Egypt, J. Plast. Reconstr. Surg., Vol. 35, No. 1, January: 133-140, 2011 Bilateral Scarpa’s Fascia 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 abdomen, 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 abdominal wall, 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 linea alba 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.