Abdominoplasty

Moderator- Dr. Abiye (Consultant General, Plastic, and

Reconstructive Surgeon)
Presenter- Dr. Hanna (PSR3)
 Outline
• Historical Background
• Anatomy
• History and Physical Examination
• Operative Technique
• Types of Abdominoplasty
• Post operative consideration
• Complication
Historical Background
 Etiology
• Pregnancy- Commonest
• Excessive weight loss
• Fat accumulation is different for men and women.
- Women- Posterior thigh, lower abdomen, and hip
- Men- intraabdominal
Anatomy
A- Distance from Mons to Anterior Vulvar
Commissure
B-Distance from Umbilicus to Top of Mons (B):
C-Combined Distance from Umbilicus to Anterior
Vulvar Commissure
D-D=C
E.Distance from Costal Margin to Iliac Crest
H-Hip Width
R-Width of Rib Cage
W- Natural Waist
 The umbilicus
• Location
- Midline, approximately 9–12 cm above the mons pubis.
• Shape
- The periumbilical area is typically round or ellipsoid, with a slight
depression measuring 4–6 cm in diameter.
• Fascia
- The fascia around the umbilicus can be unstable, which increases
the risk of hernias. This instability poses a risk for potential bowel injury
during umbilical dissection.
• Blood Supply
 Subdermal plexus
 Right and left deep inferior epigastric artery (DIEA)
 Ligamentum teres
 Median umbilical ligament
Abdominal Blood Supply Zones (Huger’s
Zones)
1. Zone I
- Midline supplied by the deep
epigastric arcade.
2. Zone II
- Lower abdomen supplied by the
superficial epigastric, superficial
external pudendal, and superficial
circumflex iliac systems.
3. Zone III
- Lateral abdominal wall (flanks)
supplied by the six lateral
intercostal and four lumbar arteries.
 Nerve supply
- Cutaneous Sensation:
- Derived from the anterior and lateral
cutaneous branches of intercostal nerves
8 to 12.
- Anterior branches enter the rectus
abdominis, while lateral branches
penetrate intercostal muscles at the
midaxillary line.
- Lateral Femoral cutaneous nerves
- Ilioinguinal and iliohypogastric nerves:
- Not involved in abdominal wall
innervation but can be injured during
lateral transverse incisions, leading to
sensory loss in the groin and medioventral
thigh.
 History and Physical
Examination
To b e as ked To b e e x amine d Inve s tig atio n M is ce llane o us
CT/MRI- in case Constant weight for at least
Weight loss journey Quality of skin.
there is any hernia 12 months
Stop smoking for at least 6
Thickness of adipose tissue by
Pregnancy- number, weeks prior and post
pinching. And Diver test for
delivery method operation However, if not
myofascial laxity
possible 2 weeks is a must.

Prior abdominal
Antiseptic washes prior to
surgeries- Liposuction Number and location of folds.
surgery
included

- Avoid any medication that

Abdominal Hernia Location of abdominal wall defects.
could result in bleeding

Any weight
Evaluate for the straie-
fl uctuations/Bariatric
thinned/absent dermis
procedures
Comorbidities Scars- Upper midline and subcotal
Exercise routine Status of abdominal musculature.

Respiratory history Look for rashes/excoriation

Patient’s favored
clothing. Check areas of adherence
Classification
 Preoperative Preparations
 Patient Marking
• The patient should be marked in the upright position to ensure
accurate placement of incisions and alignment with natural body
contours.
 Scar Placement
• Mark the borders of underwear to help position the scars in less
visible areas, typically below the abdominal fold.
 Incision Guidelines
• Lower Incision Line
- Should run parallel to the scar line and be positioned 6–7 cm above
the vulvar commissure.
• Upper Incision Line:
- This line is an estimate and requires intraoperative tailoring based on
the tension of the skin.
 Estimation of
Resection

Use the pinch test to

estimate the amount of
tissue to be resected,
guiding both the incision
placement and the
extent of the procedure.
 Patient Positioning
• - Ensure adequate padding for the following areas to
prevent pressure injuries:
- Feet
- Knees
- Buttocks
- Back
- Shoulders
- Head

- The patient’s hips should be positioned at the level of the

break in the operating tableto facilitate proper flexion during
the wound closure phase.
 Prophylaxis
• Antibiotic • Thromboprohylaxis

-While not universally required, a - Implement perioperative

single preoperative dose of thromboprophylaxis:
antibiotics may be indicated, - Use sequential compression
particularly in cases involving devices for all patients
hernias. undergoing abdominal wall
surgery.
- Consider the intraoperative and
postoperative use of heparin to
prevent thromboembolic events.
 Contraindication
• Absolute • Relative

- Significant health risks - Scars in the upper quadrants.

- Severe comorbid conditions.
(e.g., heart disease,
- Future plans for pregnancy or
diabetes).
significant weight changes
- Body dysmorphic disorder. - A history of thromboembolic
- Unrealistic surgical disease, and morbid obesity
expectations. (BMI>40).
- Patients with disposition to
keloids or hypertrophic scars.
 Principles of Abdominoplasty
• Test the bed/table
• Placement of two traction sutures at 3 and 9 O’clock around
umbilicus.
• The umbilicus is excised circularly with dissection made to separate
the umbilicus from the skin and fat down to the rectus sheath.
• The skin and fat of abdominal wall are elevated from the fascia upto
the costal margins laterally and xiphoid medially.
• Rectus plication- transverse as well as longitudinal
• Use of permanent sutures due to failure up to 40% when using
absorbable sutures.
• Progressive tension sutures are also used to attach the abdominal
wall to fascia.
• Pollock reported 0% incidence of seroma with these sutures
without drains
Types of Abdominoplasty
 Mini- abdominoplasty
• Patient Profile • Distance Requirement

- It is crucial to maintain a distance of at

-Mild to moderate skin laxity and least 9 cm between the upper resection
tissue excess primarily in the line and the umbilicus.
lower abdomen (infraumbilical).
-This distance helps avoid an
unaesthetic appearance post-surgery.
-For young women with a - If the expected distance after skin
previous Pfannenstiel incision resection is less than 9 cm, umbilical
who seek to improve their transposition should be considered to
abdominal contour. maintain aesthetic outcomes.
 Limitations
• The primary limitation of a
mini abdominoplasty is the
presence of upper
abdominal skin folds and
rolls.
• Patients with significant
issues in the upper
abdomen
 Abdominoplasty with umbilical
resection
• Prefascial Release • Transposition of
the Umbilicus
-The procedure involves a
prefascial release, allowing for
manipulation of the underlying -The umbilicus is transposed
tissues without extensive without the need for a
detachment of the skin flap. circumferential release from the
abdominal flap, effectively
avoiding a periumbilical scar,
addressing a common concern in
traditional abdominoplasty.
 Advantages
• Balanced Approach • Ideal Candidates
- Suitable for patients with
-Effective Middle Ground: This moderate skin laxity and localized
technique bridges the gap between lower abdominal excess, while
mini abdominoplasty and standard not presenting significant upper
abdominoplasty. abdominal concerns.
 Ideal Candidates
• Improved abdominal
contour with minimal
scarring.
• A solution that does not
require the extensive
resection of skin and
tissue associated with
standard abdominoplasty.
 Standard Abdominoplasty
• For patients with excess skin and soft tissue in both the
upper and lower abdomen
• who are willing to accept a periumbilical scar.
 Steps
1. Incision
• Make the inferior incision through Scarpa fascia to rectus fascia.
2. Flap Elevation
• Elevate flap in a suprafascial plane.
3. Umbilical Release
• Use circumferential periareolar incision to free umbilicus.
• Undermine primarily in midline to xiphoid process.
4. Rectus Diastasis Correction
• Plicate anterior rectus sheath from xiphoid to symphysis with non-
absorbable sutures.
5. Paramedian Plication
• Correct umbilical stalk asymmetry; enhance hourglass figure
 Steps
6. Positioning
• Flex patient at hip 30° for superior skin incision.
7. Incision Marking
• Close medial portion temporarily to mark new umbilicus location.
8. Layered Closure
• Conduct wound closure in layers; apply progressive tension sutures
if needed.
9. Umbilicoplasty
• Shape umbilicus (ellipsoid, chevron, shield); secure with absorbable
deep-dermal sutures.
10. Drains
• Insert two subcutaneous drains for postoperative fluid drainage.
High lateral tension
Abdominoplasty
• The extended abdominoplasty
is a modification of the
traditional abdominoplasty
and include hips and lateral
thighs.
 HLT
• Procedure • Indications
Characteristics
• Patients seeking enhancement
Modified Skin Incision Technique of the hips and lateral thighs.
• Purpose: • Those with massive weight
-Utilizes a modified skin incision for a loss.
more conservative central resection. • Suitable for those not satisfied
• Benefits: with standard abdominoplasty
-Facilitates a wider excision of lateral • Provides an option for patients
skin. who do not require a full lower
-Enhances the contour of the hips body lift.
and thighs alongside the abdomen.
 • Address significant skin and
Fleur-de-lis
Abdominoplasty tissue excess in both the
upper and lower abdomen.
 Fleur-de-lis Abdominoplasty
• Procedure • Indications
Characteristics
• Excess tissue primarily in the
horizontal direction,
• This technique involves a particularly those who have
vertical incision, which experienced massive weight
allows for the removal of loss or have pre-existing
both horizontal and midline abdominal scars.
• A thorough assessment of
vertical skin and
both horizontal and vertical
subcutaneous tissue excess of skin and fat tissue is
redundancy. crucial for effective planning.
 Surgical Technique
• The umbilicus is incorporated
into the vertical scar, which is
essential for aesthetic
outcomes.
• The vertical resection should
be performed first, followed by
any necessary horizontal
resection.
• This sequence helps minimize
the risk of over-resection and
preserves optimal abdominal
contour.
 Reverse
Abdominoplasty

Indications
Who have
experienced
massive weight loss
and have residual
skin and soft tissue
excess in the upper
abdomen
 Surgical Techniques
1. Preoperative Marking
• Marking is done with the patient in an upright position.
• The patient is instructed to slightly bend forward to help
demonstrate areas of tissue excess. This allows for accurate
assessment of both vertical and horizontal tissue excess.
2. Incision Planning
• The inframammary fold is marked, extending laterally to the anterior
axillary line.
• The typical width of the resection is generally less than 15 cm,
ensuring a balance between adequate removal of excess tissue and
maintaining aesthetic results.
 Vertical Abdominoplasty
• Skin redundancy and tissue laxity in the abdomen, especially after
significant weight loss or pregnancy.
• Pre-existing scar in the abdominal midline and wish to improve their
abdominal contour without incurring additional transverse scars.
• The surgery involves a vertical incision that runs along the midline of
the abdomen, facilitating lateral mobilization of the abdominal soft
tissue
 • This approach enhances
Lipo- abdominal contour while
abdominoplasty preserving vital vascular
structures.
 Lipoabdominoplasty
1. Patient Marking:
• - Similar to traditional abdominoplasty, but with additional focus
on marking areas of rectus diastasis.
• This area indicates where tunneling will occur, avoiding the need
for traditional undermining.
2. Positioning and Preparation
• The patient is placed in the supine position.
• The epigastric and subcostal areas are infiltrated with a tumescent
solution to facilitate liposuction.
• Liposuction is performed while the patient is positioned in a
hyperextended manner, ensuring careful maintenance of flap
thickness to prevent vascular impairment and contour deformities.
• Notably, the lower abdomen should not be aspirated.
- After liposuction, incisions are made in the lower abdomen.
 Cont;d
3. Incision and Flap Mobilization
• In the midline, over the diastasis, the tunnels created by
liposuction can be selectively undermined only to the
medial border of the rectus muscles, allowing for rectus
plication.
• This selective undermining helps to avoid injury to the
abdominal perforators
4. Skin Resection and Closure
• Excess skin resection and closure are performed
similarly to traditional abdominoplasty, ensuring a tight
and aesthetically pleasing outcome.
 Post Op care for
lipoabdominoplasty
• Drains are typically left in place until the output is less
than 30 mL over a 24-hour period.
• Patients should rest in a relaxed position with a flexion of
approximately 30° at the hip joint.
• This position should be maintained for 2–3 weeks
postoperatively to ensure tension-free healing of the
surgical scar.
• A compression garment should be worn for the same
duration as the positioning recommendation (2–3
weeks).
 Cont’d
• Sporting Activities: Should be avoided for 6 weeks after
surgery. If fascial reconstruction is performed, this
restriction extends to 8 weeks.
• Patients should also refrain from using saunas and
tanning beds during the recovery period to prevent skin
irritation and complications.
 Complications
• Pain and Discomfort: Patients can expect varying levels of
postoperative pain or soreness, particularly due to increased
abdominal tension.
• Numbness: It is common to experience numbness in the abdominal
flap, which may persist for several weeks.
• Bruising and Fatigue: Bruising and general fatigue are typical during
the recovery process.
 Local Complications
• Seromas (0-14%)
• Hematoma
• Wound Infection- Smokers (49.7%) versus nonsmokers (14.8%)
• Wound Dehiscence
• Fat Necrosis
• Paresthesia and Persistent Numbness-“riding breeches deformity” or
meralgia paresthetica
• Cosmetic Issues- malposition of umbilicus
 Systemic Complications
• Deep Vein Thrombosis (DVT) and Pulmonary Embolism
(PE)
• Respiratory Compromise
• Systemic Infections-0%-8%
 Prevention of Complications
• Many of the outlined cosmetic problems can be minimized through
proper preoperative planning and meticulous surgical technique.
• Shaving is not required. Do not use razors.
• Give IV antibiotics 30-59 minutes before the incision.
• Give postoperative antibiotics for 24 hours.
• Perform elective surgery with A1C ,7.
• Prevent intraoperative hypothermia.
• Thank u!
 Reference
• Neligan 5th edition, Aesthetic surgery
• Michigan Manual of Plastic surgery
• Essentials of Plastic Surgery
• Core procedures of plastic surgery, 2nd
Edition