Egypt, J. Plast. Reconstr. Surg., Vol. 35, No. 1, January: 133-140, 2011

Bilateral Scarpa’s Advancement Flaps to Improve the Waistline in Abdominoplasty

WAEL M. ELSHAER, M.D.*; SAMEH ELNOAMANI, M.D.** and HOSSAM HOSNI, M.D.** The Department of Plastic and General surgery, Faculty of Medicine, Bani-Suef * and Cairo** Universities.

ABSTRACT better sculpting or to hide the abdominal scar [1] . With the advent and popularity of the liposuction The goal of most abdominoplasty procedures is not only to improve the contour and shape of the , but to procedure and with a better understanding of skin achieve a smooth, flowing, harmonious contour by improving retraction post-liposuction surgery, many of the the overall silhouette and appearance of the region. The waist previously abdominoplasty procedures are now is an area of paramount importance for the feminine figure, treated by the less invasive and more rapid recovery which begins at the level of the lower ribs and ends at the procedure of liposuction surgery. Nevertheless, level of the iliac crest; its narrowest point is approximately 4cm above the navel. The purpose of this study was to report abdominoplasty still holds a very intricate and self- our results on 30 patients who underwent abdominoplasty satisfying place in the world of cosmetic surgery and improvement of the waistline utilizing Scarpa’s fascial [2] . The goal of most abdominoplasty procedures advancement flaps and plication in the midline. is not only to improve the contour and shape of the abdomen, but to achieve a smooth, flowing, Patients and Technique: During a 13-month period from January 2009 to February 2010 we operated on 30 patients. harmonious contour by improving the overall sil- All patients presented for improvement of the abdominal houette and appearance of the region [3] . The waist contour. On examination there was rectus diastasis, excess is an area of paramount importance for the feminine skin and ill-defined waistline. Patients who were smoker, with figure, which begins at the level of the lower ribs uncontrolled diabetes, upper abdominal scars, ventral hernia, and ends at the level of the iliac crest; its narrowest or previous abdominoplasty were excluded from the study. point is approximately 4cm above the navel [4] . Results: 30 female patients from 17 to 37 years of age Although aponeurotic suturing in the midline was (mean 29.6 years), followed-up from 6 to 13 months (mean noted to be able to reduce anterior projection of 9.6 months) postoperatively. No cases of major complications the , it did little to reduce the were reported, while minor complications occurred in four cases. The aesthetic outcome as evaluated by the patients was diameter of the waist. Many authors have proposed good in 27 cases (90%) (Figs. 3,4,5) and fair in 3 patients different techniques to treat the deformity caused (10%), and no bad results. by the laxity of the muscular frame of the abdominal wall [2] , but the plication of the anterior rectus Conclusion: The procedure proved to be safe, with only a few minor complications and no major complications. This sheath is the most popular way to deal with this technique provides a good option for the treatment of abdom- muscular deformity. This procedure was empha- inal contour deformities, in which waistline improvement is sized by Avelar [5] and Bozola and Psillakis [6] . desired. Further comparative studies between this technique Rectus plication and its modifications have become and other traditional abdominoplasty techniques are necessary an integral part of the abdominoplasty operation to evaluate different objective outcomes. in order to narrow the waistline [7] . A row of oblique INTRODUCTION transverse plication [8] and vertically longitudinal plication [9] in the external oblique fascia have Numerous papers and articles have been written been proposed to reduce the waistline. External about different techniques of the abdominoplasty oblique muscle flaps for reinforcement of the procedure and date back from over a century ago. umbilical area have been reported [10] . Dermal Body sculpting and contouring has been a fascina- flaps have also been associated with vertical fascial tion of many cosmetic surgeons. Throughout the plication to improve the waistline [11] . H-shaped past century there have been many surgeons who and fusiform plications were reported to improve have described different procedures to achieve the waistline and to reinforce the musculoapo-

133 134 Vol. 35, No. 1 / Bilateral Scarpa’s Fascia Advancement neurotic system in the upper and lower abdomen after pictures to ensure that they clearly understand [12] and triple plication in mini-abdominoplasty the magnitude of the procedure and the location [13] . However, while this effect on the waistline is of the scars. All patients were followed-up for at clearly visible in the operating room when tying least six months after the operation. Anterior and down the plicating suture, it causes intra-abdominal lateral preoperative and postoperative photographs hypertension known to effect venous return with were taken, with particular attention paid to the a 1.1% risk of deep venous thrombosis [14] . Also waistline in the anterior view and the contour of this may cause a respiratory distress in the postop- the abdomen in the lateral view. Outcome variables erative period [15] . In addition the results of some of interest included complications and subjective studies indicate that stretching of is evaluation of aesthetic outcomes. limited to 2 inches in the majority of cases (82%) and that stretching beyond 2.5 inches occurs only Surgical Technique: in a small number of cases (2%). Therefore the • Preoperative markings: Preoperative markings reliance on linea alba stretching as an indicator of are crucial to successful surgery and to achieve abdominal wall stretching is erroneous and the desired symmetrical results. Patients were marked presence of abdominal laxity and protrusion is not preoperatively in the standing position, and a synonymous with the presence of a diastases of transverse line was made just above the pubic the recti muscles; conversely flat abdomen may hair extending laterally 7 to 9 cm in each direction exhibit significant diastases and may not correlate towards and medially to the anterior superior with the site of the maximal abdominal protrusion iliac spine. The amount of hypogastric skin flap [16] . A very important concept in body contouring excess was estimated by the tension pulling re- was set forth by Lockwood, with his emphasis on quired to approximate it to the inferior margin the superficial fascial system (SFS) [17] . He further of the incision. Another line is traced in the form described a high-lateral tension abdominoplasty of bicycle handlebars to give high lateral tension; which was designed to improve the waistline, while this second line begins and ends at the anterior the wound closure by maximum tension at the level superior iliac spine. of the superficial fascia allowed the skin closure • Upper abdomen liposuction: In all cases, a deep to be performed under minimal tension, which and superficial liposuction of the upper abdomen helps to achieve a fine-line high-quality scar [18] . from the inframammary fold to the umbilicus The superficial fascial system is the connective through an umbilical incision was performed. tissue network that resides below the dermis and The goals were to reduce the volume and to provides the major structural support for the skin mobilize the tissues downwards. However, to and fat of the body and repair of the SFS would preserve vascularization of the flap, wide contin- be expected to diffuse the tension on the skin flap, uous undermining to the costal margin was not lift areas of soft tissue ptosis, and provide long- done, but rather discontinuous tunneling was lasting support [19] . performed. Liposuction was performed following The purpose of this study was to report our the traditional tumescent method, using cannula results on 30 patients who underwent abdomino- 3 and 4mm in size. plasty and improvement of the waistline utilizing • Dermolipectomy: Dermolipectomy incision was Scarpa’s fascial advancement flaps and plication made after the prior markings down to the supra- in the midline. pubic abdominal fascia. Once the Scarpa’s fascia was exposed centrally, the incision was extended PATIENTS AND TECHNIQUE laterally above the fascia. Suprafascial sharp During a 13-month period from January 2009 dissection was then carried out in a cephalic to February 2010 we operated on 30 patients in direction to the region of the umbilicus (Fig. 1a). Bani-Suef University Hospital, Kasr Al-Aini Hos- The umbilicus was circumscribed and left in- pital (Cairo University), and author’s private clinic. situ. Above this level central dissection was All patients presented for improvement of the deepened to the aponeurosis of the rectus muscle abdominal contour. On examination there was creating a tunnel approximately 10cm wide as rectus diastasis, excess skin and ill-defined waist- far as the xyphoid process (Fig. 1b). The rectus line. Patients who were smoker, with uncontrolled muscle diastasis was repaired with continuous diabetes, upper abdominal scars, ventral hernia, non-absorbable suture from above downwards. or previous abdominoplasty were excluded from • Scarpa’s fascia flaps: Lateral flaps from the the study. The details of the operation were ex- Scarpa’s fascia were created by incising the lower plained, and the patients were shown before and border of the fascia at the skin incision level after Egypt, J. Plast. Reconstr. Surg., January 2011 135

separating the fascia from the underlying loose continuous non-absorbable sutures. Overlapping tissues, cutting only the fascial layer to preserve of the fascial flaps was avoided in order not to underlying lymphatic channels. With minimal create supra-pubic bulge (Fig. 2b). After position- undermining of the medial borders of the fascia, ing of the umbilicus and excision of the excess medial advancement of the flaps greatly enhanced skin, closure of the incision was done in two the waistline (Fig. 2a). The Scarpa’s fascia flaps layers. Two closed-system suction drains were were sutured to the underlying with left under the abdominal flaps.

(A) (B) Fig. (1): Intraoperative view. (1-A) Suprafascial sharp dissection carried out in a cephalic direction to the region of the umbilicus. (1-B) Central dissection above the umbilicus deepened to the aponeurosis of the rectus muscle creating a tunnel.

(A) (B) Fig. (2): Intraoperative view. (2-A) Lateral flaps from the Scarpa’s fascia created. (2-B) The Scarpa’s fascia flaps sutured to the underlying rectus sheath without overlap.

RESULTS sleeve gastrectomy and two cases post laparoscopic adjustable gastric banding). The operations were Lipo-abdominoplasty with bilateral Scarpa’s done under general anaesthesia. The results were fascia advancement flaps to improve the waistline evaluated according to the achievement of a nice were performed on 30 female patients from 17 to abdominal contour presenting narrowing of the 37 years of age (mean 29.6 years), followed-up waistline on a scale of good-fair-bad according to from 6 to 13 months (mean 9.6 months) postoper- patient's evaluation. No cases of major complica- atively (Table 1). The etiology of the abdominal tions were reported, while minor complications deformity was as the following: 15 patients due to occurred in four cases. We had two cases of seroma repeated multiple pregnancy; 9 cases due to weight collection after removal of suction drains, both gain; 2 cases due to weight loss; and 4 cases post- cases were treated conservatively by repeated bariatric surgery (two cases post laparoscopic aspiration and compression. The other two cases 136 Vol. 35, No. 1 / Bilateral Scarpa’s Fascia Advancement required scar revision and symmetrization under two of them were post sleeve gastrectomy and they local anaesthesia due to scar widening; one of them experienced rapid weight loss, preoperatively they had a small dog-ear at the end of the scar. All were advised for lower body lift operation but they patients gained improvements in their posture and refused long circumferential scars and asked for how their clothing fit, and they all expressed sat- only abdominoplasty. The third case complained isfaction with the results. The aesthetic outcome of the widening of the scar and a small dog-ear at as evaluated by the patients was good in 27 cases the lateral end of the wound and was treated by (90%) (Figs. 3,4,5) and fair in 3 patients (10%), scar revision and repair of the dog-ear under local with no bad results. The patients with fair results, anaesthesia.

Table (1): Patient data and outcome.

No of Aesthetic Age Sex Aetiology FU period Complications patient outcome 1 33 Female Multiple preg. 12 Good no 2 37 Female Multiple preg. 13 Good no 3 35 Female Weight loss 12 Good no 4 27 Female Weight gain 12 Good no 5 34 Female Multiple preg. 12 Good Seroma 6 33 Female Post bariatric surg. 11 Good no 7 27 Female Post bariatric surg. 11 Good no 8 30 Female Multiple preg. 8 Good no 9 18 Female Weight gain 6 Good no 10 17 Female Weight gain 7 Good Seroma 11 29 Female Multiple preg. 8 Good no 12 28 Female Weight gain 6 Good no 13 32 Female Multiple preg. 6 Good no 14 18 Female Weight gain 12 Good no 15 29 Female Multiple preg. 13 Fair Scar widening & dog-ear 16 27 Female Multiple preg. 10 Good no 17 31 Female Multiple preg. 7 Good no 18 33 Female Multiple preg. 12 Good no 19 37 Female Multiple preg. 13 Good no 20 35 Female Weight loss 12 Good no 21 17 Female Weight gain 12 Good no 22 34 Female Multiple preg. 12 Good no 23 28 Female Post bariatric surg. 11 Fair no 24 34 Female Post bariatric surg. 11 Fair no 25 30 Female Multiple preg. 8 Good no 26 33 Female Weight gain 6 Good no 27 34 Female Weight gain 7 Good Scar widening 28 32 Female Multiple preg. 8 Good no 29 28 Female Weight gain 6 Good no 30 29 Female Multiple preg 6 Good no Egypt, J. Plast. Reconstr. Surg., January 2011 137

(A) (B) Fig. (3): Twenty eight year female, with weight gain. Postoperative anterior view show good results with improved waistline.

(A) (B) Fig. (4): Thirty seven year old female, with multiple pregnancies. Postoperative anterior view showing marked improvement of waistline.

(A) (B) Fig. (5): Thirty three year old female, with weight gain. Postoperative anterior view showing good results. 138 Vol. 35, No. 1 / Bilateral Scarpa’s Fascia Advancement

(A) (B)

Fig. (6): Twenty seven year female, with Post-bariatric weight loss. Postoperative anterior view show good results with improved waistline.

(A) (B)

Fig. (7): Thirty one year female, with multiple pregnancies. Postoperative anterior view show good results.

(A) (B)

Fig. (8): Thirty five year female, with weight loss and previous caesarean section scar with asymmetrical deformity. Postoperative anterior view show good symmetrical results. Egypt, J. Plast. Reconstr. Surg., January 2011 139

DISCUSSION tions for the rectus muscle to improve the waistline depending on the Scarpa’s fascia flap in creation Improvement of the waistline is one of the goals of the waistline. The liposuction in the upper of abdominoplasty. However, its shape depends abdomen was discontinuous to preserve the vascu- on several factors such as, fat deposits, individual larity of the abdominal flap, while the tunnel in abdominal contour, and degree of muscular tension. the midline was made wide enough to allow for The latter is usually affected by pregnancy and is plication of the rectus diastasis. There was two a very common concern [3] . Several techniques of cases of seroma occurred in early cases mostly due muscular reinforcement to achieve a more harmo- to early postoperative removal of the suction drains. nious contour of the anterior abdominal wall have These cases were treated conservatively by aspira- been described [4,20-24] . These procedures are tion and compression and none required surgical basically focused on the tension of the abdominal drainage. There are many factors affecting the end wall; consequently, they may result in some im- scar results, as positioning of the patient, symmetry provement of the waistline [3] . A survey of the of the abdominal deformity, symmetry of dissection literature revealed that little effort has been made and excision. It should be noted that a scar that is to achieve a better waistline with only few apo- perfectly symmetrical in the immediate postoper- neurotic procedures focusing on this specific point ative period may become asymmetrical later on were described. Correction of rectus diastasis is a [21] . Therefore, all our patients were warned that fundamental maneuver to achieve good tension of it may be necessary to perform scar revision after the abdominal wall and is responsible for part of six months. In two cases we had widening of the the waist reduction obtained by the technique scar requiring scar revision under local anaesthesia. described in this study. Furthermore, there was no These occurred because we ignored to reattach the need for wide plication or plication under tension Scarpa’s fascia layer during wound closure. Sub- to avoid increased intra-abdominal pressure, dis- sequently, we closed the Scarpa’s fascia as a sep- ruption of plicating sutures, postoperative pain, or arate layer in all other cases. In 2008, a study done respiratory complications. Appiani [10] and Psillakis on 92 consecutive abdominoplasty patients dem- [25] understood the importance of the external ob- onstrated that the stretching of the linea alba is lique muscle for the cosmetic improvement of the usually limited to a fairly narrow range of 2 to 3 waist, and some researchers studied the technique inches compared with the much wide range of of advancing the external oblique muscles in ca- people’s waist sizes. They concluded that contrary davers. However, no objective studies have been to current theory, the protrusion and stretching of made to clarify the real effectiveness of this tech- the abdominal wall are caused by the stretching of nically demanding maneuver which leads to weak- the entire musculofascial abdominal wall and not ness of the abdominal wall close to the groin region only the linea alba [16] . The high satisfaction rate and undermine the correction of rectus diastasis we have obtained in this study is mostly because [3] . While the Scarpa’s fascia flaps technique adds by the adoption of this technique both component to the correction of rectus diastasis, improving of the abdominal wall were repaired (Figs. 6,7,8). both the muscle and fascial components of the The procedure described was designed to correct abdominal wall without the need of wide dissection the lax abdominal wall musculature, and to tighten or disturbing the musculoaponeurotic system of the superficial fascial system to efficiently improve the abdominal wall. Functionally the Scarpa’s the waistline without disrupting the abdominal fascia plays an important role in the integrity of wall integrity, weakening it, or increasing the risk the skin and support for subcutaneous structure of major complications while effectively reducing [26] and preservation of Scarpa’s fascia during the rate of minor complications. abdominoplasty proved to lower the complications Conclusion: associated with conventional abdominoplasty [27] . Reduction of total drain output, reduction of hos- Use of Scarpa’s fascia flaps during abdomino- pital stay, decrease postoperative cutaneous paras- plasty resulted in improved tension of the entire thesia, preservation of the ilioinguinal nerve, and abdominal wall, enhancement of the waistline, and decrease incidence of seroma from damaged lym- improved uniformity in the contour of the abdomen. phatics are known beneficial effects of preservation These results were maintained during follow up of Scarpa’s fascia during abdominoplasty [24] . In period. The procedure proved to be safe, with only this study, major complications such as deep venous a few minor complications and no major compli- thrombosis, pulmonary embolism, respiratory com- cations. This technique provides a good option for plications, and skin loss were not observed. Mostly, the treatment of abdominal contour deformities, because we did not need to do wide or tight plica- in which waistline improvement is desired. 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