Obesity Surgery

https://doi.org/10.1007/s11695-019-04367-5

REVIEW

Abdominoplasty: Pitfalls and Prospects

Nayef A. Louri 1 & Hamad M. Ammar 1 & Fatema Abduljabbar Abdulkariml 1 &
Turki Abdulla Sanad Ahmed Eid Alkhaldi 1 & Rashed Noaman AlHasan 1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Abdominoplasty is the cosmetic surgery of the abdomen that typically involves removing excess skin fat and tightening of
abdominal muscles. The procedure is commonly requested to restore pre-pregnancy appearance in women, maintain youthful
physique, and lose weight in obese population. Techniques of modern abdominoplasty surgery have been primarily developed in
the last 40 years concentrating on the skin and subcutaneous tissue, as well as the muscular abdominal wall for maximum esthetic
outcome. Many procedures have been combined and modified to achieve these goals. We present an insight of the development
of abdominoplasty considering the pitfalls and advancements improving patient outcomes. The result of this work will provide a
deeper perspective to the current research around abdominoplasty in healthcare.

Keywords Abdominoplasty . Healthcare . Development . Pitfalls . Prospects

Introduction Classic abdominoplasty is usually associated with compli-

Abdominoplasty is the cosmetic surgery of the abdomen and
involves surplus skin fat removal and abdominal muscle tight-
ening. The history of modern abdominoplasty surgery traces
back to 1960s with the contributions of many surgeons. These
have developed to the current procedures due to advance-
ments in techniques (e.g., muscle treatment, incision design),
changes in population of patients (e.g., massive weight loss),
technology (e.g., liposuction), improved knowledge of anato-
my (flap liposuction and combined procedures), and physiol-
ogy (e.g., wetting solutions).
The procedure is commonly requested for multiple reasons
such as concerns to restore pre-pregnancy appearance in
women, intent to maintain youthful physique in aging popu-
lation, or the pressure to lose weight in obese population. This
can be accomplished through multiple techniques such as li-
posuction alone (type I), limited/mini-abdominoplasty (type
II), modified abdominoplasty (type III), or a full standard
abdominoplasty (type IV), without or with liposuction
(lipoabdominoplasty) of the flap [1–4].
* Nayef A. Louri
bdfburn@gmail.com
1
Burn Unit, Bahrain Defence Force Royal Medical Services Military
Hospital, Riffa, Southern Governorate 28743, Bahrain
cations such as seroma, skin necrosis, wound infections, he-
matoma, and thromboembolism [4, 5]; therefore, develop-
ment of new concepts and advanced technologies is required.
In this review, we present an insight of the pitfalls of
abdominoplasty and the advanced technologies employed to
minimize the complications and improve patient outcomes.
The result of this work will provide a deeper perspective to
the current research around abdominoplasty in healthcare.
Materials and Methods
The methods used for literature search relating to
abdominoplasty surgery stemmed from three sources:
PubMed (1966–2017), Google Scholar, and the World Wide
Web (e.g., blogs, news, and magazine articles), with emphasis
on pitfalls and advancements. The search strategy used the
following key terms: “abdominoplasty,” “surgery,” “compli-
cations,” and “pitfalls,” and “advancements” as main subject
headings or text words in titles and abstracts. The search in-
cluded human studies only. References from the retrieved lit-
erature were also searched, and the relevant papers were fur-
ther analyzed. Thematic analysis was conducted on the re-
trieved papers searching for the pitfalls and advancements in
abdominoplasty. Each article was retrieved, read, and
searched for related results. Any relevant information was

retrieved from the article and placed in a word document, then
analyzed and relevant themes were identified.
Results
Pitfalls
The techniques of modern abdominoplasty surgery have been
mostly developed in the last 40 years concentrating on the skin
and subcutaneous tissue, as well as the muscular abdominal
w a l l f o r m a x i m u m e s t h e t i c o u t c o m e . H o w e v e r,
abdominoplasty has been associated with a risk of complica-
tions which ultimately affects the patient outcomes.
Seroma formation is a major problem, but its exact causes
are still not known. Marsh et al. reported a study of 102 pa-
tients who underwent abdominoplasty, and the seroma rate
was found to be 18.6% [6]. The study compared the use of
handheld electrocautery and scalpel, both of which are con-
sidered a probable factor for seroma formation, and no signif-
icant differences were observed between the two groups.
However, a direct relationship between the risk of seroma
and adjuvant liposuction was suggested. Another study by
Smith et al. presented a case of seroma formation post-
abdominoplasty due to the use of continuous infusion local
anesthetic pain pump [7]. The occurrence and progression of
seroma have also been liked with the day of post-operation as
well as the location. Martino et al. reported a study of 21
patients who underwent abdominoplasty in five regions of
the abdominal wall (right iliac fossa, left iliac fossa, epigastric,
umbilical, and hypogastric) [8]. The study highlighted that
iliac fossae were the most common site of seroma formation
and that the incidence of seroma formation was highest at
postoperative day 11 (38.1%). To reduce the risk of seroma,
several strategies have been recommended, such as raising the
abdominal flap and retaining the scarpa fascia connected to
the external oblique muscle fascia and the rectus abdominis,
thereby promoting drain removal and up to 86% reduction in
seroma cases. Alternatively, the accumulation of liquid could
be reduced by collapsing the space between scarpa fascia and
the rectus abdominis and external oblique muscle fascia [5].
Progressive tension sutures and fibrin sealants have been com-
monly utilized to reduce the incidence of sarcoma post
abdominoplasty [9–11]. Adhesion and traction sutures, de-
scribed by Baroudi and Ferreira [12, 13] and Pollock and
Pollock [14], respectively, have also been reported to reduce
seroma. Jabbour et al. reviewed seven studies and concluded
that the addition of progressive tension sutures to drains sig-
nificantly reduced the risk for seroma in standard
abdominoplasty [10]. Lee et al. evaluated the efficacy of fibrin
sealant in 65 patients who underwent post-bariatric
abdominoplasty [11]. The study reported seroma development
in 9.1% patients who received fibrin sealant as compared to
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28.1% patients who did not receive it. Another study, by
Pilone et al. studied 30 patients who significantly lost weight
post laparoscopic adjustable gastric banding followed by cir-
cular lipo-abdominoplasty. Fibrin glue with a low thrombin
concentration was found to significantly reduce seroma for-
mation in the patients [15]. However, more studies with larger
patient population are required to validate these results.
Wound infections at the operative site are another very
common complication associated with abdominoplasty.
These can be caused by several bacterial species, such as
Staphylococcus epidermidis, Streptococcus aureus,
S. pyogenes, Enterococcus faecalis, and Escherichia coli [5].
Sharma et al. presented the case of a 34-year-old female who
underwent abdominoplasty overseas [16]. The patient devel-
oped infection with rapidly growing mycobacteria (RGM),
resulting in multiple abdominal wall abscesses, which was
treated with surgical drainage and antibiotic treatment. Also,
other factors such as tobacco consumption have been known
to influence the occurrence of wound infections. Araco et al.
published a study of 84 patients and found postoperative in-
fections in 13, of which 12 smoked cigarettes, and thus sug-
gested smoking as a major factor which should be addressed
preoperatively [17]. Nevertheless, antibiotics treatment is usu-
ally employed to treat infections, and depending on the pa-
tient’s response, surgical debridement is followed. Cases of
infection-associated shock, necrotizing fasciitis, and sepsis
have been rarely published [5].
Skin necrosis is another complication that can occur post
abdominoplasty. Necrosis can occur due to inadequate perfo-
rating vessels. The risk factors include tobacco consumption
and coperforming abdominoplasty and other esthetic opera-
tions [5]. Lopez presented the case study of a 62-year-old
female who underwent modified avelar abdominoplasty and
developed skin necrosis [18]; however, it was successfully
treated with Erchonia EML 635 nm Laser and Platelet-Rich
Plasma-based treatment. For improved healing, various thera-
pies have been suggested such as using hyperbaric oxygena-
tion, which promotes oxygen availability, neovascularization,
stem cell mobilization to the area of injury, and production of
collagen [5].
Abdominoplasty is also known to cause hematoma in some
patients, and the reported cases mostly range between 1 and
10% [19–21]. It can be asymptomatic if small in volume but
can result in localized pain and swelling if large, which can
sometimes lead to hemodynamic instability and hypovolemic
shock [22]. Chronic expanding hematoma is a rare complica-
tion associated with abdominoplasty. Tatsuta and Morioka
reported the case of a 58-year-old female who underwent
abdominoplasty and developed chronic expanding hematoma
1-month post-surgery [23]. The treatment strategies rely on
the bleeding symptoms, volume of hematoma, etc. [5].
Venous thromboembolism (VTE), comprising pulmonary
embolism (PE) and deep vein thrombosis (DVT), is a fatal
OBES SURG
complication associated with abdominoplasty; however, it has
not been well addressed. Staalesen et al. reported 2–8% inci-
dences of abdominoplasty-associated VTE [24]. In another
study, Hatef et al. reported VTE in 4.65% cases, where single
abdominoplasty was performed [25]. Pancholi and Cuzalina
reported a retrospective study of 267 patients who underwent
abdominoplasty [26], with or without additional cosmetic pro-
cedures. The authors presented 1.5% and 0% cases with
abdominoplasty-specific DVT and PE.
Due to lack of sufficient information, there is a strong need
to develop suitable guidelines and measures to prevent throm-
boembolism in patients undergoing abdominoplasty. In a
study of 253 patients, Marangi et al. reported a
thromboprophylaxis protocol comprising pre-, intra-, and
postoperative measures. DVT was observed in 2 cases, where-
as PE was observed in none of the cases [27]. Thus, the com-
prehensive prophylaxis protocol followed in the study was
found effective in decreasing the number of
abdominoplasty-associated VTE cases.
Prospects
The advent of new concepts in abdominoplasty is based on
creating a balance in eliminating the vertical excess, reducing
the scar width, creating proper mons pubis contour, removing
umbilical defect, and positioning the umbilicus. Several pro-
cedures have been combined and modified to achieve many of
these goals [28].
The technique of liposuction has revolutionarily improved
the treatment of trunk and extremities-associated deformities.
Combining abdominoplasty and liposuction has been reported
to significantly reduce the risk of overall complications and
seroma [29]. Derrick et al. presented the case of a 12-year-old
patient who underwent liposuction, followed by breast aug-
mentation, brachioplasty, abdominoplasty, and thigh lift [30].
The treatment was successful and it enhanced self-confidence
in the patient.
Robotic surgery has been applied in many fields of
healthcare such as general surgery, urology, gynecology, heart
surgery, and neurosurgery. Correa introduced the application
of a robotic system, da Vinci Surgical System, for mini-
abdominoplasty and reported successful results in five cases
[31]. Patient BMI between 18 to 23, skin elasticity, and ab-
sence of redundant skin were found to give the best results.
The application of robotic surgery in abdominoplasty has sig-
nificant advantage over the conventional endoscopic methods
as it provides a high-definition 3D view and image
amplification.
The concepts of abdominoplasty have also been employed
for correcting the unaesthetic deformities on the medial thigh.
Surgical procedures for both regions are similar due to the
same abnormalities in the inner thigh and abdominal wall such
as localized adiposities, excess skin, cutaneous fold, and
cutaneous flaccidity. However, studies have reported minor
wound healing problems associated with the technique [32].
Flanklipoplasty and torsolipoplasty are employed for the
unaesthetic and surgical correction of the flanks and posterior
torso regions. Both these segments are important for the es-
thetic appearance of body contour. The technique has been
challenging for plastic surgeons for several years. This surgery
could be performed at two levels: (a) on the full thickness of
panniculus, where skin resection is performed preserving the
perforator vessels, and (b) under panniculus fascia
superficialis, where resection of the skin is not achieved, thus
not damaging perforator vessels [28].
New concepts in abdominoplasty have also been applied in
the correction of severe deformities on buttocks such as flabby
or ptotic buttocks. The surgery involves full-thickness lipo-
suction of the skin resection area, deep tunnelization of rest
of the panniculus, full-thickness resection of the skin, no
undermining of panniculus, and finally, the panniculus is su-
tured. A study by Muresan et al. reported a case of 9 patients
who underwent dual torsoplasty or abdominoplasty and
dermal-fat graft augmentation gluteoplasty [33]. The patients
were successfully operated, and the technique has enormous
potential as it is being explored. Similar results have been
reported by Colebunders and Landuyt [34]. Thus, results on
final appearance are satisfactory as the patient selection, sur-
gical demarcations, and the operations are efficiently
performed.
Dorsolipoabdominoplasty is another advanced procedure,
which comprises a combination of lipoplasty on the torso and
lipoabdominoplasty for improving the body contour. A surgi-
cal tunnel is made from the navel to the pubic xiphoid process
for the plication of rectus abdominis. Final results of the sur-
gery are outstanding with fine surgical scars [28].
Vertical abdominoplasty has been widely used for
correcting unsightly scars or large hernias. Traditional
abdominoplasty is not efficient in cases requiring correction
of the extreme sagging in the abdomen of emaciated patients
as skin resection is required vertically also for better body.
Advancements in vertical techniques have proven to be an
efficient alternative for treating the excess skin and subcuta-
neous tissue after immense weight loss in patients.
Nevertheless, low-risk complications have been reported
[28, 35].
Discussion and Conclusion
Abdominoplasty surgery is considered a safe and effec-
tive procedure for correcting body contour, which is oth-
erwise not feasible by diet or exercise. Surgery of the
abdominal wall for esthetic and functional improvement
has gained popularity, especially when it is changed by
pregnancies, excess weight, aging, or due to previous

surgeries. Furthermore, the therapeutic application of
abdominoplasty has also been reported, wherein wide ab-
dominal rectus plication abdominoplasty has been suc-
cessfully performed for improvement in major health
problems such as back pain, urinary incontinence, and
neuro-myodystrophy [36]. Nevertheless, when compared
with other surgical procedures, abdominoplasty displays
higher complication rates [37]. Previous studies have re-
ported a complication rate as much as 4% in patients who
underwent abdominoplasties as compared to 1.4% in oth-
er esthetic surgeries [37]. The complications include he-
matomas, wound infections, thromboembolism, seroma,
delayed wound healing, hematoma, postoperative bleed-
ing, umbilical necrosis, infected seroma, and wound in-
fection [37, 38]. Several complications following laparo-
scopic adjustable gastric band (LAGB) abdominoplasty
have also been reported in the literature, including both
minor (port leak, port displacement, minor port infection,
pouch enlargement) and major (band slip, band erosion,
late port or band infection, intra-abdominal abscess) com-
plications, thus requiring careful assessment and appro-
priate management for improved outcomes [39].
Sometimes, complications are not immediately seen after
the surgery, and delayed complications post abdominoplasty
have been reported. Georgiou et al. presented the case of a
patient with insidious subcutaneous abscess 10 years post
abdominoplasty [40]. Thus, quiescent infections can also pos-
sibly exist after abdominoplasty, especially skin flip elevation.
The risk of developing abdominoplasty-associated
complications is linked to multiple factors such as male
sex, old age, high BMI, smoking, and multiple procedures
[37, 41]. A study by Modarressi et al. evaluated the risk
of circular abdominoplasty following massive weight loss.
An overall complication rate of 23.2%, which comprised
mostly minor events, except one (1.7%), thus suggesting
circular abdominoplasty a safe technique when key fac-
tors such as selection of patients (e.g., BMI < 30 kg/m2),
precise planning, and surgical procedure are ensured [42].
Rosa et al. published a study of 139 patients who
underwent abdominoplasty combined with mammoplasty,
rhytidoplasty, brachioplasty, and herniorrhaphy (42.46%,
17.27%, 13.67%, 13.08%, respectively), of which 26.65%
cases displayed postoperative complications [43]. Thus,
careful assessment of the risk factors is required prior to
the surgery to minimize complications. Risk calculators
are a novel tool for accurate and personalized assessment
of abdominoplasty-associated risks. Vu et al. developed
such a risk calculator to predict complications 30-days
post abdominoplasty [44]. The authors internally validat-
ed the tool and suggested it as a means to improve deci-
sion making between the patient and surgeon.
The development of abdominoplasty surgery has been driv-
en by the need to improve patient outcomes. Warner and
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Gutowski described the progressive tension suture technique
to prevent post abdominoplasty complications such as skin ne-
crosis and seroma [45]. Similarly, Xiao and Ye reported a com-
prehensive analysis of the safety and efficacy of scarpa fascia
preservation to improve patient outcomes [46]. The study re-
ported a significant decrease in seroma; however, hematoma
and infection did not change significantly. Nevertheless, the
study recommended use of scarpa fascia during
abdominoplasty. Furthermore, Pilone et al. compared the effi-
cacy of synthetic glue and energy device over standard proce-
dure in patients undergoing post-bariatric abdominoplasty. The
study reported improved patient outcomes with both synthetic
glue and energy device, with reduced bleeding and seroma with
synthetic glue and improved hemostasis and shortened opera-
tive time with the energy device [47]. Another study by
Giordano et al. employed a novel energy device, LigaSure
Impact™ vessel-sealing system, in abdominoplasty procedure
in patients with massive weight loss. The device was found to
improve patient outcomes by reducing blood loss and compli-
cations and the need for re-operations [48].
Increasing demand for scarless treatment of small to
medium-sized abnormal deformities has been met by robot-
assisted procedures for muscle aponeurotic abdominal wall
plication [7].
Thus, despite the risk of complications, abdominoplasty
has been shown to improve the quality of life in people [49].
Although we do not completely disregard the potential com-
plications of abdominoplasty in healthcare, we believe that
both the risks and benefits of abdominoplasty surgery must
be considered while deciding for the procedure.
We included a comprehensive survey of literature; howev-
er, some sources may have been missed and not included in
the study. Future studies should examine the possible effect of
abdominoplasty surgery by providing more research evidence
on the impacts abdominoplasty can have on overall patient
health and quality of life.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.
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