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Mini-abdominoplasty
MINI-ABDOMINOPLASTY BRUCE A. MAST, MD, AND DENNIS J. HURWITZ, MD
A subset of patients seeking aesthetic correction of abdominal deformities will be aptly treated with mini-abdominoplasty. Such patients have deformities largely limited to the lower abdomen and have only mild to moderate excesses of skin and fat. Compared with the full abdominoplasty, the mini-abdominoplasty consists of fewer incisions, less dissection, tissue resection, musculofascial surgery, and scarring. Accordingly, such patients can receive excellent surgical correction of their deformity while morbidity is substantially minimized. Copyright 9 1996 by W.B. Saunders Company KEY WORDS: infraumbilical, mini-abdominoplasty
Contour irregularities of the abdominal wall result from a combination of several causative factors, including: pregnancy, aging, gravity, weight changes, and sequellae of abdominal operations. 1,2 The resultant irregularities of the abdominal wall consist of" varying degrees of the following: excessive adiposity, redundant skin, and laxity of musculofascial units. 2 Until recently, these problems were treated uniformly with a complete abdominoplasty. The entire abdominal wall skin and fat were raised and the tissue between the pubis and umbilicus was resected. The remaining skin was redraped over a plicated linea alba. Translocation of the umbilicus and suction-assisted lipectomy completed the operation. If insufficient lower abdominal skin prevented complete resection, then the infraumbilical flap was closed vertically, leaving a short vertical midline suprapubic scar. This traditional abdominoplasty is usually performed under general anesthesia and postoperative pain and discomfort tend to be significant, necessitating I or 2 days of hospitalization. Despite the efficacy of this operation, it has become clear that a subset of patients may be treated with a less extensive, but equally effective, operation: the mini-abdominoplasty. For some individuals (almost all of these patients are women), the abdominal wall defect is confined chiefly to the lower abdomen. Therefore, a mini-abdominoplasty is the ideal treatment, often combined with liposuction to reduce residual bulk. These patients tend to have a single roll of loose skin overlying an abdominal bulge, limited to the area between the pubis and umbilicus (Fig 1). Miniabdominoplasty can provide these women with excellent correction of their abdominal deformities with significantly less morbidity than that which is associated with a full abdominoplasty. This procedure can also provide an understandable compromise for the patient who is not an
From the Divisions of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Florida and University of Pittsburgh, Pittsburgh, PA. Address reprint requests to Bruce A. Mast, MD, Division of Plastic and Reconstructive Surgery, University of Florida, Health Science Center, 1600 Archer Rd, JHMHC Box 100286, Gainesville, FL 32610-0286. Copyright 9 1996 by W.B. Saunders Company 1071-0949/96/0301-000855.00/0
38
ideal candidate for mini-abdominoplasty, but is unwilling to put forth the physical and financial outlay required for the full abdominoplasty. Contraindications to mini-abdominoplasty are epigastric hernias or laxity, which usually require a full abdominoplasty or endoscopically-assisted abdominoplasty. Likewise, severely excessive skin and/or fat is not adequately treated by mini-abdominoplasty.
CLINICAL FINDINGS Ideal candidates for the mini-abdominoplasty are displeased with their lower abdominal bulges, especially when sitting. Full examination of the patient's abdomen is done in several positions: sitting, standing, supine, and the diving position. This provides a full appreciation of the degree of excessive soft tissue and the extent of musculofascial laxity. The sitting position will show a roll of excessive flesh that is easy to grasp and particularly unsightly in a bathing suit, but it's not as noticeable with the patient in a standing position. The excess tissue confined to the lower abdomen is confirmed with the patient standing while downward traction is provided to the abdominal skin, showing the absence of sufficient laxity above the umbilicus to bridge the gap to the pubis. Additionally, the diving position allows the loose skin to fall away from the abdominal wall and provide further assessment. With the patient supine, bilateral straight leg raising will show the status of the anterior musculofascial layer. Generalized weakness should not proceed much above the umbilicus. If there is much loose skin or muscuolofascial laxity above the umbilicus, then a full abdominoplasty is needed.
OPERATIVE TECHNIQUE A mini-abdominoplasty on an ideal patient will be described. The central transverse aspect of the inferior skin incision is marked at the superior border of the pubic hairline while the patient is standing. The incision line is continued laterally in a nearly horizontal sweeping arc. Alternatively, a "lazy" W incision can be used (Fig 2). Unlike the full abdominoplasty, in which the incision is
Operative Techniquesin Plastic and Reconstructive Surgery, Vol 3, No 1 (February), 1996: pp 38-41
Fig 1. (A and B) Abdominal wall deformity suitable for mini-abdominoplasty. There is significant abdominal wall bulging below the umbilicus with only a moderate amount of excessive skin and fat. Additionally, the upper abdomen and flanks are flat with little excessive tissue.
carried to the anterior superior iliac spines, the most lateral extent of the mini-abdominoplasty incision usually extends no farther than the midclavicular line and must be equidistant from the midline bilaterally. One may estimate the amount of tissue to be excised and draw the superior limb of the incision, or wait until the flap is raised. Thinner patients and the surgeon's experience will facilitate this decision. The skin to be excised encompasses about one third of the vertical height of the skin between the pubis and umbilicus. Additional markings of excessive adipose deposits in the regions of the iliac crests, trochanteric regions, flanks or upper abdomen should be done if
MINI-ABDOMINOPLASTY
suction-assisted lipectomy is to be concomitantly performed (Fig 2). I usually perform this procedure under local anesthesia with intravenous sedation and monitoring. Application of the tumescent technique for liposuction has improved the local anesthetic effect, as well as hemostasis. If maximal musculofascial plication is critical, then the procedure is done under general anesthetic with pharmaceutical paralysis. In recent years, we have initiated the operation with syringe vacuum liposuction in the regions remote from the suprapubic skin and fat excision. The smaller diameter (3.0 to 4.6 mm), thin caliber Tulip cannulas (Tulip, San Diego, CA) are preferred, because when combined with tumescent infiltration, they cause little bleeding and are virtually atraumatic to the surrounding vasculature perfusing the remaining tissues. Because the negative pressure within the syringes would be lost in the open wound, the surgical incisions are made following liposuction. The lower incision is created and carried down to the loose areolar plane just superficial to the anterior rectus sheath and external oblique fascial aponeuroses. The skin and subcutaneous tissue is then raised off the abdominal fascia superiorly and laterally. The superior extent of mobilization is to the point where the diastasis recti ceases. Therefore, it is sometimes necessary to perform this dissection to a point 2 to 5 cm above the umbilicus. If this procedure is necessary, the umbilicus remains attached to the abdominal skin and abdominal wall, and care must be exercised around the umbilical stalk to avoid devascularization. Lateral mobilization of the skin unit is carried out to the anterior axillary lines. This will result in sufficient anterior retraction of the skin unit such that abdominal wall plication can be done under direct visualization. Dissection and retraction of the abdominal skin and subcutaneous tissue provides direct inspection of the musculofascial laxity, most often resulting from diastasis recti. The diastasis in these patients is primarily confined to the infraumbilical region, with the most pronounced aspect below the level of the arcuate line. Not infrequently, the diastasis will extend a limited distance above the umbilicus, where the laxity is much less severe. The goal of musculofascial plication is to reconstruct the normal anatomic relationships of the abdominal wall musculature, ie, the rectus muscles should be parallel to each other with a straight line juxtaposition at the linea alba. Accordingly, plication is undertaken to remove the resultant bulging and restore a flat abdominal wall. The plication lines on the anterior rectus sheaths are marked to guide suture placement; these marks are usually in a crescent shape. Plication is undertaken with inverted, figure-of-eight sutures, placed through the anterior rectus sheath. I use 0-Ethibond (Ethicon, Sommerville, NJ), a braided nylon suture, which is permanent but soft and thereby avoids a palpable suture line postoperatively. If plication is necessary superior to the umbilicus, sutures must be placed so as to avoid strangulation of the umbilical stalk. Following plication, the excessive skin and subcutaneous tissue, if not already excised, is brought inferiorly to overlap the lower suprapubic incision and removed. The deep surface of the superior flap is trimmed to the approximate thickness of the suprapubic skin. While the
39
/ Fig 2. Preoperative markings for mini-abdominoplasty include the suprapubic incision (limited sweeping arc or lazy W) and areas to be treated by suction-assisted lipectomy.
table is partially flexed, Scarpa's fascia is meticulously closed with an absorbable suture under mild tension. If the umbilicus is drawn closer than 9 cm to the pubis (this is an average distance, because individual anatomic proportions of each patient will determine acceptable downward displacement of the umbilicus), it is translocated to the appropriate position through a vertical, elliptical, midline incision. This is usually not necessary. The skin is then temporarily closed with staples, and final liposuction is performed. Most areas will be accessible via the lower abdominal incision, although separate stab incisions for cannula portals should be used when necessary. One large closed suction drain, either a Jackson-Pratt (Baxter Healthcare, Deerfield, IL) or Blake (Johnson & Johnson Medical, Arlington, TX), is then placed and brought out via a separate stab incision within the mons pubis. An intracuticular monofilament 3-0 pull-out suture is run the full length of the incision for skin closure. Reston foam with numerous 2-cm perpendicular slits (3M Medical/Surgical Division, St Paul, MN) is placed over areas of liposuction. These slits relieve the occasional shear stress on the epidermis that causes superficial wounds under the foam. Wound closure strips are placed over the incision, and paper tape is applied over a layer of fluffy gauze. An abdominal binder is securely fitted.
amounts of excessive skin and adiposity, mini-abdominoplasty is successful in providing excellent correction of their deformities (Figs 3 and 4). It is estimated that approximately 20% of patients seeking correction of abdominal contour defects are candidates for this procedure. 2,3The advantages of using this procedure rather than
POSTOPERATIVE CARE Patients are discharged to home following the surgery with instructions to avoid strenuous activities and heavy lifting. The drain is usually removed within I week from surgery. Patients are able to return to full exercise and activities at 6 weeks postoperatively.
DISCUSSION In selected patients with abdominal wall laxity confined to lower abdominal bulging and only mild to moderate
40
Fig 3. Four-year postoperative result of the patient shown in Figure 1. The patient was treated with mini-abdominoplasty without Iiposuction.
BRUCE A. MAST
the patient to remain completely supine or erect following surgery. This results in less pain and discomfort such that an overnight, inpatient stay is solely dependent on the patient's desires, rather than medical necessity. The limited dissection in mini-abdominoplasty also reduces the risks of abdominal wound complications and tissue loss. Risks of postoperative hematoma and seroma are reduced and suction drains are generally required for a shorter period of time. Additionally, the umbilicus is usually not translocated, thus avoiding scarring around the umbilicus and minimizing the risk of ischemic mishap. Indeed, Greminger 3 reported that only 2 complications occurred in 20 patients: minimal tissue loss in a heavy smoker and one small hematoma. Additionally, the mini-abdominoplasty minimizes potential adverse aesthetic outcomes that occasionally occur with full abdominoplasty, such as straightening of the waistline, incisional dog-ears and difficulty concealing scars within swimwear. Nevertheless, potential suboptimal outcomes in mini-abdominoplasty may occur: upper abdominal bulging may result with overzealous musculofascial plication, and a noticeable inferiorly displaced umbilicus may occur. As with most deformities treated by plastic surgery, it is important to analyze each deformity based on its various components and "customize" procedures to each particular patient. The mini-abdominoplasty represents such an approach. With careful patient selection, a significant aesthetic deformity can be corrected with minimization of morbidity and convalescence, while providing the patient with a high standard of care and a high level of satisfaction.
REFERENCES Fig 4. Same patient as in Figure 4. Lateral view.
full abdominoplasty in properly selected patients relates entirely to morbidity. The mini-abdominoplasty uses incisions and dissections that are considerably smaller, while abdominal skin resection is of lesser quantity permitting
MINI-ABDOMINOPLASTY
1. WilkersonTS, Swartz BE: Individual modificationin body contour surgery: The "limited" abdominoplasty.Plast Reconstr Surg 77:779783, 1986 2. MatarassoA: Abdominoplasty.ClinPlastSurg 16:289-303, 1989 3. GremingerRF: The mini-abdominoplasty.Plast ReconstrSurg 79:356364, 1987
41
A subset of patients seeking aesthetic correction of abdominal deformities will be aptly treated with mini-abdominoplasty. Such patients have deformities largely limited to the lower abdomen and have only mild to moderate excesses of skin and fat. Compared with the full abdominoplasty, the mini-abdominoplasty consists of fewer incisions, less dissection, tissue resection, musculofascial surgery, and scarring. Accordingly, such patients can receive excellent surgical correction of their deformity while morbidity is substantially minimized. Copyright 9 1996 by W.B. Saunders Company KEY WORDS: infraumbilical, mini-abdominoplasty
Contour irregularities of the abdominal wall result from a combination of several causative factors, including: pregnancy, aging, gravity, weight changes, and sequellae of abdominal operations. 1,2 The resultant irregularities of the abdominal wall consist of" varying degrees of the following: excessive adiposity, redundant skin, and laxity of musculofascial units. 2 Until recently, these problems were treated uniformly with a complete abdominoplasty. The entire abdominal wall skin and fat were raised and the tissue between the pubis and umbilicus was resected. The remaining skin was redraped over a plicated linea alba. Translocation of the umbilicus and suction-assisted lipectomy completed the operation. If insufficient lower abdominal skin prevented complete resection, then the infraumbilical flap was closed vertically, leaving a short vertical midline suprapubic scar. This traditional abdominoplasty is usually performed under general anesthesia and postoperative pain and discomfort tend to be significant, necessitating I or 2 days of hospitalization. Despite the efficacy of this operation, it has become clear that a subset of patients may be treated with a less extensive, but equally effective, operation: the mini-abdominoplasty. For some individuals (almost all of these patients are women), the abdominal wall defect is confined chiefly to the lower abdomen. Therefore, a mini-abdominoplasty is the ideal treatment, often combined with liposuction to reduce residual bulk. These patients tend to have a single roll of loose skin overlying an abdominal bulge, limited to the area between the pubis and umbilicus (Fig 1). Miniabdominoplasty can provide these women with excellent correction of their abdominal deformities with significantly less morbidity than that which is associated with a full abdominoplasty. This procedure can also provide an understandable compromise for the patient who is not an
From the Divisions of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Florida and University of Pittsburgh, Pittsburgh, PA. Address reprint requests to Bruce A. Mast, MD, Division of Plastic and Reconstructive Surgery, University of Florida, Health Science Center, 1600 Archer Rd, JHMHC Box 100286, Gainesville, FL 32610-0286. Copyright 9 1996 by W.B. Saunders Company 1071-0949/96/0301-000855.00/0
38
ideal candidate for mini-abdominoplasty, but is unwilling to put forth the physical and financial outlay required for the full abdominoplasty. Contraindications to mini-abdominoplasty are epigastric hernias or laxity, which usually require a full abdominoplasty or endoscopically-assisted abdominoplasty. Likewise, severely excessive skin and/or fat is not adequately treated by mini-abdominoplasty.
CLINICAL FINDINGS Ideal candidates for the mini-abdominoplasty are displeased with their lower abdominal bulges, especially when sitting. Full examination of the patient's abdomen is done in several positions: sitting, standing, supine, and the diving position. This provides a full appreciation of the degree of excessive soft tissue and the extent of musculofascial laxity. The sitting position will show a roll of excessive flesh that is easy to grasp and particularly unsightly in a bathing suit, but it's not as noticeable with the patient in a standing position. The excess tissue confined to the lower abdomen is confirmed with the patient standing while downward traction is provided to the abdominal skin, showing the absence of sufficient laxity above the umbilicus to bridge the gap to the pubis. Additionally, the diving position allows the loose skin to fall away from the abdominal wall and provide further assessment. With the patient supine, bilateral straight leg raising will show the status of the anterior musculofascial layer. Generalized weakness should not proceed much above the umbilicus. If there is much loose skin or muscuolofascial laxity above the umbilicus, then a full abdominoplasty is needed.
OPERATIVE TECHNIQUE A mini-abdominoplasty on an ideal patient will be described. The central transverse aspect of the inferior skin incision is marked at the superior border of the pubic hairline while the patient is standing. The incision line is continued laterally in a nearly horizontal sweeping arc. Alternatively, a "lazy" W incision can be used (Fig 2). Unlike the full abdominoplasty, in which the incision is
Operative Techniquesin Plastic and Reconstructive Surgery, Vol 3, No 1 (February), 1996: pp 38-41
Fig 1. (A and B) Abdominal wall deformity suitable for mini-abdominoplasty. There is significant abdominal wall bulging below the umbilicus with only a moderate amount of excessive skin and fat. Additionally, the upper abdomen and flanks are flat with little excessive tissue.
carried to the anterior superior iliac spines, the most lateral extent of the mini-abdominoplasty incision usually extends no farther than the midclavicular line and must be equidistant from the midline bilaterally. One may estimate the amount of tissue to be excised and draw the superior limb of the incision, or wait until the flap is raised. Thinner patients and the surgeon's experience will facilitate this decision. The skin to be excised encompasses about one third of the vertical height of the skin between the pubis and umbilicus. Additional markings of excessive adipose deposits in the regions of the iliac crests, trochanteric regions, flanks or upper abdomen should be done if
MINI-ABDOMINOPLASTY
suction-assisted lipectomy is to be concomitantly performed (Fig 2). I usually perform this procedure under local anesthesia with intravenous sedation and monitoring. Application of the tumescent technique for liposuction has improved the local anesthetic effect, as well as hemostasis. If maximal musculofascial plication is critical, then the procedure is done under general anesthetic with pharmaceutical paralysis. In recent years, we have initiated the operation with syringe vacuum liposuction in the regions remote from the suprapubic skin and fat excision. The smaller diameter (3.0 to 4.6 mm), thin caliber Tulip cannulas (Tulip, San Diego, CA) are preferred, because when combined with tumescent infiltration, they cause little bleeding and are virtually atraumatic to the surrounding vasculature perfusing the remaining tissues. Because the negative pressure within the syringes would be lost in the open wound, the surgical incisions are made following liposuction. The lower incision is created and carried down to the loose areolar plane just superficial to the anterior rectus sheath and external oblique fascial aponeuroses. The skin and subcutaneous tissue is then raised off the abdominal fascia superiorly and laterally. The superior extent of mobilization is to the point where the diastasis recti ceases. Therefore, it is sometimes necessary to perform this dissection to a point 2 to 5 cm above the umbilicus. If this procedure is necessary, the umbilicus remains attached to the abdominal skin and abdominal wall, and care must be exercised around the umbilical stalk to avoid devascularization. Lateral mobilization of the skin unit is carried out to the anterior axillary lines. This will result in sufficient anterior retraction of the skin unit such that abdominal wall plication can be done under direct visualization. Dissection and retraction of the abdominal skin and subcutaneous tissue provides direct inspection of the musculofascial laxity, most often resulting from diastasis recti. The diastasis in these patients is primarily confined to the infraumbilical region, with the most pronounced aspect below the level of the arcuate line. Not infrequently, the diastasis will extend a limited distance above the umbilicus, where the laxity is much less severe. The goal of musculofascial plication is to reconstruct the normal anatomic relationships of the abdominal wall musculature, ie, the rectus muscles should be parallel to each other with a straight line juxtaposition at the linea alba. Accordingly, plication is undertaken to remove the resultant bulging and restore a flat abdominal wall. The plication lines on the anterior rectus sheaths are marked to guide suture placement; these marks are usually in a crescent shape. Plication is undertaken with inverted, figure-of-eight sutures, placed through the anterior rectus sheath. I use 0-Ethibond (Ethicon, Sommerville, NJ), a braided nylon suture, which is permanent but soft and thereby avoids a palpable suture line postoperatively. If plication is necessary superior to the umbilicus, sutures must be placed so as to avoid strangulation of the umbilical stalk. Following plication, the excessive skin and subcutaneous tissue, if not already excised, is brought inferiorly to overlap the lower suprapubic incision and removed. The deep surface of the superior flap is trimmed to the approximate thickness of the suprapubic skin. While the
39
/ Fig 2. Preoperative markings for mini-abdominoplasty include the suprapubic incision (limited sweeping arc or lazy W) and areas to be treated by suction-assisted lipectomy.
table is partially flexed, Scarpa's fascia is meticulously closed with an absorbable suture under mild tension. If the umbilicus is drawn closer than 9 cm to the pubis (this is an average distance, because individual anatomic proportions of each patient will determine acceptable downward displacement of the umbilicus), it is translocated to the appropriate position through a vertical, elliptical, midline incision. This is usually not necessary. The skin is then temporarily closed with staples, and final liposuction is performed. Most areas will be accessible via the lower abdominal incision, although separate stab incisions for cannula portals should be used when necessary. One large closed suction drain, either a Jackson-Pratt (Baxter Healthcare, Deerfield, IL) or Blake (Johnson & Johnson Medical, Arlington, TX), is then placed and brought out via a separate stab incision within the mons pubis. An intracuticular monofilament 3-0 pull-out suture is run the full length of the incision for skin closure. Reston foam with numerous 2-cm perpendicular slits (3M Medical/Surgical Division, St Paul, MN) is placed over areas of liposuction. These slits relieve the occasional shear stress on the epidermis that causes superficial wounds under the foam. Wound closure strips are placed over the incision, and paper tape is applied over a layer of fluffy gauze. An abdominal binder is securely fitted.
amounts of excessive skin and adiposity, mini-abdominoplasty is successful in providing excellent correction of their deformities (Figs 3 and 4). It is estimated that approximately 20% of patients seeking correction of abdominal contour defects are candidates for this procedure. 2,3The advantages of using this procedure rather than
POSTOPERATIVE CARE Patients are discharged to home following the surgery with instructions to avoid strenuous activities and heavy lifting. The drain is usually removed within I week from surgery. Patients are able to return to full exercise and activities at 6 weeks postoperatively.
DISCUSSION In selected patients with abdominal wall laxity confined to lower abdominal bulging and only mild to moderate
40
Fig 3. Four-year postoperative result of the patient shown in Figure 1. The patient was treated with mini-abdominoplasty without Iiposuction.
BRUCE A. MAST
the patient to remain completely supine or erect following surgery. This results in less pain and discomfort such that an overnight, inpatient stay is solely dependent on the patient's desires, rather than medical necessity. The limited dissection in mini-abdominoplasty also reduces the risks of abdominal wound complications and tissue loss. Risks of postoperative hematoma and seroma are reduced and suction drains are generally required for a shorter period of time. Additionally, the umbilicus is usually not translocated, thus avoiding scarring around the umbilicus and minimizing the risk of ischemic mishap. Indeed, Greminger 3 reported that only 2 complications occurred in 20 patients: minimal tissue loss in a heavy smoker and one small hematoma. Additionally, the mini-abdominoplasty minimizes potential adverse aesthetic outcomes that occasionally occur with full abdominoplasty, such as straightening of the waistline, incisional dog-ears and difficulty concealing scars within swimwear. Nevertheless, potential suboptimal outcomes in mini-abdominoplasty may occur: upper abdominal bulging may result with overzealous musculofascial plication, and a noticeable inferiorly displaced umbilicus may occur. As with most deformities treated by plastic surgery, it is important to analyze each deformity based on its various components and "customize" procedures to each particular patient. The mini-abdominoplasty represents such an approach. With careful patient selection, a significant aesthetic deformity can be corrected with minimization of morbidity and convalescence, while providing the patient with a high standard of care and a high level of satisfaction.
REFERENCES Fig 4. Same patient as in Figure 4. Lateral view.
full abdominoplasty in properly selected patients relates entirely to morbidity. The mini-abdominoplasty uses incisions and dissections that are considerably smaller, while abdominal skin resection is of lesser quantity permitting
MINI-ABDOMINOPLASTY
1. WilkersonTS, Swartz BE: Individual modificationin body contour surgery: The "limited" abdominoplasty.Plast Reconstr Surg 77:779783, 1986 2. MatarassoA: Abdominoplasty.ClinPlastSurg 16:289-303, 1989 3. GremingerRF: The mini-abdominoplasty.Plast ReconstrSurg 79:356364, 1987
41