→ Reference [[Abdominal Wall Anatomy]] ## Contraindications #### Absolute - Body dysmorphic disorder, unrealistic expectations, or significant health risks that prevent safe surgery #### Relative - Previous abdominal scarring, especially subcostal scars (compromises blood supply to abdominoplasty flap) - Major comorbidities: heart disease, uncontrolled diabetes, BMI >40, active smoking - Planned future pregnancy - History of thromboembolism - Tendency for keloid/hypertrophic scarring - Elevated intra-abdominal pressure (abdomen rises above costal margin-iliac crest line when supine) #### Special Considerations - Massive weight loss patients typically require circumferential procedures rather than abdominoplasty alone - Deformities in adjacent areas may affect aesthetic outcomes - Non-scaphoid abdomen requires careful consideration for rectus plication # Traditional Abdominoplasty Technique #### Preoperative Planning - Have patient wear preferred undergarments for optimal incision planning - Identify and mark: 1. Pubic bone and anterior superior iliac crest 2. Transverse incision at pubic bone level (maintain 5 cm from vulvar commissure) 3. Lateral extension below ASIS 4. Lateral abdominal folds with patient standing 5. Areas for concomitant liposuction - Perform pinch test to determine resection extent #### Surgical Procedure 1. **Umbilical Management** - Place two traction sutures 180° apart for orientation - Circumferentially incise and dissect umbilicus to rectus sheath - Preserve small fat cuff around umbilical stalk to maintain vascularity 2. **Initial Dissection** - Make bilateral inferior incisions through Scarpa's fascia - Elevate skin/fat from underlying fascia to costal margins and xiphoid - Perform limited undermining from umbilicus to xiphoid 3. **Rectus Muscle Repair** - Mark elliptical area on rectus sheath with methylene blue - Place interrupted sutures along elliptical borders - Add reinforcing sutures from xiphoid to umbilicus and umbilicus to pubis - Use horizontal plication sutures if needed - Begin plication at xiphoid level to prevent epigastric bulge 4. **Flap Management and Closure** 1. Position bed in beach chair with hips flexed 30° 2. Mark tension-free closure 3. Resect excess skin and fat 4. Irrigate wound copiously 5. Place surgical drains through lateral incisions if needed 6. Apply [[Progressive Tension Sutures (PTS) Technique]] (2-0 Vicryl) to secure flap 7. Transpose and inset umbilicus 8. Close Scarpa's fascia with interrupted sutures 9. Close deep dermal and subcuticular layers 10. Apply surgical cyanoacrylate glue if desired (allow proper drying time) 11. Place gauze dressing with abdominal binder ![[Pasted image 20250114212241.png]] ### Critical Safety Tips - Preserve periumbilical perforators during central dissection - Maintain fat pad over ASIS to protect lateral femoral cutaneous nerve (prevents meralgia paresthetica) - Advance flaps medially to avoid "dog-ears" - Consider extending scar laterally if needed for optimal contour