During the last decades, multiple studies have been published presenting surgical refinements in abdominoplasty. Several objectives need to be considered, but achievement of a short, hidden scar is a major objective that has rarely been addressed in the literature. We developed a new technique for skin closure in abdominoplasty that addresses two major concerns of this procedure: excessive postoperative scar length and rate of delayed wound healing.
Since the midline in particular displays an alarmingly low rate of perfusion,1 which will result in delayed wound healing or even skin necrosis when subject to tension upon closure, it is evident that a tension-free closure, especially in the midline, is essential for surgical success. Having learned from Lejour,2 we applied principles derived from her experience in vertical mammaplasty and thus were able to easily achieve a tension-free skin closure as well as a short scar postoperatively.
The procedure is routinely performed under general anesthesia. After infiltration of the surgical field with a tumescent anesthetic solution (1 to 2 liters) for reduction of intraoperative blood loss as well as postoperative pain, a modified Regnault incision is made, but it never extends beyond the anterior superior iliac spines laterally. Subsequently, suprafascial dissection is performed up to the xiphoid. A wide anterior abdominal plication is performed whenever indicated.
Tuxedo flaps created during dissection are resected after an inferomedial pull that results not only in a stretch of the anterior abdominal skin vertically but also in considerable lifting of the flanks. However, it will result in dog-ears along the lateral margins provoked by bulging subcutaneous tissue rather than abundant skin. Therefore, cutaneous resection of these dog-ears with resultant rounded skin edges should be extremely conservative, with removal of any residual subcutaneous adipose tissue underneath the lateral dog-ears (Fig. 1). Thus, a full-thickness dog-ear is converted into a small dermoepidermal structure that is subject to significant shrinking.
After reinsertion of the neoumbilicus, the skin is closed in a single running subcuticular layer using 2-0 polypropylene; this is the only way to achieve a continuous “plissé” with the desired distribution of tension (high laterally, low medially). It is essential to avoid beginning at the most lateral point of the incision. Moreover, needle entrance is defined individually after medial pull of lateral tissues. This maneuver allows a more medial needle entrance and results in a considerably shorter scar. Furthermore, needle bites vary while the skin is gathered from lateral to medial. When suturing the lateral third, much bigger needle bites should be taken from the lower wound margin (Fig. 2). This results in some tension along the lateral (well-perfused) flap margin. In addition, by this means, flank contour can be defined very precisely. Moving medially, the incongruent needle bites are reversed.
Performed adequately, this technique will result in a short scar postoperatively as well as allow an absolute tension-free closure in the critical midline, thus reducing the occurrence of delayed wound healing.
Arash Momeni, M.D.
Nestor Torio-Padron, M.D.
Holger Bannasch, M.D.
Jörg Borges, M.D.
G. Björn Stark, M.D.
Department of Plastic and Hand Surgery
University of Freiburg Medical Center
1. Mayr, M., Holm, C., Höfter, E., et al. Effects of aesthetic abdominoplasty on abdominal wall perfusion: A quantitative analysis. Plast. Reconstr. Surg.
114: 1586, 2004.
2. Lejour, M. Vertical mammaplasty and liposuction of the breast. Plast. Reconstr. Surg.
94: 100, 1994.
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