COSMETIC

Tensioned Reverse Abdominoplasty

Mauro F. Deos, M.D.
Ricardo A. Arnt, M.D.
Eduardo I. Gus, M.D.
Porto Alegre, Brazil
Background: Deformities of the upper portion of the abdominal wall can be
difficult to solve, as in many cases abdominoplasties or mini-abdominoplasties
lead to unsatisfactory results. Direct approaches to this region through infra-
mammary incisions can be a good therapeutic option, once adequate patient
selection has been performed and certain surgical principles are followed.
Methods: This technique should be primarily indicated for patients complain-
ing of skin laxity predominantly in the upper abdomen and for patients who will
have such excess after liposuction. In patients who require resection of a large
amount of tissue, a single, broad, U-shaped dissection should be used, associated
with midline fascia plication, when required (group 1). In patients with a smaller
amount of tissue to be resected, two oblique tunnels can be made toward the
navel, with no incision unification at the midline, to provide less evident scars
(group 2).
Results: Eighteen procedures were performed: 12 in group 1 and six in group
2. Patients and surgeons were satisfied with the results. Only minor complica-
tions occurred, and they did not result in definitive sequelae.
Conclusions: The principle of progressive tension suture, previously utilized in
conventional abdominoplasties, is now originally employed in reverse abdomi-
noplasties as a continuous suture, enabling proper flap positioning, keeping the
inframammary sulcus at its original position, and preventing tension on the
resulting scar. Tensioned reverse abdominoplasty is an easily applicable tech-
nique that provides good results and should be considered in cases of abdominal
laxity predominantly in the upper abdomen. (Plast. Reconstr. Surg. 124: 2134,
2009.)

T
he first description of skin and adipose tissue
resection in the upper abdomen was made by
Thorek in 1942.1 However, Rebello and
Franco, in 1977, described and systematized the
approach through the inframammary sulcus for
abdominal plastic surgery.2 After this period, re-
verse abdominoplasty was practically forgotten for
many years, primarily because it was said to pro-
vide poor aesthetic quality in resulting inframam-
mary scars.3
We believe, however, that reverse abdomino-
plasty should be considered a therapeutic option
by plastic surgeons, as it is possible, through in-
From the Mauro Deos–Clı́nica de Cirurgia Plástica.
Received for publication February 7, 2009; revised June 23,
2009.
Presented at the XII Curso Taller Internacional de Avances
en Cirurgia Plástica Estetica y Reconstrutiva, in Mazatlán,
Mexico, February of 2008; IX International Symposium of
Plastic Surgery, in São Paulo, Brazil, March of 2008; and
45th Congresso Brasileiro de Cirurgia Plástica, in Brası́lia,
Brazil, November of 2008.
Copyright ©2009 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181bf8353
framammary incisions, to correct abdominal de-
formities in the supraumbilical portion. We pro-
pose a modification of the original technique,
based on the upper traction of the flap and its
strong fixation to the abdominal aponeurosis, re-
sulting in a tension-free inframammary scar. The
inframammary scar extension and the dissection
amplitude are determined by the intensity of the
supraumbilical deformities.
PATIENTS AND METHODS
Selection of Patients
This technique should be primarily indicated
for patients complaining of skin laxity predomi-
nantly in the upper abdomen and patients who
will have such excess after liposuction.
Patients with previous inframammary scars fa-
vor the indication of this technique, especially if
Disclosure: None of the authors has a financial
interest or commercial association that poses or cre-
ates a conflict of interest in this study.

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Volume 124, Number 6 • Tensioned Reverse Abdominoplasty

the scars are extensive and are unifying or almost abdominal wall. The incision will be limited to the
unifying at the midline. Similarly, breasts with inframammary regions, without unification at the
wide bases, even without previous incisions, favor midline. The dissection will be performed by
the utilization of this technique, as they tend to means of two oblique tunnels toward the umbilical
better hide the scar. This technique can also be scar. The width of each tunnel will be determined
indicated for patients who have undergone ab- by the width of the breasts, and each tunnel joins
dominoplasty in the past and have unsatisfactory the contralateral portion halfway between the
results. The technique is only contraindicated in breasts and the umbilical scar (Fig. 2).
patients with a previous history of keloid or hy- We infiltrate the flap to be dissected with saline
pertrophic scarring, especially in cases that re- solution and adrenalin. In cases of excessive fat, we
quire scar unification at the midline. begin the procedure with liposuction, which can
be limited to the flap region or include the entire
abdominal wall.4 In both groups, dissection is per-
Surgical Technique formed at the anterior aponeurotic plane, result-
Preoperative markings are made with the pa- ing in one or two dermal fat flaps (Fig. 3). If
tient in the orthostatic position by performing
upper traction on the flap toward the breasts
and determining the amount of skin that will be
resected. At this moment, the required exten-
sion of the inframammary scar and the eventual
need to unify the scars at the midline are de-
fined, so that patients can be divided into one of
two groups.
In group 1, larger amounts of skin to be re-
sected require incision unification at the midline.
Regarding the lower extension of the flap dissec-
tion, the limit should be the umbilical scar, with a
single U-shaped tunnel (Fig. 1).
In group 2, the patients have little or moderate
supraumbilical skin laxity and no diastasis of the

Fig. 2. Incision (dotted red line) and dissection (gray area) in a

group 2 patient.

Fig. 1. Incision (dotted red line) and dissection (gray area) in a

group 1 patient. Fig. 3. Traction lines and midline fascia plication markings.

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 Plastic and Reconstructive Surgery • December 2009

indicated, supraumbilical plication of the abdom-

inal midline fascia is performed (Figs. 4 and 5).
After performing the dissection and muscle
plication according to each case, we apply the
principle of progressive and continuous tension
sutures toward the inframammary incision (Fig.
6). We mark the location of traction lines, with
each stitch intended to perform superior traction
on the flap. In group 1 patients, we perform the
upper traction of the flap with three to five lines
of parallel sutures, because the dissections are
wide and the flaps are heavy, requiring strong
fixation. In group 2 patients, two smaller and
lighter flaps are produced and we usually make
two traction lines in each tunnel. Fig. 6. Progressive and continuous tension sutures toward the
For flap fixation and traction, the surgeon or inframammary incision.
the assistant should pull the flap toward the inci-
sion in such a way that each stitch determines a
superior traction of the flap (Fig. 7), as a support-

Fig. 7. Upper traction of the flap for fixation to the

aponeurosis.

Fig. 4. Midline fascia plication, first suture with separated

stitches. ing maneuver for flap progression. The suture
should include the Scarpa fascia, but getting close
to the dermis should be avoided, because external
marks take a long time to solve and can cause
anxiety in patients.
In larger dissections with a single flap (group
1), after flap traction and fixation, the dermal fat
excess is cut in two at the midline and symmetri-
cally resected (Fig. 8). In smaller dissections with
two flaps (group 2), the fixation with superior
oblique traction determines a bilateral dermal-fat
excess, which is resected after precise measurement.
For the production of the new mammary sulcus, we
perform a deep flap fixation, a second plane of sub-
cutaneous sutures, and a third plane of intradermal
sutures. In cases of incision unification at the mid-
line, the scar is M-shaped to reduce risks of hyper-
Fig. 5. Complete midline fascia plication. trophic scars and scar contractures.

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Table 2. Prior and Associated Procedures

Group 1 Group 2
(n ⴝ 12) (n ⴝ 6)
Prior procedures
Reduction mammaplasty 4 1
Liposuction 7 4
Abdominoplasty 4 —
Mini-abdominoplasty 3 1
Augmentation mammaplasty
(prostheses) 1 2
Associated procedures
Reduction mammaplasty 1 —
Mastopexy 1 —
Liposuction 9 5
Mini-abdominoplasty 4 2
Augmentation mammaplasty
(prostheses) 2 3
Augmentation mammaplasty
Fig. 8. Symmetric resection of the dermal-fat excess. (dermal-fat flap) 3 —

RESULTS
ficient dissection of the oblique tunnels. In the
A total of 18 procedures were performed be-
other case, we believe the indication was mis-
tween November of 2005 and December of 2008.
judged, once the skin laxity was moderate to in-
Patients’ demographic characteristics and preg-
tense, and the patient should have been included
nancy history are listed in Table 1, and prior and
in group 1 from the beginning.
associated procedures are shown in Table 2. Al-
There were no keloids or hypertrophic scars.
though most patients were satisfied with the final
Scar widening, which occurred in two cases, was
result (Figs. 9 to 11), some minor complications
not expressive. There was no seroma or vascular
occurred.
impairment of any nature.
In patients requiring incision unification at the
midline (group 1), we had one case of skin redun-
dancy in this region that produced an aesthetically DISCUSSION
unpleasant situation, similar to symmastia. This sit-
The abdominal wall is one of the body regions
uation was due to insufficient skin resection at the
that most frequently present variations due to sev-
midline and was subsequently treated with excision
eral factors, such as inadequate diet, pregnancy,
of the skin excess.
sedentarism, weight loss, and loss of skin elasticity.
One other case resulted in dual unilateral
Solving these deformities is not always easy. Ab-
mammary sulcus (group 1). This situation could
dominoplasties and mini-abdominoplasties, asso-
be understood as asymmetric resection of the der-
ciated or not with liposuction, usually solve most
mal fat excess, resulting in unilateral skin redun-
of these problems. However, skin and/or fat ex-
dancy, or as asymmetric traction sutures, especially
cess, especially in the supraumbilical portion of
at the stitches closer to the new mammary sulcus.
the abdominal wall, remains a challenge to most
In two cases (group 2), there was persistent
plastic surgeons.
upper abdominal laxity as the final result. In one
The reverse abdominoplasty is a technique uti-
case, we attribute the partial resolution to insuf-
lized in an attempt to solve these problems. In
1979, Baroudi et al. published this technique in
Table 1. Demographic Characteristics and association with reduction mammaplasty. The
Pregnancy History authors indicated the procedure for patients
who did not have history of previous conven-
Group 1 Group 2
(n ⴝ 12) (n ⴝ 6) tional abdominoplasty.5
Average (range) Average (range) In a recently published article, Halbesma and
Age, years 45.2 (25–59) 41.8 (28–54) van der Lei concluded that reverse abdomino-
Body mass index, plasty has precise indications, especially in pa-
kg/m2 24.8 (21.7–27.3) 21.6 (20.2–23.1) tients with previous submammary scars and those
No. of pregnancies 1.6 (0–3) 1.8 (1–3)
Surgical time, hours* 3.4 (2.5–4) 2.7 (1.5–4) with persistent redundant tissue after other pro-
Follow-up, months 20.4 (4–36) 16.5 (9–24) cedures for abdominal contour.6 The authors em-
*Including associated procedures. phasize that this technique is safe, presents ac-

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 Plastic and Reconstructive Surgery • December 2009

Fig. 9. Patient undergoing tensioned reverse abdominoplasty, group 1. (Left) Preoperative

views. (Right) Five-month postoperative results.

ceptable complication rates, and usually results in
significant improvements in abdominal contour.
Although the first description of abdominal
flap fixation to the aponeurosis was reported
in 1988 by Baroudi and Ferreira, Harlan and
Todd Pollock proposed progressive traction of
the flap toward the suprapubic region in tradi-
tional abdominoplasties.7–9 They reported a low
rate of complications compared with histori-
cal abdominoplasties that did not apply this
method. They also pointed out that the progres-
sive tension suture performed in abdominoplas-
ties, besides its collaboration in the prevention
of seroma, reduced the risk of skin necrosis and
improved the suprapubic scar quality, as it dis-
tributed tension across the whole abdominal
flap. Since then, several authors have presented
evidences in the literature that confirm these
observations.10 –13
Based on theses principles and in an attempt
to solve the problem of upper abdominal laxity, we
proposed a modification of the tension suture
method— continuous and with guiding lines—
and started to apply it in reverse abdominoplas-

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Fig. 10. Patient undergoing tensioned reverse abdominoplasty, group 1, with resection of
excess skin on the breasts and lower abdomen. (Left) Preoperative views. (Right) Three-month
postoperative results.

ties. We named this method tensioned reverse
abdominoplasty.
Tensioned reverse abdominoplasty is a simple,
fast, and easy technique that can be applied in
association with other procedures, such as mini-
abdominoplasty—in cases of excessive infraum-
bilical skin—and augmentation mammaplasty, ei-
ther with prostheses through the same access
route or retromammary insertion of dermal fat
flaps that would be resected from the most cranial
portion of the abdominal flap.14 Reduction mam-
maplasty can also be performed concomitantly.5
The association with liposuction is possible in
patients with diffuse or localized lipodystrophy of
the abdominal wall, once the principles and care
with the flap proposed in the lipoabdominoplas-
ties are respected.15,16
In most cases, we used the navel as the inferior
limit of dissection. Even so, due to intense upper
traction of the flap, we observed reduced skin

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 Plastic and Reconstructive Surgery • December 2009

Fig. 11. Patient undergoing tensioned reverse abdominoplasty, group 2, with mini-
abdominoplasty. (Left) Preoperative views. (Right) Twenty-two-month postoperative
results.

redundancy in the infraumbilical segment as well.
We verified that in cases in which we planned
concomitant suprapubic skin resections in the
preoperative period, resection was smaller or even
not required at the end of the surgery.
Even though this was not a prospective study,
and thus we did not apply a patient satisfaction
survey or any other kind of rating system, the
postoperative follow-up permitted us to conclude
that both patients and surgeons were satisfied or
absolutely satisfied. There was a low complication
rate, and we attribute the occurrences in our cases
to difficulties inherent to the learning curve, as
they occurred only in the first cases.
Tensioned reverse abdominoplasty offers
good results in the treatment of cases in which
laxity predominates in the supraumbilical por-
tion. It should be noted that in larger dissections

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Volume 124, Number 6 • Tensioned Reverse Abdominoplasty
with scar unification at the midline (group 1),
because of the larger scar extension, we can resect
most of the dermal fat excess with no risk of re-
sidual tissue. However, when performing resec-
tions with limited mammary sulcus incisions
(group 2), many times we needed to associate
tensioned reverse abdominoplasty with mini-ab-
dominoplasty to have results of good aesthetic
quality. In this way, tensioned reverse abdomino-
plasty performs upper traction of the abdominal
wall, and mini-abdominoplasty performs lower
traction toward the pubis.
Although we did not apply it, the inferior dis-
section can be carried further down, releasing the
umbilical scar and enabling plication along the
whole extension of the abdominal midline fascia,
as proposed by Rebello and Franco.2
The continuous sutures make the procedure
easier and faster, but we understand that the tech-
nique can also be performed with separated
stitches without affecting the final result. In cases
of continuous suture lines, they should be per-
formed almost simultaneously, as the progress of
a suture line reduces the space between the apo-
neurosis and the flap, making it harder to deal
with the lateral suture lines.
Adequate reconstruction of the inframam-
mary sulcus is extremely important for the final
result. The incision is sutured in three planes, with
the deeper sutures fixed to the aponeurosis for
better definition of the mammary sulcus position.
When performed as described above, the flap is
fixed to the abdominal wall and does not tend to
displace caudally to its initial position. This pro-
cedure also minimizes the tension on the resulting
scar. We always try to keep the mammary sulcus at
its original position.
Another advantage of the tensioned reverse
abdominoplasty is the possibility of association
with abdominal liposuction, including liposuction
of the dissected flap.4 Moreover, the flap fixation
to the aponeurosis drastically reduces the inci-
dence of seroma, as confirmed by the literature.
The upper traction of the flap shapes the upper
abdomen and distributes its supporting forces
across the abdominal aponeurosis. This principle
reduces tension on the resulting scar, favoring the
scar quality and preventing postoperative displace-
ment of the new mammary sulcus.
CONCLUSIONS
Tensioned reverse abdominoplasty is an easy
technique that can present good aesthetic results
in cases of abdominal laxity predominantly in the
supraumbilical portion. The continuous suture of-
fers reduced surgery duration, and when follow-
ing the premarked lines of suture, it is possible to
determine a better balance in the distribution of
tension forces that act on the flap. This technique
should be considered in cases when conventional
abdominoplasties would not result in an adequate
aesthetic effect and, if carefully indicated, is an
important option among the surgical possibilities
for corrections in the abdominal region.
Mauro Fernando Deos, M.D.
Mauro Deos–Clı́nica de Cirurgia Plástica
Rua 24 de Outubro, 1681/401
Porto Alegre, RS, CEP 90510-003, Brazil
mdeos@terra.com.br
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