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MINI-ABDOMINOPLASTY

BRUCE A. MAST, MD, AND DENNIS J. HURWITZ, MD

A subset of patients seeking aesthetic correction of abdominal deformities will be aptly treated with
mini-abdominoplasty. Such patients have deformities largely limited to the lower abdomen and have only mild to
moderate excesses of skin and fat. Compared with the full abdominoplasty, the mini-abdominoplasty consists of
fewer incisions, less dissection, tissue resection, musculofascial surgery, and scarring. Accordingly, such patients can
receive excellent surgical correction of their deformity while morbidity is substantially minimized.
Copyright 9 1996 by W.B. Saunders Company
KEY WORDS: infraumbilical, mini-abdominoplasty

Contour irregularities of the abdominal wall result from


a combination of several causative factors, including:
pregnancy, aging, gravity, weight changes, and sequellae
of abdominal operations. 1,2 The resultant irregularities of
the abdominal wall consist of" varying degrees of the
following: excessive adiposity, redundant skin, and laxity
of musculofascial units. 2 Until recently, these problems
were treated uniformly with a complete abdominoplasty.
The entire abdominal wall skin and fat were raised and the
tissue between the pubis and umbilicus was resected. The
remaining skin was redraped over a plicated linea alba.
Translocation of the umbilicus and suction-assisted lipectomy completed the operation. If insufficient lower abdominal skin prevented complete resection, then the infraumbilical flap was closed vertically, leaving a short vertical
midline suprapubic scar. This traditional abdominoplasty
is usually performed under general anesthesia and postoperative pain and discomfort tend to be significant, necessitating I or 2 days of hospitalization. Despite the efficacy of
this operation, it has become clear that a subset of patients
may be treated with a less extensive, but equally effective,
operation: the mini-abdominoplasty.
For some individuals (almost all of these patients are
women), the abdominal wall defect is confined chiefly to
the lower abdomen. Therefore, a mini-abdominoplasty is
the ideal treatment, often combined with liposuction to
reduce residual bulk. These patients tend to have a single
roll of loose skin overlying an abdominal bulge, limited to
the area between the pubis and umbilicus (Fig 1). Miniabdominoplasty can provide these women with excellent
correction of their abdominal deformities with significantly less morbidity than that which is associated with a
full abdominoplasty. This procedure can also provide an
understandable compromise for the patient who is not an

From the Divisions of Plastic and Reconstructive Surgery, University of


Florida, Gainesville, Florida and University of Pittsburgh, Pittsburgh, PA.
Address reprint requests to Bruce A. Mast, MD, Division of Plastic and
Reconstructive Surgery, University of Florida, Health Science Center,
1600 Archer Rd, JHMHC Box 100286, Gainesville, FL 32610-0286.
Copyright 9 1996 by W.B. Saunders Company
1071-0949/96/0301-000855.00/0

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ideal candidate for mini-abdominoplasty, but is unwilling


to put forth the physical and financial outlay required for
the full abdominoplasty.
Contraindications to mini-abdominoplasty are epigastric hernias or laxity, which usually require a full abdominoplasty or endoscopically-assisted abdominoplasty. Likewise, severely excessive skin and/or fat is not adequately
treated by mini-abdominoplasty.

CLINICAL FINDINGS
Ideal candidates for the mini-abdominoplasty are displeased with their lower abdominal bulges, especially
when sitting. Full examination of the patient's abdomen is
done in several positions: sitting, standing, supine, and the
diving position. This provides a full appreciation of the
degree of excessive soft tissue and the extent of musculofascial laxity. The sitting position will show a roll of excessive
flesh that is easy to grasp and particularly unsightly in a
bathing suit, but it's not as noticeable with the patient in a
standing position. The excess tissue confined to the lower
abdomen is confirmed with the patient standing while
downward traction is provided to the abdominal skin,
showing the absence of sufficient laxity above the umbilicus to bridge the gap to the pubis. Additionally, the diving
position allows the loose skin to fall away from the
abdominal wall and provide further assessment. With the
patient supine, bilateral straight leg raising will show the
status of the anterior musculofascial layer. Generalized
weakness should not proceed much above the umbilicus. If
there is much loose skin or muscuolofascial laxity above
the umbilicus, then a full abdominoplasty is needed.

OPERATIVE TECHNIQUE
A mini-abdominoplasty on an ideal patient will be described. The central transverse aspect of the inferior skin
incision is marked at the superior border of the pubic
hairline while the patient is standing. The incision line is
continued laterally in a nearly horizontal sweeping arc.
Alternatively, a "lazy" W incision can be used (Fig 2).
Unlike the full abdominoplasty, in which the incision is

Operative Techniquesin Plastic and Reconstructive Surgery, Vol 3, No 1 (February), 1996: pp 38-41

Fig 1. (A and B) Abdominal wall deformity suitable for


mini-abdominoplasty. There is significant abdominal wall
bulging below the umbilicus with only a moderate amount of
excessive skin and fat. Additionally, the upper abdomen and
flanks are flat with little excessive tissue.

carried to the anterior superior iliac spines, the most lateral


extent of the mini-abdominoplasty incision usually extends no farther than the midclavicular line and must be
equidistant from the midline bilaterally. One may estimate
the amount of tissue to be excised and draw the superior
limb of the incision, or wait until the flap is raised. Thinner
patients and the surgeon's experience will facilitate this
decision. The skin to be excised encompasses about one
third of the vertical height of the skin between the pubis
and umbilicus. Additional markings of excessive adipose
deposits in the regions of the iliac crests, trochanteric
regions, flanks or upper abdomen should be done if

MINI-ABDOMINOPLASTY

suction-assisted lipectomy is to be concomitantly performed (Fig 2).


I usually perform this procedure under local anesthesia
with intravenous sedation and monitoring. Application of
the tumescent technique for liposuction has improved the
local anesthetic effect, as well as hemostasis. If maximal
musculofascial plication is critical, then the procedure is
done under general anesthetic with pharmaceutical paralysis. In recent years, we have initiated the operation with
syringe vacuum liposuction in the regions remote from the
suprapubic skin and fat excision. The smaller diameter (3.0
to 4.6 mm), thin caliber Tulip cannulas (Tulip, San Diego,
CA) are preferred, because when combined with tumescent infiltration, they cause little bleeding and are virtually
atraumatic to the surrounding vasculature perfusing the
remaining tissues. Because the negative pressure within
the syringes would be lost in the open wound, the surgical
incisions are made following liposuction.
The lower incision is created and carried down to the
loose areolar plane just superficial to the anterior rectus
sheath and external oblique fascial aponeuroses. The skin
and subcutaneous tissue is then raised off the abdominal
fascia superiorly and laterally. The superior extent of
mobilization is to the point where the diastasis recti ceases.
Therefore, it is sometimes necessary to perform this dissection to a point 2 to 5 cm above the umbilicus. If this
procedure is necessary, the umbilicus remains attached to
the abdominal skin and abdominal wall, and care must be
exercised around the umbilical stalk to avoid devascularization. Lateral mobilization of the skin unit is carried out to
the anterior axillary lines. This will result in sufficient
anterior retraction of the skin unit such that abdominal
wall plication can be done under direct visualization.
Dissection and retraction of the abdominal skin and
subcutaneous tissue provides direct inspection of the
musculofascial laxity, most often resulting from diastasis
recti. The diastasis in these patients is primarily confined to
the infraumbilical region, with the most pronounced aspect below the level of the arcuate line. Not infrequently,
the diastasis will extend a limited distance above the
umbilicus, where the laxity is much less severe. The goal of
musculofascial plication is to reconstruct the normal anatomic relationships of the abdominal wall musculature, ie,
the rectus muscles should be parallel to each other with a
straight line juxtaposition at the linea alba. Accordingly,
plication is undertaken to remove the resultant bulging
and restore a flat abdominal wall. The plication lines on the
anterior rectus sheaths are marked to guide suture placement; these marks are usually in a crescent shape. Plication
is undertaken with inverted, figure-of-eight sutures, placed
through the anterior rectus sheath. I use 0-Ethibond (Ethicon, Sommerville, NJ), a braided nylon suture, which is
permanent but soft and thereby avoids a palpable suture
line postoperatively. If plication is necessary superior to
the umbilicus, sutures must be placed so as to avoid
strangulation of the umbilical stalk.
Following plication, the excessive skin and subcutaneous tissue, if not already excised, is brought inferiorly to
overlap the lower suprapubic incision and removed. The
deep surface of the superior flap is trimmed to the
approximate thickness of the suprapubic skin. While the

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/
Fig 2. Preoperative markings for mini-abdominoplasty include the suprapubic incision (limited
sweeping arc or lazy W)
and areas to be treated by
suction-assisted lipectomy.

table is partially flexed, Scarpa's fascia is meticulously


closed with an absorbable suture under mild tension. If the
umbilicus is drawn closer than 9 cm to the pubis (this is an
average distance, because individual anatomic proportions
of each patient will determine acceptable downward displacement of the umbilicus), it is translocated to the
appropriate position through a vertical, elliptical, midline
incision. This is usually not necessary. The skin is then
temporarily closed with staples, and final liposuction is
performed. Most areas will be accessible via the lower
abdominal incision, although separate stab incisions for
cannula portals should be used when necessary. One large
closed suction drain, either a Jackson-Pratt (Baxter Healthcare, Deerfield, IL) or Blake (Johnson & Johnson Medical,
Arlington, TX), is then placed and brought out via a
separate stab incision within the mons pubis. An intracuticular monofilament 3-0 pull-out suture is run the full
length of the incision for skin closure. Reston foam with
numerous 2-cm perpendicular slits (3M Medical/Surgical
Division, St Paul, MN) is placed over areas of liposuction.
These slits relieve the occasional shear stress on the
epidermis that causes superficial wounds under the foam.
Wound closure strips are placed over the incision, and
paper tape is applied over a layer of fluffy gauze. An
abdominal binder is securely fitted.

amounts of excessive skin and adiposity, mini-abdominoplasty is successful in providing excellent correction of
their deformities (Figs 3 and 4). It is estimated that
approximately 20% of patients seeking correction of abdominal contour defects are candidates for this procedure. 2,3The advantages of using this procedure rather than

POSTOPERATIVE CARE
Patients are discharged to home following the surgery with
instructions to avoid strenuous activities and heavy lifting.
The drain is usually removed within I week from surgery.
Patients are able to return to full exercise and activities at 6
weeks postoperatively.

DISCUSSION
In selected patients with abdominal wall laxity confined to
lower abdominal bulging and only mild to moderate

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Fig 3. Four-year postoperative result of the patient shown in


Figure 1. The patient was treated with mini-abdominoplasty
without Iiposuction.

BRUCE A. MAST

the patient to remain completely supine or erect following


surgery. This results in less pain and discomfort such that
an overnight, inpatient stay is solely dependent on the
patient's desires, rather than medical necessity. The limited
dissection in mini-abdominoplasty also reduces the risks
of abdominal wound complications and tissue loss. Risks
of postoperative hematoma and seroma are reduced and
suction drains are generally required for a shorter period of
time. Additionally, the umbilicus is usually not translocated, thus avoiding scarring around the umbilicus and
minimizing the risk of ischemic mishap. Indeed, Greminger 3 reported that only 2 complications occurred in 20
patients: minimal tissue loss in a heavy smoker and one
small hematoma. Additionally, the mini-abdominoplasty
minimizes potential adverse aesthetic outcomes that occasionally occur with full abdominoplasty, such as straightening of the waistline, incisional dog-ears and difficulty
concealing scars within swimwear. Nevertheless, potential
suboptimal outcomes in mini-abdominoplasty may occur:
upper abdominal bulging may result with overzealous
musculofascial plication, and a noticeable inferiorly displaced umbilicus may occur.
As with most deformities treated by plastic surgery, it is
important to analyze each deformity based on its various
components and "customize" procedures to each particular patient. The mini-abdominoplasty represents such an
approach. With careful patient selection, a significant
aesthetic deformity can be corrected with minimization of
morbidity and convalescence, while providing the patient
with a high standard of care and a high level of satisfaction.

REFERENCES
Fig 4. Same patient as in Figure 4. Lateral view.

full abdominoplasty in properly selected patients relates


entirely to morbidity. The mini-abdominoplasty uses incisions and dissections that are considerably smaller, while
abdominal skin resection is of lesser quantity permitting

MINI-ABDOMINOPLASTY

1. WilkersonTS, Swartz BE: Individual modificationin body contour


surgery: The "limited" abdominoplasty.Plast Reconstr Surg 77:779783, 1986
2. MatarassoA: Abdominoplasty.ClinPlastSurg 16:289-303, 1989
3. GremingerRF: The mini-abdominoplasty.Plast ReconstrSurg 79:356364, 1987

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