Abdominoplasty has long been considered a cosmetic procedure, improving the shape of the abdomen by excess skin removal, liposuction, and rectus muscle plication. Performed chiefly on the postpartum and weight loss population, there have been reports of improvement in the functional symptoms of back pain and incontinence following abdominoplasty with rectus plication, but there has been no prospective multicenter study to investigate the issue.
The incidence of chronic back pain greater than 2 years after pregnancy has been reported to be between 5 and 21.1 percent.1–3 Persistent urinary incontinence rates 10 to 12 years after pregnancy range between 25 and 37.9 percent.4–6 Vaginal delivery is associated with a higher incidence of long-term stress incontinence. The Australian female population is approximately 11 million. Twenty-four percent of Australian women are childless in their lifetime.7 A 20 percent incidence of chronic back pain and a 35 percent incidence of urinary incontinence in the remaining 8.36 million childbearing women would mean that up to 1.67 million Australian women are suffering chronic back pain and 3.2 million are suffering stress incontinence. Both of these conditions negatively affect the quality of life and are usually underreported.
This is a multicenter prospective study on the impact of abdominoplasty on back pain and urinary incontinence in the postpartum population. All postpartum patients presenting for abdominoplasty were enrolled to give an indication of the incidence of symptoms in this population and the magnitude of improvement or deterioration.
PATIENTS AND METHODS
The prospective study used validated questionnaires. For back pain, the Oswestry Disability Index was selected, as it is an excellent measure of a patient’s functional disability and has been in use for nearly 40 years. The Oswestry Disability Index is a multiple-choice questionnaire, divided into 10 sections assessing pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, traveling, and the impact on employment and homemaking.8,9 Each section is scored from 0 to 5; the maximum score is 50. The score is then doubled to become a percentage disability index (Table 1). Urinary incontinence was measured with the International Consultation on Incontinence Questionnaire–Urinary Incontinence–Short Form. This is also a multiple-choice questionnaire asking the patient to score the frequency of urine leakage; how much they think leaks; and, on a scale of 1 to 10, how much it interferes with daily life. It is not a disability index like the Oswestry instrument. A maximum score is 21 with urine leaking all the time, large amounts, and interfering with life a great deal.10
Patients completed the questionnaires before abdominoplasty and at 6 weeks and 6 months postoperatively. The following demographic information was collected: age, parity, age range of children (the years between the oldest and youngest), method of birth (vaginal or cesarean), and body mass index preoperatively. Surgical data were also obtained regarding method of abdominoplasty, weight removed, volume of liposuction, width of diastasis, and the presence of a hernia. No data on postoperative complications or any history of abdominal surgery other than cesarean delivery were collected. Patients signed an informed consent form to participate after reading an information pamphlet, and the study was approved by the Australian Capital Territory Health Human Research Ethics Committee.
A presentation at the 37th Annual Australasian Society of Aesthetic Plastic Surgeons conference in August of 2014 recruited surgeons to the study. Nine surgeons agreed to take part and were given packs of questionnaires, patient information brochures, consent forms, demographic forms, and a surgeon’s information sheet. The nine participants were individual private practitioners, four from Sydney, New South Wales, and one each from Canberra, Australian Capital Territory; Toowoomba, Brisbane, and Gold Coast, Queensland; and Newcastle, New South Wales, a mix of capital city and smaller regional centers along the east coast of Australia.
The objective was to study both the incidence of functional symptoms in the population presenting for abdominoplasty and the outcome. Study surgeons were instructed to enrol all postpartum abdominoplasty patients. Nulliparous weight loss patients were excluded, as were male patients. The completed forms were posted back to the study author, who compiled the results. Statistical analysis was performed by Datalytics (Bruce, Australian Capital Territory, Australia).
The study ran from September of 2014 to March of 2016. There were 230 patient records, but only 214 had a complete data set; thus, 16 patients were excluded.
Demographic data are listed in Table 2. The mean age of the patients was 42.1 years, and the mean parity was 2.5. The mean age range of children was 5.2 years. Sixty percent of births were vaginal and 40 percent were cesarean. The mean body mass index was 26.3 kg/m2.
Method of Abdominoplasty
Methods of abdominoplasty are listed in Table 3. There are very few miniabdominoplasties (3 percent), as patients were generally larger. In this study, a miniabdominoplasty is a short-scar abdominoplasty with either no movement of the umbilicus or a limited “float” of 2 cm. The rectus is plicated fully, from the pubis to the xiphisternum. Thirty-three percent of the patients underwent a radical abdominoplasty. This is defined as full rectus plication and elliptical or handlebar excision of lower abdominal skin from above the umbilicus to the pubis, with umbilical transposition. Forty-four of the 70 radical abdominoplasties (63 percent) had liposuction as part of the procedure. Thirty-four percent of the procedures were Lockwood high-lateral-tension abdominoplasty.11 Thirty percent were high-oblique-tension abdominoplasties,12 which uses a tension vector perpendicular to the high-lateral-tension method.
Surgical statistics in Table 4 show a mean weight removed of 1222 g and a mean liposuction fat volume of 795 ml. Mean diastasis was 4.5 cm measured at the widest point intraoperatively. Sixty-two patients (29 percent) (Table 5) had hernias requiring repair, with nearly all being umbilical. Five patients had more than one hernia.
Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence Scores
Back pain and incontinence scores are summarized in Tables 6 and 7 and displayed in Figures 1 and 2. Before surgery, 8.8 percent (n = 19) of patients had no back pain and 27.5 percent (n = 59) had no urinary incontinence. Although back pain and incontinence were usually present together, they could exist as isolated symptoms.
Postoperative scores were lower than preoperative scores, indicating improvement in functional symptoms. These results were statistically significant at both 6 weeks and 6 months for both the International Consultation on Incontinence Questionnaire–Urinary Incontinence and the Oswestry Disability Index, with p < 0.001 in each case. Six patients (2.8 percent) experienced a rise in their International Consultation on Incontinence Questionnaire–Urinary Incontinence score at 6 months, three patients by 1 point (from 4 to 5, from 7 to 8, and from 15 to 16), one patient by 3 points (from 7 to 10), one patient by 4 points (from 0 to 4), and one patient by 6 points (from 10 to 16). Even though the International Consultation on Incontinence Questionnaire–Urinary Incontinence score increased for the amount of leakage and frequency, the 0 to 10 rating scale as to how much the leakage was an issue was static in one case (10), rose by up to 2 points (6 to 8, 0 to 1, and 1 to 2) in three cases, and fell (3 to 2, and 7 to 3) in the remaining two cases. Likewise, the Oswestry Disability Index also improved for nearly all. Three patients (1.4 percent) recorded higher scores at 6 months, two patients by 1 point and one patient by 6 points. One patient had no change from the preoperative score.
The subjective improvement in urinary incontinence was significant (p < 0.001) in the 0 to 10 rating scale as to how much leaking urine interferes with everyday life. Fifty-nine patients had no incontinence preoperatively; of the remaining 155, 66 scored 5 and over on this scale, indicating that 42.5 percent of patients with incontinence rated it a significant concern. At 6 months postoperatively, only four patients (1.8 percent) scored this scale 5 or higher.
A paired t test shows a statistically significant difference in the mean scores across the follow-up for both back pain and incontinence. The t test looks at each individual patient’s score as a paired value before and after surgery. A negative value represents an improvement in the patient’s condition, the higher the more significant. Back pain improved at 6 weeks (−13.14) and again by 6 months (−19.34). Urinary incontinence improved by 6 weeks (−13.94) if it was going to and then it was static at 6 months (−14.49).
Predictors of Back Pain
Regression analysis was performed on the presurgical back pain score against the independent variables age, age range, parity, method of birth, body mass index, diastasis width, and hernia. The statistically significant independent variables in the forward regression model were body mass index over 25 kg/m2 (p = 0.002) and the presence of an umbilical hernia (p = 0.02). Width of diastasis was not a predictor of back pain. The larger the woman, the higher the initial Oswestry Disability Index score. If a hernia is present, she is also more likely to have back pain.
Predictors of Urinary Incontinence
Regression analysis was performed on the presurgical International Consultation on Incontinence Questionnaire–Urinary Incontinence scores against the independent variables age, age range, parity, method of birth, body mass index, diastasis width, and hernia. The statistically significant variables in the forward regression model were age older than 40 years (p = 0.006) and number of vaginal deliveries (p = 0.044). For each decade of age, the score increased by 1.3. Each vaginal delivery increased the score by 1.26. Width of diastasis was not a predictor of urinary incontinence.
Predictors of Change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence with Patient Demographics
Regression analysis was performed on the change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence postoperatively against the independent variables age, age range, parity, method of birth, and body mass index. None of the variables was statistically significant in the change of Oswestry Disability Index at 6 weeks or 6 months. The variables age range (p = 0.006) and parity (p = 0.043) were significant in the change in International Consultation on Incontinence Questionnaire at 6 weeks and 6 months. Older patients with a larger age range of children do not improve as well as younger patients who have their children closer together.
Change in Oswestry Disability Index Score by Method of Abdominoplasty
There were no statistically significant differences between procedure types at either follow-up when controlling for the presurgical scores.
Change in International Consultation on Incontinence Questionnaire–Urinary Incontinence Score by Method of Abdominoplasty
High-lateral-tension abdominoplasty was associated with a slightly larger score decrease at 6 weeks, but there was no statistically significant difference between procedure types at 6 months.
Change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence by Other Surgical Variables
Regression analysis was performed on the change in Oswestry Disability Index and International Consultation on Incontinence Questionnaire–Urinary Incontinence against the independent variables of surgical center, liposuction volume, and weight removed. None of the variables was statistically significant. Liposuction volume was almost significant (p = 0.06) in predicting the change in Oswestry Disability Index score at 6 months, but the effect size was not clinically relevant. For an additional 2000 ml of aspirate above the mean of 800 ml, the score further improved 1 point. None of the surgical variables was statistically significant for the change in International Consultation on Incontinence Questionnaire–Urinary Incontinence score.
This study has demonstrated a statistically significant improvement in back pain and urinary incontinence at both 6 weeks and 6 months after abdominoplasty with rectus repair in 214 patients. The data were collected prospectively; nine independent surgeons were involved and six different methods of abdominoplasty were used. No single method of abdominoplasty was more effective at 6 months. The patients undergoing abdominoplasty were the whole presenting population, not specially selected back pain patients, nor were the procedures modified for any extra functional benefit. This study is an observation of the functional improvement following abdominoplasty in normal surgical practice.
There have been reports in the literature of improvement of these functional symptoms after abdominoplasty. Many are case reports, detailing a serendipitous improvement in urinary incontinence following abdominoplasty13,14 or retrospective studies. Solanki et al.15 contacted 46 patients after abdominoplasty. Twenty-seven (59 percent) stated they experienced stress incontinence preoperatively and seven of these patients (26 percent) experienced improvements after surgery. The retrospective review by Carruthers et al.16 of 100 patients who had undergone cosmetic abdominoplasty reported 60 percent of patients with improved symptoms. Vaginal delivery was a predictor of improvement. The closing recommendation was for patients undergoing aesthetic abdominoplasty and incontinence surgery to undergo the abdominoplasty first, as separate incontinence surgery may not be required.
There are case reports, too, of improvement in back pain.17,18 Toranto19,20 and Oneal et al.21 demonstrated this best. Toranto developed the wide abdominal rectus plication abdominoplasty with plication of the rectus from lateral border to lateral border so that the abdominal wall is “drum tight.” The skin flap is closed with no tension. Selected back pain patients underwent the procedure with long-term alleviation of pain in 24 of 25 cases. Oneal used the wide abdominal rectus plication abdominoplasty in eight chronic low-back-pain patients successfully up to 11 years postoperatively. Three of these patients had less plication than the full lateral borders and did just as well. There is no mention of urinary incontinence improvement in these studies.
This study has demonstrated a dramatic improvement in functional symptoms following regular abdominoplasty. The questions to ask are, “What is the mechanism by which this change occurs?” and “Why have we not noticed this before?”
We assume that the improvement in back pain is caused by a restoration of the prepartum condition with plication of the diastasis and removal of excessive skin and fat. All patients underwent plication of the rectus anatomically (i.e., to the midline only).
The postpartum decrease in functional capacity is attributable to a reduction in stability. It is the synergistic action of all the trunk muscles that carries load and function through the lumbopelvic region. Apart from low back pain, postpartum patients often struggle with a lack of “core strength,” finding it difficult to stand on one leg or to get up from a supine position on the floor. They also suffer repetitive musculoskeletal injuries stemming from pelvic instability until the integrity of the abdominal canister is restored.22 As the anterior rectus distance is closed, function increases.23–25 The closure of the diastasis restores fascial tension throughout the abdominal canister, in particular, in the transversus abdominis and internal oblique complex. This restores these muscles to their physiologic length and exerts tension on the lumbodorsal fascia, tightening this broad structure and stabilizing the lumbar spine, even in the absence of erector spinae contraction when the body is in flexion.26 Pelvic stability is restored from above, as the lordosis of the spine is the most important parameter controlling the distribution of forces between the fascia and muscles.27 Abdominoplasty with rectus plication improves posture with a retropositioning of the pelvis and a compensatory advancement of the head and shoulders.28 The lordosis is restored to the prepartum condition along with stability.
This effect can be demonstrated in the preabdominoplasty unstable patient by the wearing of a pelvic belt. Back pain improves, as does posture by the application of an external stabilizer.29 Indeed, if the patient does improve with a belt, an abdominoplasty is likely to effect a permanent improvement.20 Other tests that can be used to assess a patient’s suitability include the abdominal compression test, in which abdominal pressure with lumbar stabilization improves pain19 and straight leg raising is improved by holding the rectus muscles together,22 used by the author.
Abdominoplasty also works to increase intraabdominal pressure. An elevation in intraabdominal pressure acts as a stabilizer of the lumbar spine.30–32 When lifting heavy objects, the diaphragm is tensed for greater mechanical advantage. Intraabdominal pressure is raised when the rectus is plicated, but this elevation in pressure has not been measured other than intraoperatively33 or up to 24 hours afterward.34 These studies were performed to aid in risk assessment of pulmonary complications of abdominoplasty, chiefly deep venous thrombosis/pulmonary embolism. It is not known whether the intraabdominal pressure rise is stable or falls over a few days as symptoms of respiratory distress subside.
The mechanism of improvement in urinary symptoms is the subject of several theories. These range from a reduction of anterior abdominal weight14 to increased strength of the anterior abdominal wall leading to more complete bladder emptying.13 These factors no doubt apply, but it seems likely that retensioning in the elevation of the pubis and Scarpa fascia, contiguous with Colles fascia of the urogenital triangle, acts to lengthen the urethra and improve continence.16 This concept of tension distributed throughout the fascial network to effect change at a distant point is central to the tensegrity theory of biomechanics.35
Our study does have recognized flaws. There is no control group; patients acted as their own controls. It is unlikely they would have improved without intervention. There was also no randomization; all patients underwent the operation the surgeon saw fit. This led to a skewing in the method, as three surgeons contributed 83 percent of the data. All three surgeons prefer a cutaneous closure method under tension, be it high-oblique-tension12 (n = 65), high-lateral-tension11 (n = 72), or progressive-tension sutures used in radical abdominoplasty36 (n = 37). Whether this added tightening contributed to the results is difficult to say. One surgeon submitted three patients, only one of which had improvement from radical abdominoplasty. This was hidden in the weight of numbers. Classification of operation method was also an issue. A high-lateral-tension abdominoplasty is well defined and understood, as is high-oblique-tension abdominoplasty, but what constitutes a standard radical abdominoplasty, a miniabdominoplasty, or a lipoabdominoplasty varies from surgeon to surgeon. A miniabdominoplasty is internationally understood to be a subumbilical plication of the rectus with a minimal skin excision and little if any umbilical movement. In this series, the rectus was plicated fully, to the xiphisternum, along with minimal skin excision and little umbilical movement. Eighty-six percent of patients in this study had liposuction along with skin resection. The amount and aim of the liposuction varies from surgeon to surgeon. Initially, lipoabdominoplasty was a category the surgeon could nominate on the surgical demographics form but, because of the difficulty of defining the operation, from between any liposuction performed to liposuction being the main method of reduction,37 the lipoabdominoplasty patients were incorporated into the radical group. Forty-five of the 70 patients (63 percent) therefore had liposuction in the radical abdominoplasty group. The mean body mass index of patients in whom liposuction was not performed was 22.1 kg/m2, compared with the study mean of 26.3 kg/m2. Sixty-six of the 70 patients in the standard radical group (94 percent) had progressive-tension sutures as part of the closure, increasing tension in the superficial fascial system and limiting dead space.
Significantly, only a tiny number suffered a worsening of their symptoms, and even then only minimally. A deterioration in the Oswestry Disability Index score at 6 weeks could be explained by incomplete recovery from the procedure and was not uncommon, but 98.6 percent improved or returned to their presurgery score at the 6-month survey. One patient had a high score of 62 percent disability entering the study; this patient’s score rose to 94 percent at 6 weeks but returned to 62 percent at 6 months. This illustrates the Oswestry Disability Index’s subjective nature. The patient was supposed to be bedridden but had filled out her 6-week form in the surgeon’s rooms. The follow-up is also short at only 6 months, but the group consensus was that symptoms had stabilized by this time and, if anything, tended to improve further by 1 year. The mean Oswestry Disability Index was below 4 percent at 6 months; thus, there was not a lot of improvement expected to be gained by extending the length of the survey. Anecdotally, patients tended to improve even further by 1 year postoperatively, stabilizing with better exercise habits, social and family activity, and the enhanced self-esteem that comes from greater ability. A deterioration in the International Consultation on Incontinence Questionnaire score at 6 months occurred in six patients (2.8 percent) in the study group. Half of these patients had a mild deterioration of a preexisting incontinence, with only one patient becoming incontinent, with a score increase of 0 to 4. Scores improved in 97.2 percent of the study group by fascial stabilization and pubic elevation kinking the urethra. Abdominoplasty may also create an upset in the delicate urodynamic balance, causing deterioration, but only rarely. The study has not given an insight into the duration of symptoms preoperatively. Abdominoplasty with rectus repair improves the pregnancy-related back pain and urinary incontinence by restoring the abdomen to the prepregnancy state but may not be able to correct a prepregnancy back injury or undefined urodynamic issues.
This prospective multicenter study has demonstrated a significant improvement in low back pain and urinary incontinence following abdominoplasty in 214 patients. No method of abdominoplasty was superior in effecting this change. All patients had closure of a rectus diastasis, and most had a cutaneous closure using tension. By restoring prepartum contour, it is also possible to restore prepartum function.
1. Norén L, Ostgaard S, Johansson G, Ostgaard HCLumbar back and posterior pelvic pain during pregnancy: A 3-year follow-up. Eur Spine J. 2002;11:267271.
2. Ostgaard HC, Zetherström G, Roos-Hansson EBack pain in relation to pregnancy: A 6-year follow-up. Spine (Phila Pa 1976) 1997;22:29452950.
3. To WW, Wong MWFactors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand. 2003;82:10861091.
4. Altman D, Ekström A, Gustafsson C, López A, Falconer C, Zetterström JRisk of urinary incontinence after childbirth: A 10-year prospective cohort study. Obstet Gynecol. 2006;108:873878.
5. Viktrup L, Rortveit G, Lose GRisk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstet Gynecol. 2006;108:248254.
6. MacArthur C, Wilson D, Herbison P, et alProlong Study Group. Urinary incontinence persisting after childbirth: Extent, delivery history, and effects in a 12-year longitudinal cohort study. BJOG 2016;123:10221029.
8. Fairbank JC, Pynsent PBThe Oswestry Disability Index. Spine (Phila Pa 1976) 2000;25:29402952; discussion 2952.
9. Davidson M, Keating JLA comparison of five low back disability questionnaires: Reliability and responsiveness. Phys Ther. 2002;82:824.
10. Timmermans L, Falez F, Mélot C, Wespes EValidation of use of the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) for impairment rating: A transversal retrospective study of 120 patients. Neurourol Urodyn. 2013;32:974979.
11. Lockwood THigh-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:603615.
12. Taylor DAZones of adhesion of the abdomen: Implications for abdominoplasty. Aesthet Surg J. 2017;37:190199.
13. Mast BAAlleviation of urinary incontinence after abdominoplasty. Ann Plast Surg. 1999;42:456457.
14. Güneren E, Eroğlu L, Koçak I, Uysal OAUrinary incontinence was improved after abdominoplasty using a very low incision. Plast Reconstr Surg. 1999;104:15821584.
15. Solanki NS, Duffield JA, Dean NR, Morgan RGThe effect of abdominoplasty on urinary incontinence in women. Plast Reconstr Surg. 2010;126:206e209e.
16. Carruthers KH, Kocak E, Hulsen JH, McMahan JDImprovement in stress urinary incontinence after abdominoplasty. Aesthet Surg J. 2014;34:10911098.
17. Gallus KM, Golberg KF, Field RFunctional improvement following diastasis rectus abdominis repair in an active duty navy female. Mil Med. 2016;181:e952e954.
18. Petrakis I, Xenaki S, Andreou A, Panagiotakis G, Chalkiadakis GTherapeutic abdominoplasty: Report of a case. Int J Surg Case Rep. 2015;8C:9699.
19. Toranto IRResolution of back pain with the wide abdominal rectus plication abdominoplasty. Plast Reconstr Surg. 1988;81:777779.
20. Toranto IRThe relief of low back pain with the WARP abdominoplasty: A preliminary report. Plast Reconstr Surg. 1990;85:545555.
21. Oneal RM, Mulka JP, Shapiro P, Hing D, Cavaliere CWide abdominal rectus plication abdominoplasty for the treatment of chronic intractable low back pain. Plast Reconstr Surg. 2011;127:225231.
22. Lee DG, Lee LJ, McLaughlin LStability, continence and breathing: The role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008;12:333348.
23. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu ATThe relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: A 6-month follow-up study. J Orthop Sports Phys Ther. 2011;41:435443.
24. Gilleard WL, Brown JMStructure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther. 1996;76:750762.
25. Gunnarsson U, Stark B, Dahlstrand U, Strigård KCorrelation between abdominal rectus diastasis width and abdominal muscle strength. Dig Surg. 2015;32:112116.
26. Gracovetsky SIs the lumbodorsal fascia necessary? J Bodyw Mov Ther. 2008;12:194197.
27. Gracovetsky SThe Spinal Engine. 1988:New York: Springer; 286308.
28. Mazzocchi M, Dessy LA, Di Ronza S, Iodice P, Saggini R, Scuderi NA study of postural changes after abdominal rectus plication abdominoplasty. Hernia 2014;18:473480.
29. Cholewicki J, Juluru K, Radebold A, Panjabi MM, McGill SMLumbar spine stability can be augmented with an abdominal belt and/or increased intra-abdominal pressure. Eur Spine J. 1999;8:388395.
30. Hodges PW, Eriksson AE, Shirley D, Gandevia SCIntra-abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005;38:18731880.
31. Cholewicki J, Juluru K, McGill SMIntra-abdominal pressure mechanism for stabilizing the lumbar spine. J Biomech. 1999;32:1317.
32. Hodges PW, Cresswell AG, Daggfeldt K, Thorstensson AIn vivo measurement of the effect of intra-abdominal pressure on the human spine. J Biomech. 2001;34:347353.
33. Pereira N, Sciaraffia C, Danilla S, Parada F, Asfora C, Moral CEffects of abdominoplasty on intra-abdominal pressure and pulmonary function. Aesthet Surg J. 2016;36:697702.
34. Talisman R, Kaplan B, Haik J, Aronov S, Shraga A, Orenstein AMeasuring alterations in intra-abdominal pressure during abdominoplasty as a predictive value for possible postoperative complications. Aesthetic Plast Surg. 2002;26:189192.
35. Myers TWAnatomy Trains: Myofascial Meridians for Manual and Movement Therapists. 2009.2nd ed. New York: Churchill Livingstone;
36. Pollock H, Pollock TProgressive tension sutures: A technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105:25832586; discussion 25872588.
37. Saldanha ORLipoabdominoplasty. 2006.Rio de Janeiro: DiLivros;