Analysis of Extended Deep Fat Pad Excision in Abdominoplasty

Nunes da Costa, João MD; Matias, Júlio MD

Annals of Plastic Surgery:
doi: 10.1097/SAP.0000000000000791
Aesthetic Surgery

Background: Because abdominoplasty flap’s major vascularization is suprafascial, some surgeons perform excision of the deep fat pad below Scarpa’s fascia to achieve a better abdominal contour and balance the lower abdominal projection above and below the scar. The dimensions of this excised adipose flap and its correlations to both the classic abdominoplasty flap and patient biometrics have not been studied yet and are the aim of this article. Short-term complication outcomes are also reported.

Methods: We performed a prospective case series study, operating 74 consecutive women using an otherwise standard abdominoplasty technique, and recorded patient variables, flap dimensions, and complications.

Results: Average values are as follows: BMI, 27.35 kg/m2; total flap weight, 1868 g; adipose flap weight, 157 g (corresponding to 9% extra flap weight); adipose flap height, 7.2 cm; and preserved infraumbilical deep fat pad thickness, 7.7 mm. Statistical analysis of correlations between variables was performed.

Conclusions: Increased patient weight, umbilical perimeter, BMI, and width of the operative specimen can be used to predict a heavier extra adipose flap. The extra fat excision is safe, preventing inadvertent invasion of the abdominoplasty flap’s suprafascial plane that can happen with liposuction. No flap necroses were observed. The use of this technique may prove useful to achieve a slimmer abdominal contour and harmonize it with the pubic region.

Author Information

From the *Department of Plastic, Reconstructive and Maxillofacial Surgery, Hospital de Egas Moniz–CHLO, Lisbon, Portugal; and †Hospital St. Louis, Lisbon, Portugal.

Received December 8, 2015, and accepted for publication, after revision February 4, 2016.

Conflicts of interest and sources of funding: The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Reprints: João Nunes da Costa, MD, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental Lisboa, Lisboa, Portugal. E-mail:

Ethical Standards: The authors declare that this study was performed complying with the principles outlined in the Declaration of Helsinki of Ethical Principles for Medical Research Involving Human Subjects. All persons gave their informed consent before their inclusion in the study.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Article Outline

Abdominoplasty is one of the most frequent procedures performed by plastic surgeons. Consequently, it comes as no surprise that the amount of techniques and refinements proposed is ever increasing. One of these is the excision of the deep fat pad below Scarpa’s fascia in the abdominoplasty flap. Gradinger et al1 first described this approach in 2005, and Brink et al2 furthered the concept in 2009, proposing a modification of the standard excision pattern, thus removing the deep fat pad under the plane of Scarpa’s fascia in the abdominoplasty flap to achieve a better abdominal contour instead of using superficial and deep plane liposuction according to lipoabdominoplasty principles by Saldanha et al3 or only deep plane liposuction, as reported by Brauman and Capocci.4 Brink et al argued that liposuction has an intrinsic difficulty in differentiating deep from superficial fat because it is performed blindly, endangering the superficial layer, which is where the main vascular supply courses, as proven by the works of Taylor and Daniel,5 Hester et al,6 and Worseg et al.7 Also relevant is the study by Schaverien et al,8 which demonstrated that the suprafascial arterial plexus is responsible for the perfusion of the adipose tissue deep to Scarpa’s fascia.

Because the thickness of the fat below Scarpa's fascia in the bottom third of the abdomen is usually thinner than in the middle third,9 the excision of the deep fat pad in the abdominoplasty flap (which grossly corresponds to the preoperative middle third of the abdomen) may also favorably contribute to reduce the lower abdominal projection in lateral view (Fig. 1).

The use of preserving infraumbilical Scarpa's fascia while raising the abdominoplasty flap is also a matter of discussion, but studies from Le Louarn,10 Saldanha et al,3 and Costa-Ferreira et al11 demonstrated reasonably well that Scarpa’s fascia and deep fat pad preservation is relevant in reducing seroma, total drainage volume, and the number of days with drains. Its vertical suspension can also achieve a mild pubic lift.

What seems to be missing in literature is a study determining the dimensions of the excised adipose flap and its correlations to both the classically excised specimen and the biometrics of the patient. The main objective of our study was to study these characteristics.

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We performed a prospective case series, operating 74 consecutive women using this technique over a period of 21 months, all by the same surgeon. This study complied with the principles outlined in the Declaration of Helsinki of Ethical Principles for Medical Research Involving Human Subjects and adhered to STARD guidelines. All patients gave their written informed consent for surgery. Biometric measurements were taken with the patient standing, during markings, and specimen measurements were performed perioperatively. Patients with morbid obesity with indication for hygienic panniculectomy and those requiring a fleur-de-lis abdominoplasty were excluded from the study, as were male patients, because of a different body fat distribution.

The preoperative markings are the same as those of a standard abdominoplasty. Antibiotics are administered preoperatively and postoperatively (5 days). A wetting solution is infiltrated, 500 to 1000 mL, according to the size of the excised surgical specimen. After skin incisions, dissection is entirely performed using electrocautery. Superficial fat incision and preservation of Scarpa’s fascia begins laterally, where it is easier to identify. Near the midline the fascia is excised full thickness to allow rectus muscle plication down to the pubic symphysis. Above the level of the anterior superior iliac spines, the dissection plane deepens to the muscular aponeurosis, preserving the areolar tissue.

The excised operative specimen is extended superiorly to remove all the deep fat from the abdominoplasty flap, while preserving Scarpa’s fascia (see Video, Supplemental Digital Content 1, which shows the excision of the deep fat pad). The specimen always included the umbilical aperture (Fig. 2). After rectus plication, Scarpa’s fascia is suspended to lift the pubic region (Fig. 3). If the thickness of this fat pad is more than 6 to 8 mm, a conservative liposuction is performed. The distal region of the abdominoplasty flap, where most of the extra fat is removed, will then become the lower third of the abdomen and is superimposed on the preserved infraumbilical Scarpa’s fascia. A moderate amount of flank liposuction was routinely performed.

We do not routinely use low molecular weight heparin, but patients are ordered to get out of bed the next morning. A binder is placed immediately after surgery, and we recommend using it for at least 6 weeks. Drains are usually removed before discharge on the second day (after shower) but only if drainage is less than 30 mL/24 h per reservoir. If drainage persists, they go home with the drains and return after 2 days for observation.

The following variables were measured: age, sex, height, weight, body mass index (BMI), abdominal perimeter at umbilicus, abdominal perimeter at projected scar position, total flap (excised specimen) weight, classic flap (specimen without extended fat excision) weight, total flap width (straight line connecting the lateral ends of specimen), maximum classic flap thickness, adipose flap (extended fat excision specimen) weight, adipose flap height (maximum height, considering the upper skin border as the starting point), deep fat pad thickness at lower abdomen, and days until drainage removal. Complications were also recorded, including hematoma, seroma, flap necrosis (partial or total); umbilical epidermolysis or necrosis; suture dehiscence; and need for reintervention.

Statistical analysis was performed with SPSS 20.0. Pearson product-moment correlation coefficient was used to analyse the correlation between quantitative variables and its strength classified according to Dancey and Reidy categorization. Student t test and 1-way analysis of variance were used when comparing the mean, respectively, of 2 or 3 groups, on dependent and quantitative variables. To examine the independence of qualitative variables, we used the χ2 test. The level of significance was set at α = 0.05.

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The study’s population consisted of 74 consecutive female patients, aged 23 to 63 years, with a mean of 41.8 years. Table 1 shows the results of all measured variables.

The geometric pattern of the adipose flap was varied, with some having a homogeneous distribution throughout their width, others being localized in the medial part (up to xiphoid process), and some with little fat in the central portion (Fig. 4). In only 1 case was there no fat below Scarpa’s fascia amenable to excision, and 3 other patients with total flap weight greater than 2.5 kg had an adipose flap with less than 50 g (which may have been limited by a more conservative dissection).

We identified 3 groups: “massive weight-loss” (MWL) patients (n = 36), defined as having more than 40 kg of weight loss or a reduction of excess weight greater than 50% (most of them after bariatric surgery, weight stabilized for at least 1 year); a group of “obese” patients with BMI of 30 kg/m2 or greater that did not satisfy MWL definitions (n = 12), operated due to extensive abdominal aprons; and finally, a group of “nonobese” patients (BMI, <30 kg/m2), which vastly corresponded to postpregnancy sequelae (n = 26).

The most frequently associated pathology with systemic impact was depression (n = 18), followed by hypertension (n = 7), diabetes mellitus type 2 (n = 6), asthma (n = 5), and hypothyroidism (n = 5). Fifteen patients had smoking habits (20.3%), although most of a few cigarettes per day (6 patients smoked ≥10 cigarettes/day). Patients were asked to stop smoking at least 3 weeks before surgery.

The rate of complications seems to be within the range of what has been reported in other articles. Table 2 summarizes the occurrences. There was one partial umbilical necrosis requiring a small local debridement at the office, but after 2 months, the aesthetic result was normal. There were no necroses, partial or complete, of the abdominal flap, and no reoperation was required for any reason. The global rate of seroma was 14.9%. The “nonobese” group had a seroma rate of 11.5% versus 22.2% in the “massive weight-loss” group, and no seroma occurred in the “obese” group. Within smokers (n = 15), the rate was 20.0%. Seromas were all treated with needle aspiration. The average total volume (including all sessions) of aspirated liquid was 370 mL (n = 11), with a mean of 2.9 sessions of aspiration (range, 1–7 sessions) and 2.6 weeks until seroma production stopped (range, 1–6 weeks). Excluding seroma, all complications occurred within the “MWL” group, except for one umbilical epidermolysis in the “obese” group and the episode of pulmonary embolism (“nonobese”).

With all these measurements, we went on to study possible correlations between variables using Pearson correlation coefficient (Table 3). We verified that the thickness of the preserved deep fat pad increases with BMI and with the umbilical perimeter. The weight of adipose flap removed with the specimen also increases with BMI and with the umbilical perimeter (Fig. 5). It is therefore logical that the adipose flap weight increases with the thickness of the preserved deep fat. The increase in patient weight obviously increases the weight of the total operative specimen and also the extra weight of the adipose flap. The weight of the adipose flap is related to the weight of the total operative specimen, but this correlation is stronger when the total specimen weight is less than 3 kg, probably because of a more conservative approach when treating obese patients, which leads to a reduction in the aggressiveness of dissection. Neither the width of the operative specimen nor patient height was statistically correlated to the adipose flap weight.

Student t test showed that the variation of the weight of the adipose flap is not affected by group (nonobese versus MWL) within the same BMI class, specifically the classes “normal weight” (BMI, <25 kg/m2) and “overweight” (BMI, between 25 and 29.99 kg/m2). However, applying a 1-way analysis of variance with Tukey HSD test resulted in a significant difference between the obese group (average, 248 g) and both the other groups (125 g for the nonobese and 151 g for the MWL), which is expected because the obese subjects are included in a BMI class different from the other 2 groups. Student t test also showed that the difference between groups “nonobese” and “MWL,” when comparing the classic flap’s maximum thickness within the formerly considered BMI groups, was also statistically insignificant.

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We conclude that increased patient weight and umbilical perimeter are the best predictors of a heavier adipose flap. Body mass index and total operative specimen weight, especially in specimens with less than 3 kg, may also help. History of a massive weight loss is not an independent factor in this determination, given the same BMI class, and so it cannot help us predict the size of the adipose flap. The width of the operative specimen and patient height are not useful as well. Approximately 9% more weight of operative specimen can be removed, from an average of 157 g, up to around 500 g. The main vessels for the vascularization of this removed extra fat are in a plane superficial to Scarpa’s fascia, so its excision may even improve perfusion to the remaining tissues. It is also noteworthy that there was no flap necrosis, demonstrating the safety of this additional procedure. In addition, this study’s population included individuals with a significantly high BMI and shows that, given proper care and conservative dissection, this technique can also be applied to them with no increase in the complication rate.

The 2-month follow-up end point may not be long, but it is enough to clearly define the studied early complication rates. Besides the typical redness of the scar still present in many patients at 2 months, we believe that, overall, it is an acceptable length of time to evaluate the results, as most of the edema has reverted, and there are no long-term biases like weight gain or further surgery.

An acceptable seroma rate (14.9%) was achieved, although the “nonobese” showed a lesser rate (11.5%). The removal of drains was as early as 2 days, comparing with other series’ means of 3 to 5 days11,12 up to 14 to 17 days,13 only because the drainage volume was low at that point. The preservation of infraumbilical Scarpa’s fascia and deep fat is likely related to the low drainage registered after 48 hours, although it did not lower the seroma rate as expected. We also acknowledge that there are other techniques that may reduce the total drainage volume and seroma rate, such as quilting sutures or fibrin sealant.

This study measured for the first time the average dimensions of the extended operative specimen’s adipose flap. We believe that the excision of this extra adipose flap may help balance the thickness of the abdominal wall in the lower third of the abdomen, especially in heavier patients where the fat below Scarpa’s fascia is considerable (Figs. 6–8). Thus, we are able to achieve an abdominal contour that looks slimmer and in harmony with the pubic region.

There are now 2 options to remove this adipose tissue: liposuction and direct excision. Both are supported by multiple publications, showing nice results with a good safety record. It can be argued that direct excision of this deep fat has less risk than blind liposuction of the abdominal flap; although in experienced hands, liposuction can be solely and safely performed below Scarpa’s fascia, the average surgeon, during his/her learning curve will most likely, more than once, violate the superficial fat pad with the liposuction cannula because the thickness of the deep fat pad is variable and can be quite thin in some cases. On the other hand, the fact that liposuction preserves abdominal perforators adds to the vascularization of the flap, increasing its safety.

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abdominoplasty; Scarpa's fascia; deep abdominal fat; extended abdominoplasty

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