"Redefining Abdominal Anatomy: 10 Key Elements for Restoring Form in Abdominoplasty"

This article originally appeared in the Aesthetic Surgery Journal, November/December 2015

While traditional abdominoplasty methods can successfully achieve the objective of restoring a flat appearance, the results can be board-like, lacking the subtle anatomical features that characterize a youthful, attractive female abdomen. Previous methods have not consistently placed a primary emphasis on recreating specific anatomical features of the native abdomen. In addition, the technical tools required to attain the anatomical details present on the ideal aesthetic abdomen were limited prior to the publication of the Progressive Tension Suture technique.1

Numerous published studies have contributed to a more thorough understanding of the vascular anatomy of the entire abdominal unit, providing critical guidelines for more advanced techniques. By incorporating selective detailed maneuvers, three-dimensional anatomical character can be achieved safely and consistently.2,3

In my experience, anatomical authenticity is a particularly important objective in a prospective patient’s search for any cosmetic procedure, including abdominoplasty. The surgical stigmata of the traditional abdominoplasty dissuades many prospective patients from considering it as an option for improvement, except in the most profound situation, such as the major weight loss condition where a cumbersome redundant panniculus is present.

During the initial consultation, an increasing number of my prospective patients express a desire to avoid the uniformly, flat abdominal appearance which characterizes many of the abdominoplasty results they have viewed directly in person or online (Figure 1A,B). In my opinion, their candid comments are a direct consequence of the abundance of digital media available, which includes before and after photos and detailed conversations in women’s internet forums. These resources cultivate scrutinizing, sophisticated consumers whom I am seeing in consultations on a regular basis.

In 2000, Pollock and Pollock published the Progressive Tension Suture (PTS) technique they originated,1 with the primary objective to reduce abdominoplasty-related clinical complications. This technique dramatically reduces seroma formation and theoretically enhances vascularity by distributing tension over the entire flap rather than at the incision line only. I began using this technique at that time, incorporating a modified anatomy-defining application as I became more proficient with the method. In addition, over the ensuing 5 years, I incorporated numerous other technical modifications aimed at improving overall aesthetic results and patient satisfaction.

Patient Evaluation and Technique

During the physician-patient consultation of a potential abdominoplasty candidate, four elements of the abdomen require evaluation: skin laxity, excess subcutaneous fat, diastasis/hernia and intra abdominal fat. As part of my strategy, the abdominal flap is fully mobilized in nearly all cases; therefore, I have been reluctant to perform concomitant liposuction of the central flap.

If significant intra abdominal fat is present, regardless of whether other factors also exist, preoperative weight loss is necessary to provide a safe procedure and to achieve optimal aesthetic outcomes. If diastasis or skin laxity is present, an abdominoplasty of some type is recommended. The type of abdominoplasty (mini, modified, full) is based upon the specific anatomical location of skin laxity, excess fat, and diastasis. The most favorable circumstance, where liposuction alone is recommended, occurs when there is good skin tone with no more than moderate excess fat present (usually in the nulliparous young patient). The key aesthetic goals of this abdominoplasty procedure include the following:

1)      low scar positioning to facilitate concealment in a modest   undergarment or swimsuit

2)      uniform upper and lower fascial repair, limited to the defect present, to ensure congruent restoration

3)      differential fat thickness of the abdominal flap to more accurately replicate the native condition

4)      uniform skin tone of the entire abdominal aesthetic unit from the costal margin and xiphoid to the symphisis pubic and inguinal crease

5)      subtle three-dimensional character that delineates the linea alba and linea semilunaris  and the contour depression of the lateral abdomen/anterior waist

6)      concomitant mons treatment for skin laxity, atrophic loss of skin tone and excess fat content within the aesthetic unit

7)      smooth soft tissue transitioning at the incision line to reduce the “step-off” effect

8)      attentive treatment of the entire torso unit, particularly the hip and waist, to ensure overall aesthetic harmony

9)      a deeply-contoured, vertical umbilicus that accurately recreates an attractive prepartal umbilicus

From 2000-2014, I have performed a total of 1138 abdominoplasty procedures. Within the first five years of this period, the technical details described here were progressively employed and refined through repetition. In the ensuing 10 years all of these elements were consistently employed in all patients. Ten key technical elements comprise this abdominoplasty method:

Element 1: Strategic low position of the incision (Figure 2)

The incision is placed approximately 6 centimeters above the vulvar
commissure as described by Lockwood and others.4, 5 This allows resection of hair-bearing suprapubic skin, providing the advantage of avoiding elevation of the hairline. The scar is horizontal to 1-2 cm above the inguinal crease and ascends at a slight 20-30 degree angle to a point approximately 6-9 cm (dependent on bony anatomy and torso length) below the anterior-superior iliac spine (ASIS). This design most closely follows the underwear waistband or swimsuit bottom in women’s current styles.

Not infrequently, low positioning of the incision necessitates vertical closure of the umbilical defect at some point between the umbilicorraphy and the suprapubic incision. Attentive Scarpa’s fascia approximation of the vertical repair, from beneath the raised flap, usually prevents an unattractive scar depression. During lower abdominal incisional repair, a three-point fixation of Scarpa’s fascia to rectus and external oblique fascia with 0 PDS suture helps reduce the tendency toward superior migration of the scar. Finally, a low incision puts the lateral femoral cutaneous nerve more at risk for injury, necessitating cautious dissection and avoidance.

Element 2: Thorough Abdominal Flap Mobilization (Figure 3)

To facilitate the technical details of this procedure, a thorough abdominal flap mobilization is required. The flap dissection is continuous centrally to the xiphoid, preserving the superior lateral rectus perforators along the upper third of the rectus muscle. Cautious discontinuous dissection is performed along the costal margin lateral to the lateral rectus perforators, preserving segmental perforators as well.  The extent of discontinuous dissection is made intraoperatively when the vascular anatomy and flap mobility can be more accurately assessed. Because the flap is thoroughly mobilized as described with this technique, liposuction of the central flap is not performed.

Element 3: Complete Diastasis Repair (Figure 4A-D)

Ideally, in most circumstances, an accurate correction of the rectus muscle separation along its medial edge, and no more, provides the best chance for balanced harmony of the aesthetic abdominal unit. This is achieved by applying equal tension above and below the umbilicus, from the xiphoid process to the umbilicus and from the umbilicus to the symphysis pubis, utilizing a single, 2-layer, running permanent monofilament suture (#1 Prolene) for each segment.  Additionally, a separate purse string periumbilical repair (#1 Prolene) is incorporated in order to strengthen this weak zone and subtly invaginate the umbilicus for a more deeply contoured umbilicorraphy (described in Element 10).

Element 4: Sub-Scarpa’s Fat Thinning (Figure 5A-B, 6)

Once the abdominal flap is elevated, the vascularity of the deep fat is dependent upon the subdermal plexus of the superficial fat pad.6 Therefore, the deep fat pad below Scarpa’s fascia can be safely trimmed along the linea alba, linea semilunaris and external oblique fascia. A thinner fat pad over the external oblique muscle deepens the waist and improves anatomical accuracy. In addition, thinning the sub-Scarpa’s fat over the external oblique exposes Scarpa’s fascia, facilitating secure placement of Anatomy Defining-Progressive Tension Sutures (2-0 PDS). This emphasizes definition along the semilunaris by simulating the zone of adherence. The lateral skin flap can then be advanced inferiorly and medially to enhance waistline definition.

Element 5: Anatomy Defining-Progressive Tension Sutures (Figure 7A-B, 8A-B)

Progressive Tension Sutures1 are strategically placed to enhance anatomical definition. After midline fat thinning over the linea alba via small cannula liposuction or direct excision,7 a running Anatomy Defining-Progressive Tension Suture (AD-PTS) is utilized to further define and add tone to the midline sulcus. This usually requires 10-12 loops of 2-0 PDS in a running fashion advancing the midline from the origin of the xiphoid process to the base of the umbilicus. The linea semilunaris is reestablished with a series of 5-6 interrupted 2-0 PDS Anatomy Defining-Progressive Tension Sutures on each side along the confluence of the external oblique and anterior rectus fascia. The lateral skin flap is advanced medially and inferiorly to define the anterior waist and to reduce the potential for lateral skin redundancy (dog ears) with an additional series of 2-0 PDS interrupted sutures (6-8) on each side. Additional interrupted 2-0 PDS Progressive Tension Sutures (6-8) are placed centrally and inferiorly to advance the flap and reduce potential space.

Element 6: Vertical Closure of Umbilical Defect If Needed

In the technique described here, a priority is placed on keeping the horizontal incision very low as described in Element 1. When inadequate skin is available to allow complete resection of skin from the suprapubic incision to the umbilicus, a vertical umbilical defect repair may be required. The vertical defect is first approximated from beneath the abdominal flap while it is still elevated.  Deep internal flap repair of Scarpa’s fascia may reduce the chance that a scar contracture with a contour depression (referred to as “2nd belly button” by some patients) will occur.

Element 7: Mons Rejuvenation (Figure 9A-B)

Resection of excess fat and redundant skin are frequently both required for adequate treatment. This is initiated by sub-Scarpa’s fat resection, thinning the mons fat pad while also exposing Scarpa’s fascia. Superior mons advancement and stabilization is then accomplished by utilizing 3-5 interrupted deep 0 PDS sutures attaching the exposed Scarpa’s fascia to the underlying rectus fascia. After mons advancement, additional resection of lax hair-bearing pubic skin may be necessary to maintain a low superior pubic hairline and to ensure equalization of skin tone of the abdominal-mons aesthetic unit.

Element 8: Customization of the Abdominal Skin Flap (Figure 10)

Skin flap resection as the standard initial maneuver in an abdominoplasty may limit precise evaluation of redundancy. Over-resection of the skin flap may sometimes occur, leading to the adverse effects of excess skin tension and superior scar migration. Thorough flap mobilization, diastasis correction, and flap advancement with Progressive Tension Sutures facilitates a truer assessment of skin laxity and; for that reason, I prefer for this step to precede resection. The flap design can then be shaped along the lower incision for a precise match and tension-free repair.

Element 9: Precise Tissue Transition at Incision (Figure 11A-B)

Soft tissue equalization at the incision line by sub-Scarpa’s fat thinning of either the upper flap or mons, subject to relative thickness, is frequently required to achieve a smooth transition at the incisional repair. A comparatively thicker abdominal flap at the incision may result in an unnatural looking step-off. The fat thickness of the inferior horizontal incision is usually much thinner than the upper flap, requiring sub-Scarpa’s fat resection of the upper flap.  In addition, deep repair of Scarpa’s fascia is performed to reduce the potential for a depressed, contracted scar.

Element 10: Deeply Contoured Umbilicus (Figure 12A-G)

As the initial maneuver, the umbilicus is assessed for an umbilical hernia, which is especially common in the postpartum patient. On occasion an umbilical hernia may be detected intraoperatively when it wasn’t recognized preoperatively. When present, I utilize the subfascial technique described by Bruner et al.8 The umbilical hernia is accessed through a 2-3 cm vertical fascial incision 2 cm inferior to the umbilical base and repaired with 1 or 2 horizontal mattress 2-0 permanent suture. This technique is simple and reliably preserves umbilical blood supply.

When redundant, the umbilical stalk is shortened by direct skin excision to a length of approximately 50% of the skin flap depth. The umbilical skin at the base is then deeply fixated to the rectus fascia with 3-0 PDS at 1, 5, 7 and 11 o’clock to create a stable, vertically-oriented foundation.

After umbilical base fixation, a periumbilical purse string suture of 0 Prolene is utilized to strengthen the weak zone between the upper and lower diastasis repair. This technique also shortens and subtly invaginates the umbilicus and surrounding periumbilical area to assist in deepening the umbilicus.

A generous vertically-oriented fat resection is performed at the umbilicorraphy inset site to replicate the native condition and enhance the appearance of depth.

A deepithelialized vertically-oriented oval, measuring 2 cm x 1.2 cm superiorly and 2 cm x 0.8 cm inferiorly, is created overlying the stabilized umbilicus. An “X” incision is made in the dermis of this oval creating 4 separate dermal flaps (superior, inferior, right lateral and left lateral) that can be utilized to advance the oval deeply to the rectus fascia with long lasting 3-0 PDS sutures. Umbilical length is then reassessed, and shortened if needed to approximate the dermis of the deepithelialized skin edge to the umbilical dermis.

This approach is similar to that described by Pollock and Pollock,9 except that the umbilical skin edge is not included in the suture advancing the abdominal flap to the rectus fascia but approximated independently so that additional redundant umbilical skin can first be resected once accurately assessed as the final manuever. The umbilicus is inset into a vertical oval skin excision, slightly wider superiorly than inferiorly, in the skin flap directly over it. Meticulous dermal edge closure with a subcuticular absorbable suture (5-0 Monocryl) reduces the chance for suture cross hatches. The combination of these independent steps assists in bringing the scar posteriorly toward the base and reduces the potential for widening and/or eversion of the umbilicorraphy (Figure 1A-B).

Results

In my series, 210 consecutive abdominoplasties (207 women, 3 men) during a 27-month period from January 1, 2012 through March 31, 2014 with an average follow up of 7.6 months (range 2-30 months) were retrospectively reviewed.  Age ranged from 26 to 67 with an average age of 41.3. BMI ranged from 19 to 38, with an average of 25.4 (Table 1).

In 83% (174/210) of patients, concomitant liposuction of lateral areas (hips, flanks, thighs) was performed. Because the technique described here requires full abdominal flap mobilization to the costal margin, central liposuction of the abdominal skin flap was not performed in any patient. In addition, 34% (71/210) of patients had adjacent hip/flank skin excision for redundancy or a formal lower body lift procedure. In 30% of patients (63/210) a vertical umbilical defect repair was required to avoid a high horizontal incision. An umbilical float was performed in 2.3% (5/210) of patients.

A major complication rate of 2.3% (5 patients) was seen (Table 2). All 5 patients developed hematomas requiring evacuation under anesthesia in the operating room. An additional patient (0.5%) required evacuation of a small hematoma under local. In our cohort, all 210 abdominoplasty patients were treated with DVT chemoprophylaxis using Xarelto for 5 days post op. Since April 2014, we have switched to Eliquis because of a higher than acceptable post op hematoma rate with Xarelto. There were no occurrences of major flap necrosis (≥ 5 sq cm) while 1.4% (3/210) had minor (< 5 sq cm) ischemic necrosis along the lower abdominal incision line. There were no clinically relevant seromas in our series.

In approximately 8.1% (17/210) of my patient cohort, revision of the lower abdominal horizontal scar, lateral dog ears, and/or vertical scar under local anesthesia to correct contraction/depression, protruberance, or hypertrophy was necessary to optimize aesthetics (Table 3). An additional 4.3% (9/210) of patients required umbilical revision for residual redundant skin, lack of sufficient depth or scar constriction.

In summary, a total of 15.2% (32/210) of patients required a secondary procedure of which 2.3% (5 hematoma evacuations) were performed under general anesthesia and 12.9% (26 scar revisions and 1 hematoma evacuation) were performed under local anesthesia in the office (Table 4).

An unvalidated satisfaction survey request was sent by direct mail and by email through Constant Contact (independent online survey company) to 156 consecutive abdominoplasty patients treated over the 18 month period from October 2012 through March 2014) with a minimum follow up of 6 months. All requests allowed complete anonymity. A total of 139 patients actually received the email request with 17 bouncing back as undeliverable. Of the 139 receiving email requests, a total of 67 patients returned completed questionnaires. An additional 23 patients returned questionnaires by direct mail in self-addressed envelopes. All surveys were tallied by an independent observer. A total of 90 patients completed questionnaires via Constant Contact or direct mail out of a total 156 receiving them (58% response rate). A grading scale of 1-5 ranging from poor to excellent was provided. The survey results are provided in Table 5.

Discussion

Positive advances in aesthetic surgery predominantly focus on transformation that is safe and natural, as it should. The 10 elements described provide a surgical plan that is straightforward to implement and which has achieved predictable and improved aesthetic outcomes for my abdominoplasty patients.

The 10 elements described provide a methodical strategy for most patients, regardless of potentially limiting factors generated by preexisting conditions such as higher or lower than ideal body mass index (BMI) or history of major weight loss.

In my practice over the last 2 decades, abdominoplasty surgery has trended toward lower incisions as a direct result of patient demand. Women are very consistent in their criticism of a scar that cannot be concealed in underwear or a two-piece swimsuit. In my experience, patients overwhelmingly prefer a short vertical closure of the umbilical defect to a high abdominoplasty scar, when given a choice.

While a vertical scar from an umbilical defect repair is not ideal, a high horizontal scar seems to be more unfavorable to women when inadequate upper abdominal skin laxity precludes complete skin flap excision to the umbilicus. In my experience, a vertical scar, in the patient’s mind, is not a definitive characteristic of a “tummy tuck”, and therefore the patient is more comfortable in a 2-piece swimsuit than she would be with a high horizontal scar. Generally, when approximated well, a vertical scar is inconspicuous and less identifiable as a stigmata of abdominoplasty surgery than a high horizontal scar.

In addition, excessive skin flap removal and a high-tension closure has numerous potential disadvantages both clinically and aesthetically.  Vascular compromise can result in skin flap necrosis with the distressing attendant consequences physically and emotionally for both the patient and the surgeon. Many discriminating female patients consider a high scar aesthetically unacceptable because it fails to achieve a common goal to wear a two-piece swimsuit without the obvious stigmata of a “tummy tuck.” Equally disappointing adverse aesthetic consequences of excessive skin flap removal are an unattractive elevation of the pubic hairline and altered genital anatomy. Hypertrophic scarring is also more likely.

So that all elements of this technique can be effectively implemented, a thorough mobilization of the abdominal flap is required (Figure 3). Full flap mobilization facilitates skin tone equalization between the upper and lower abdomen and allows an even, thorough distribution of Anatomy Defining Progressive Tension Sutures. The advantages are:

a)    Uniform skin tone can be restored over the entire abdominal aesthetic unit.

b)    Zones of adherence can be recreated.

c)    Skin advancement will facilitate more accurate skin removal and maintenance of a stable low incision placement by reducing excessive tension at the incision.

Preservation of the superior row of lateral rectus perforators can be accomplished with cautious discontinuous upper flap separation. Exposure of the upper midline over the xiphoid process is necessary to adequately thin the superior origin of the linea alba and taper the diastasis repair to avoid a potential epigastric bulge. In addition, full mobilization facilitates advancement of the upper flap with progressive tension sutures from the costal margin to the lower incision so that an even skin tone of the entire abdominal unit can be established and toned definition of the linea alba and linea semilunaris can be achieved (Figure 13A-F).

Inadequate flap mobilization may result in abdominal unit disharmony, most commonly seen in mini-abdominoplasty surgery. This occurs when there has been excessive lower abdominal skin resection and/or isolated lower diastasis repair without treatment of upper abdominal skin laxity or diastasis, leaving a relative upper abdominal protuberance that appears unnatural (Figure 14A-C). The isolated lower fascial repair focuses tension in an unequal manner on the lower segment of the aesthetic unit, potentially creating an unusual and unattractive convexity of the upper abdomen. In my experience, the resulting abdominal unit disharmony is a common source of patient dissatisfaction. The well-informed potential patient may describe this as a “botched tummy tuck” decreasing their confidence in the procedure when it is recommended. Revision surgery is often required.

Diastasis is an attenuation of the intermuscular raphe with widening of the distance between the rectus abdominus muscles, most often occurring during pregnancy. There are no non-surgical corrective techniques or exercises to correct this. During surgical exposure there is an identifiable defect between the medial edges of the rectus muscles that can be outlined and repaired. Much has been written by Nahas and others about the technical details of diastasis repair.10, 11,12, 13, 14, 15, 16  When overcorrected beyond the medial edge of the rectus muscle, Van Uchelen demonstrated recurrence to be as high as 40%.11 In my experience, when overcorrected, the risk of intra-operative fascial tears and intramuscular hematomas is much higher despite the use of muscular paralytics employed during this portion of the procedure. Postoperatively, when pain, spasm and movement occurs, theoretically there may be an even higher likelihood that fascial tears, bleeding, and separation will result.

In addition, overcorrection beyond the medial rectus, may not accurately recreate the native anatomy as it existed prior to pregnancy. In my opinion, adequately treated diastasis is more likely to restore a more natural state that gives a slight concavity of the upper abdomen and a slight convexity of the lower abdomen represented by a soft lazy ‘S’ on oblique view (Figure 13A-F).

The primary advantage of the Progressive Tension Suture technique as originally described by Pollock and Pollock in 200017 has emphasized the successful reduction in the risk of clinically relevant seromas.  My experience has paralleled that of Pollock and Pollock20 and Antonetti and Antonetti18 regarding seroma formation. There have been no clinically significant fluid collections in the 210 consecutive cases in this cohort. Preventing seroma formation and the potential sequela avoids adverse aesthetic consequences as well.

This technique can also now be utilized to enhance aesthetic outcomes through an anatomy defining application. In its natural state, the 3-dimensional character of the well-toned, attractive abdomen exhibits differential fat thickness along the different zones of the abdominal aesthetic unit.

Once the flap is elevated, the deep sub-Scarpa’s fat is entirely dependent on its vascularity through the sub dermal plexus. Therefore, it is safe to thin sub-Scarpa’s fat in a precise pattern over the linea alba, linea semilunaris and external oblique fascia recreating a more aesthetic 3-dimensional effect that characterizes the youthful, well-toned abdomen (Figure 15A-F). Precise advancement with progressive tension sutures along the zones of adherence of the linea alba and linea semilunaris, as well as over the external oblique, further accentuates definition of these features. The anterior waist is also deepened and the soft contour depression over the external oblique is restored with sequential progressive tension sutures. In addition, strategic advancement of the flap from the costal margin to the inguinal crease and symphysis pubis with progressive tension sutures facilitates restoration of a uniform skin tone over the entire aesthetic unit. By distributing tension over the entire abdominal flap, there theoretically may be less tension at the incision line, thus less tendency toward superior scar migration.

Minor visible indentations of the skin flap created by the sutures will resolve when the sutures are resorbed completely in 4-6 months. The sutures splint the flap precisely along the linea alba, the linea semilunaris, and the lateral skin flap over the external oblique, for a period of 12 weeks or more while the sutures still have their integrity. Theoretically, by eliminating potential space and minor pseudobursa formation from fluid collections, and promoting scar tissue adherence along these anatomical landmarks, a stable and durable effect is achieved with long-lasting absorbable sutures (Figure 13A-F). Among the absorbable suture groups, PDS has the most durable profile, with 50% of its strength still present at 4 weeks and complete resorption not occurring until about 26 weeks. In my experience, progressive suture advancement and stabilization allows a more toned appearance of these anatomical landmarks than is achieved with fat thinning alone. The skin laxity of the upper abdomen can also be worked down with progressive tension sutures to improve the overall consistency of skin tone of the entire aesthetic unit. Furthermore, the lateral flap can be more effectively advanced inferomedially to eliminate lateral redundancy (e.g. dog ears). The overall effect of these independent maneuvers creates a more authentic-appearing abdomen than the one that I could accomplish previously.

It is my observation that the optimal aesthetic three-dimensional effect is realized when the abdominal flap is neither too thick (BMI > 30) nor too thin (BMI < 20). In my experience, an average flap thickness between 1.5 to 4 centimeters (BMI 20-30) provides the ideal situation for optimal application of the elements described (Figure 13A-F) It is “vascular unsafe” to thin the subcutaneous fat superficial to Scarpa’s fascia, thereby, limiting the three-dimensional effect of Anatomy Defining- Progressive Tension Sutures in the heavy patient with a BMI > 30.

In the very thin patient with a BMI < 20, inadequate fat thickness reduces the effectiveness of Anatomy Defining-Progressive Tension Sutures for two reasons. First, fully mobilizing a very thin flap (< 1.5 cm) is a more tenuous proposition to accomplish in a vascular-safe manner. Second, the lack of fat reduces the differential thickness required to create the intended three-dimensional effect with Anatomy Defining-Progressive Tension Sutures.

A redundant, plump mons is a common source of embarrassment (Figure 15A-F). In pregnancy, expansion with skin stretching and hormonal fat accumulation of the mons frequently accompanies the same process that is occurring on the abdomen. In this abominoplasty technique, rejuvenation of the mons is an essential component. Matarrasso19 and others have emphasized mons treatment to complete rejuvenation of the aesthetic unit. This requires attentive treatment of excess fat and redundant skin when present. Skin tone equalization between the abdominal skin flap and the mons also provides a more authentic aesthetic abdominal unit. After elevation of the mons, further excision of hair-bearing pubic skin is frequently required to avoid elevation of the hairline.

Soft tissue closure at the incision is optimal when the transition between the upper flap and the lower incision is smooth, reducing the tendency toward a step-off deformity after healing. This is easily accomplished by equalizing fat thickness wherever needed. Additional sub-Scarpa’s fat thinning of the upper flap and/ or mons prior to closure is usually required to create a smooth soft tissue transition. By equalizing fat thickness and including Scarpa’s fascia in the closure, a more inconspicuous scar is typically achieved.  When the lower abdominal scar is not aesthetically acceptable, a revision can usually be performed in the office under local anesthesia (8.1% in this cohort).

Creating a natural and inconspicuous umbilicus has been one the most challenging aspects of abdominoplasty in my practice. Numerous umbilicorraphy methods have been described over the years with varied effectiveness.20, 21 The central purpose for any technique should be the creation of a natural, inconspicuous umbilicus. To accomplish this, a recreation of the native condition is necessary. In a recent computer analysis of Playboy models, Lee22 demonstrated prevalence of the vertically shaped umbilicus, and concluded that this is an important parameter of the “beautiful umbilicus.” The goal of my technique has been to create a deep vertical oval shape, which coincides with the parameters of the “beautiful umbilicus” described by Lee.

Many post-partal women with diastasis also have an accompanying umbilical hernia. Clinical diagnosis pre-operatively isn’t always successful therefore close inspection intraoperatively is advisable. Failure to repair an inconspicuous and undiagnosed umbilical hernia may become obvious post operatively, and will adversely affect the appearance of depth and possibly require secondary repair. The subfascial repair described by Bruner et al.8 is easy, reliable and preserves native vascularity to the umbilical stalk.

The umbilicorraphy technique described here attempts to recreate the native condition as accurately as possible. Inspection of the umbilical defect beneath the raised abdominal flap demonstrates a striking absence of fat in a spacious, vertically-oriented pattern (Figure 4C). Generous fat removal at the umbilicorraphy site in a matching pattern facilitates a deep umbilical inset. Under-resected fat at the inset site will encroach upon the stalk and limit the desired appearance of depth (Figure 1).

Shortening of the stalk, secure stabilization with durable absorbable sutures (PDS), and advancement of the abdominal dermal X-flaps to the rectus fascia at the umbilical base are also all important steps in the creation of a deep vertical umbilicus (Figure 12A-G). A long umbilical stalk and/or one that is inadequately stabilized may result in redundancy and eversion (Figure 4A).

Despite the details employed in the technique described here, there is still a 4.3% revision rate to improve umbilical aesthetics in my cohort. The thin patient (flap thickness < 1.5 cm) is the most challenging for achieving the deep vertical umbilicus and, therefore, these patients should be advised accordingly.

In my experience, obtaining the most authentic abdominal contour correlates strongly with the preoperative condition when applying these elements.  The heavier patient, especially one with an excessive intra-abdominal fat component, is a particularly challenging endeavor. Critical evaluation and cautious recommendations with appropriate description of expectations is always prudent. For most patients with a BMI less than 35, though, a dramatic authentic effect and significant contour improvement can be achieved with the safe and reliable steps detailed here. All of the elements are applied routinely with each patient, yet variation in the overall achievement in aesthetic goals is more dramatic in those closer to ideal body weight, as one would expect. Nevertheless, a positive aesthetic effect is still consistently seen in all patients under a BMI of 35. (Figures 13-15).

Lockwood, Matarasso, and others have emphasized the importance of rejuvenating the entire torso/thigh aesthetic unit.23, 7 Lockwood unambiguously advised, “Be artistic. Think outside the box….How can we judge our success in body contouring if we don’t look at the entire aesthetic unit?” (23) Harmonized contouring of the body should be considered for every patient who requests or is a candidate for abdominoplasty. In our cohort, 83% had adjacent lateral hip, flank and/or outer thigh liposuction and 34% had some type of skin excision procedure of the hip/flank region. The abdomen is only one component of the thoraco-abdominal-thigh aesthetic unit. Hormonal fat redistribution and skin expansion associated with pregnancy occurs along the lower torso and hip/buttock region as well as the abdomen and mons. Coordinated treatment of adjacent areas will complement and enhance the authenticity of abdominal shaping (Figure 13A-F). Consider the artificial contrast of a well-contoured, toned abdomen adjacent to a thick waistline or a redundant, bulging mons. Such anatomy seldom exists naturally and will likely create annoying clothes fitting issues for women. Consideration of lipocontouring of the flanks and hips, possibly with a lifting procedure of the hips, buttocks and outer thighs and/or fat grafting of the lateral gluteal and gluteal areas is complementary as an adjunct to abdominoplasty in many patients.

Aesthetic results are not effectively analyzed in the typical scientific sense. Patient perception is an important criteria for analysis. The quality of aesthetic results is often measured by patient satisfaction through referrals. A satisfied patient will often say so and refer other patients. An unsatisfied patient will also say so and negatively impact referrals.

A satisfaction survey was sent by direct mail and by email with a request for completion online through Constant Contact, an online survey company (Table 5). Anonymity was ensured for all patients to encourage candor. Nonresponse bias is always a consideration with satisfaction surveys, yet the 58% response rate compares favorably to recent aesthetic surgery surveys published in the Aesthetic Surgery Journal.(23, 25)A standardized validated satisfaction survey for body contouring surgery similar to the Breast-Q for breast surgery would be valuable for future analysis.(26)

In my experience, patients frequently criticize the “unnatural belly-button” and the “surgical, flat as a board” appearance of many tummy tucks they have seen. These are frequently their primary hesitance with the abdominoplasty procedure. One of my objectives has been to create a more authentic-appearing abdomen so that patients would be more satisfied with their results. The survey demonstrated a 97% (81% excellent, 16% good) satisfaction rating to the question: “How natural looking is the appearance of your abdomen?” A slightly less positive response was elicited to the question,“ How would you rate the appearance of your belly-button,” with 87% (59% excellent, 28% good) rating it favorably. I believe that the overall high level of satisfaction with results, reported at 93%,(78% excellent, 15% good) provides support that this objective is being met.

Conclusions

Ten key elements of a well-executed abdominoplasty provide a unified, anatomically accurate recreation of the abdomen. This technique relies heavily on extensive use of Progressive Tension Sutures placed specifically to enhance the native anatomy (Anatomy-Defining Progressive Tension Sutures). The incorporation of these elements 10 years ago has led to a perceptible improvement in the aesthetic quality of my abdominoplasty results. Overall satisfaction was high (93%).  In particular, better anatomical accuracy is supported by the high level of patient satisfaction (97%) regarding the natural appearance of their results, as consistently demonstrated in the patient photos included.