal wall. Again, superior abdominal wall tends to drain in the axilla
and inferior wall tends to drain in the groin area.
Due to the embryological origin of the umbilicus,
gastrointestinal tutors may spread by the ligament’s teres to the abdominal wall area.
25.1.1.3 Innervation
Abdominal wall innervation comes from T7 to
T12 by its anterior divisions coming in segmentary nerves that course between transversus and
internal oblique from medial to inferior. From L1
root and a contribution of T12 arises the iliohypogastric and ilioinguinal nerves. These nerves provide sensation to the anterior abdominal wall in
the suprapubic area and groin and femoral region.
They perforate the transversus muscle and make
connections in the same plane as the nerves
described previously.
The iliohypogastric and ilioinguinal nerves
arise from the lateral side of iliopsoas. The rst
provides sensation to the lateral hip region and
motor innervation to internal oblique and transversus muscles. The second runs inferior to the
rst and perforates the transversus giving communicating branches with the iliohypogastric
nerve. It passes through the supercial inguinal
ring giving branches to spermatic cord/round
ligament. Then it pierces the skin of upper and
medial thigh and the pubic area via the anterior
scrotal/labial nerve. The ilioinguinal nerve does
not cross the deep inguinal ring so it cannot be
encountered through the inguinal canal.
25.1.1.4 Skin andMuscles
As described previously, there are nine components in the abdominal wall. From supercial to
deep layers, each component has its role in contributing for better outcome during surgery.
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Skin andSubcutaneous Tissue
Skin is the most supercial component of the
abdominal wall. Assessing its quality, excess,
laxity, etc. is crucial for abdominoplasty procedures. Under the skin, the subcutaneous tissue
contains fat, whose distribution is a key point for
surgical procedures, and Camper’s and Scarpa’s
fascia. The latter is an important layer to consider
in abdominoplasty for many reasons. It divides
the supercial fat from the deep fat, and it may
have a role in lymphatic drainage.
In this layer, the umbilicus is one of the key
points of the abdominoplasty because it is a recognizable landmark of the abdominal wall.
Normally it is situated in the midline 9–12 cm
above pubis. The fascia around this area is one of
the most commonly affected by abdominal hernias due to the changes during or after pregnancy.
Its blood supply is provided by dermal vessels
and from the umbilical ligament.
Muscles andFascia
External Oblique
The outer muscle of the abdominal wall is the
external oblique muscle. It originates in the lower
ribs and runs obliquely from superolateral to
inferomedial. It is inserted in the iliac crest and
folds to form the inguinal ligament. At its end
towards the midline its aponeurosis extends to
the rectus sheath.
Internal Oblique
It courses deep to the external oblique and forms
the mid layer of the anterolateral wall. It is originated from the iliopsoas fascia, iliac crest, and
thoracolumbar fascia running in the opposite
direction of the external oblique to insert in the
ribs and the pubic tubercle. Inferiorly, it will be a
part of the conjoined tendon with the transversus
muscle. At its medial end, the aponeurosis continues as well to the rectus sheath. Above the
arcuate line, the internal oblique fascia passes
around rectus muscle surrounding it but inferior
to the line, it only courses in the anterior aspect of
the sheath.
Transversus Abdominis
This is the thinnest and deepest layer of the
abdominal muscle wall. Its bers are transversally oriented and originated from ribs, iliac
crest, lumbar vertebrae, and iliopsoas fascia. Its
contribution to the rectus sheath is similar to
internal oblique. Above the arcuate line, the fascia courses behind rectus and below passes
through the anterior aspect of the sheath.
Fascia
The muscular/deep fascia covers the muscles
with different congurations especially within
the inguinal canal and the rectus sheath. This
layer is key for correct management in abdominoplasty procedures.
In the deepest part of the abdominal wall, we
encounter the transversalis fascia posterior to the
transversus muscle. Its disruption denes an
abdominal hernia. Deep in the transversalis fascia is the parietal peritoneum which surrounds
the abdominal viscera.
25.2 Patient Selection
The more common consultation for this kind of
surgery is after pregnancy and post bariatric
patients. In these conditions, the muscleaponeurotical structures are dilatated and are
not able to retract to their initial status. Thus,
resulting in thinning of the skin, losing elasticity and appearance of striae, and in an elongation of the fascia which will more commonly
determine rectus diastasis. Hyperextension of
the rectus sheath ends in an anterior abdominal
wall weakness that can be associated with ventral hernia. Previous exploration of abdominal
wall defects is crucial to avoid major
complications.
As mentioned, skin excess and fascial loosening are key points to assess during patient exploration. On the other hand, fat distribution and its
management is key for a better outcome considering abdominoplasty. For this purpose, associated liposuction is a helpful option.
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Different classication of patients have been
described depending on the fat and skin distribution; however, these are not very practical because
in author’s opinion, modern abdominoplasty is a
customized, well-balanced mixture of all the
techniques available.
25.3 Preoperative Evaluation
In the rst consultation, the surgeon must review
patient’s medical history and previous conditions. BMI and weight stability should be considered. Current medication, allergies, and previous
surgeries must be recorded.
Smoking habit can seriously impair wound
healing and may be considered as exclusion criteria. Patients must quit smoking at least 3weeks
before surgery to be considered for surgery. Other
exclusion criteria are BMI over 30, anticoagulation/hypercoagulability conditions, active infectious condition, and high cardiovascular risk.
Future pregnancy desires have to take into
account to postpone surgery, or patient should be
warned that aesthetic result may be worsened
after future pregnancies. Furthermore, body
weight changes also may change the nal result,
so one should encourage the patient to go for the
surgery in a weight-stable period for at least the
past 3–6months.
25.3.1 Physical Examination
A detailed exploration is done in all patients.
First of all, we explore the patient in an upstanding position. The skin excess is measured by
pinching the panniculus as well as the elasticity.
Distribution of striae, if present, is assessed to be
included as much as possible within the planned
skin excision. Skin adherences zones are better
explored upstanding. Distribution of fat (supraumbilical, anks, infraumbilical, etc.) is recorded
and marked for comparison when the patient is
lying down. One should pay attention to symmetry, previous surgeries, scoliosis, or hip asymmetry. Presence of previous scars is very usual,
especially C-section. One should take into
account those scars for correct placement of the
incision considering possible blood ow impairment due to previous surgeries. A very low scar
can be easily reached if the patient has a good
laxity, but in some cases, it is preferable to make
a vertical incision to avoid jeopardizing wound
healing.
Once this is completed, we should ask the
patient to lie on the bed to re-explore skin excess,
laxity, and fat distribution. Previous scars may
change scar planned site. In this position, we
explore abdominal wall integrity by manual palpation, and we also assess the degree of rectus
diastasis. Care should be taken to explore any
hernias if present [10].
Determining and explaining to patients all
their personal characteristics in this phase will
lead to better design of the surgical procedure as
well as better comprehension of scar position and
techniques needed by the patient.
Whenever the patient is correctly explored
and the surgery indicated, a few key steps are to
be completed. Pre- and postoperative photographs should be taken at the ofce in a standard
setting.
Informed consent has to be reviewed at the
ofce with the patient and signed before the
day of surgery. Any other or special consideration is discussed, and if requested, surgery
outcomes or complications photographs are
showed to the patient. At this point, surgeon
must explain in a realistic way the possible limitations to the aesthetic results depending on
patient characteristics.
Finally, preoperative instructions are given.
They should include avoidance of anticoagulant/
antiaggregant drugs the days before surgery,
shower with antiseptic solution, bowel purgation
to decrease abdominal pressure, etc.
25.3.2 Markings
Incision location is one of the most important
aspects in this procedure. Classically, the lower
horizontal mark is between 5 and 7cm above the
labia cojunction area in an upstanding position.
Then the midline is carefully traced. Depending
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on the patient characteristics, this marking may
vary and ascend some centimeters considering
natural folds or other particularities. Lowering
the scar more may distort labia majora and produce pubic lymphedema.
Once the lower aspect of the scar is placed,
lateral extension is marked depending on the
planned resection: usually the limit is planned in
the superior iliac spine which confers a slight
upward curvature to the incision. The ideal nal
scar should be low enough to be covered by bottom clothes, especially bathing clothes. The goal
is to plan the shortest and lowest scar with minimal tension.
Also, in upstanding position, the selected
areas for liposuction are marked. Then the patient
is asked to lie in the examination table. The lateral extension is checked asking patient to bend
so that the skin bulge/excess is hanging. We also
asses the estimated skin excision by pinching
test, and we can mark it as the upper incision line
but keeping in mind that these lines are not denitive. It is important to understand that the more
lateral extension is made, the more horizontalization of the scar would result at the end of the scar
due to the lateral thigh tension.
At this point, we have to alert the patient if any
vertical scar would be needed if umbilical scar
cannot be removed completely. It is preferable to
design a little vertical scar rather than ending
with excessive tension at the central part of the
wound.
When incision marking is complete, we have
to conrm its symmetry in length and position
paying special attention to the preexisting
asymmetry.
25.4 Anesthesia
Although this surgery is performed under local
and regional anesthesia [11, 12], we prefer general anesthesia. We also prefer to do the surgery
as an admission procedure. However, it could
also done as an outpatient procedure.
Epidural catheter can be placed to control
postoperative pain, but in our practice, we pre-
fer to do a TAP (transverus abdominal plane)
block [13–16]. This block has gained popularity when ultrasound-guided techniques have
been described [17]. A variation of the classic
TAP block, the subcostal TAP block, has also
been described; it is designed to provide more
reliable coverage of the upper abdominal wall
[18–21].
Once patient is under anesthesia, lower limbs
garments are placed, and intermittent pressure
boots can be used to reduce thromboembolism
phenomena.
25.5 Surgical Technique
Since the rst report by Demars and Marx [22]
at the end of the nineteenth century, the concept of abdominoplasty has changed to a multimodal approach combining different
techniques. Various skin incisions, planes of
dissection, levels of undermining, placing of
drains, suture techniques, and combined liposuction had been described. Thus, it resulted in
various procedures such as classical abdominoplasty, high-lateral- tension abdominoplasty,
lipoabdominoplasty, eur-de-lys abdominoplasty, vertical abdominoplasty, reverse
abdominoplasty, etc.
No standard technique is accepted, due to the
wide variability of patients requiring customized
surgical plans.
Due to the different variables on the surgery,
we can summarize options in each part.
Depending on patient’s phenotype, differ-
ent techniques have been described. All of
them are similar in some way. First, lipo-
suction, if indicated is performed. Then
lower incision is made and desired
undermining is carried out. Careful
hemostasis is done. After this, fascia
plication is marked and sutured as desired.
Finally, skin excision is made and wound is
sutured.
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25.5.1 Patient Positioning
Patient is placed in a standard upright position.
Surgery table is checked for hip exion. Arms are
usually placed open (to make the liposuction
more comfortable) and must be secured.
Alignment of patient is corrected. After skin
resection, patient is made to bend forward to
facilitate skin closure. Once surgery is nished,
patient should be placed in “V” shaped position
while resting.
25.5.2 Procedure Step by Step
Since every patient may benet from a variety of
techniques, we try to combine all tools available
to improve our results by minimizing complications. In this manner, our approach is usually
between classical abdominoplasty and
lipoabdominoplasty.
Preoperative markings are design following
the previous exposed principles, in a custom
fashion for each patient. Liposuction areas are
marked also.
If liposuction of anks is performed, we prefer to start in a prone position. Inltration with
Ringer Lactate and epinephrine is made in a
tumescent fashion, and when the vasoconstriction is achieved, the liposuction starts [23, 24].
Wounds are closed when posterior side surgery is
nished, and patient is turned to supine position.
Once patient is correctly placed, new drapes
are placed after skin preparation. Previous markings are redrawn to avoid mistakes. Again, if any
area was planned to be lipoaspirated, we commence with the liposuction. Inltration is made
and fat is removed taking care to place incisions
over the skin resection areas. Incision is made in
the previous marked location, and dissection is
carried out on the desired plane which usually is
sub-Scarpa in the rst 5–7cm over the incision
and then turned into supra muscular fascia with
limited undermining within the rectus on the
upper abdomen area. With this maneuver, we pre-
serve lymphatics and also preserve lower incision
attachments to prevent excessive cranial migration. Lateral areas are selectively detached (preserving perforators under direct vision). If
liposuction is done in that area, detachment is
carried out by cannula. Umbilicus is freed and
dissection is nished [25]. Careful hemostasis is
done. Skin is removed starting in the middle line
and adjusting tension from lateral to medial.
Drains are placed and wound is closed. Finally,
umbilicus is performed. At this point, any renement in liposuctions is executed, if needed.
Wound is draped and nitroglycerin ointment is
carefully placed over the wound. Compression is
made with tapes/garments and patient is
awakened.
25.5.3 Surgical Modications/
Approaches
25.5.3.1 Abdominoplasty
withUmbilical Transection
(No Transposition)
Considered as an extension of miniabdominoplasty, this technique is specially considered for
patients with high position of the umbilicus and
excess of tissue in the lower abdomen. Incision is
placed in a standard position and dissection is
carried out prefascially, then umbilicus stalk is
transected pulling upward and taking care not to
harm abdominal viscera. Whilst in this maneuver,
circumferential scar in the umbilicus area is
avoided. The deep portion of the stalk is carefully
closed to avoid hernia. Dissection continues
within the edges of the rectus abdominis muscles
to the sternum. Thus, a perfect exposition of any
diastasis is achieved, and plication is carried out
easily with the preferred method. Skin excess is
removed, and umbilicus stalk is xed to abdominal wall in a caudal position maintaining a minimum distance of 9–10 cm from the pubis.
Compared to miniabdominoplasty, a longer scar
may be expected and also a bigger tissue resection is done (Fig.25.1).
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Fig. 25.1 A 43-year-old patient presenting previous
C-section and umbilical hernia. Abdominoplasty with
umbilical transection, hernia correction, and fascia
25.5.3.2 Classical Abdominoplasty
In this approach, incision is made in the lower
abdomen and undermining of skin and fat is
made over the muscular fascia up to costal arch
border to xiphoid. Upper incision is made up to
the umbilicus and the ap is tensioned downward
with umbilicus transposition. With this, upper
and lower abdominal tissue excess is treated.
Tissue undermining is carried as far as necessary
to achieve a non-tension wound closure. With
this undermining liposuction, upper abdomen is
not recommended to avoid vascular complications [26] (Figs.25.2 and 25.3).
25.5.3.3 High-Lateral Tension
Abdominoplasty
This modication pursues not only the treatment
of abdomen but also hips and upper thigh. Skin
resection pattern places less tension in the middle
part with focus on a wider resection and tension
in the lateral aspects. The nal scar is larger than
plication without umbilicus transposition. Umbilicus is
reattached to abdominal wall
in classical abdominoplasty due to an increased
lateral resection and skin removal in order to
avoid dog ear formation [27, 28] (Fig.25.4).
25.5.3.4 Vertical Abdominoplasty,
Fleur de Lys
Abdominoplasty,
andReverse
Abdominoplasty
These techniques are reserved to patients with
preexisting vertical laparotomy [29] or after massive weight loss [30, 31], which are not the main
goal for this book.
25.5.3.5 Lipoabdominoplasty
Lipoabdominoplasty probably is the most modern and popular approach for aesthetic treatment
of abdominal wall. It was popularized by
Saldanha, and it is widely used and considered a
safe technique [32]. In this approach, undermining is made by cautery dissection in the very
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