High-lateral-tension abdominoplasty with superficial fascial system suspension.

Modern abdominoplasty techniques were developed in the 1960s. The advent of liposuction has reduced the need for classic abdominoplasty and allowed more aesthetic sculpting of the entire trunk. However, the combination of significant truncal liposuction and classic abdominoplasty is not recommended due to the increased risk of complications. Although the surgical principles of classic abdominoplasty certainly have stood the test of time, they are based on two theoretical assumptions that may be proved to be inaccurate. The first assumption is that wide direct undermining to costal margins is essential for abdominal flap advancement. In fact, discontinuous undermining allows effective loosening of the abdominal flap while preserving vascular perforators. The second inaccurate assumption is that with aging and weight fluctuations (including pregnancy), abdominal skin relaxation occurs primarily in the vertical direction from the xiphoid to the pubis. This is true in the lower abdomen, but in most patients a strong superficial fascial system adherence to the linea alba in the epigastrium limits vertical descent. Epigastric laxity frequently results from a progressive horizontal loosening due to relaxation of the tissue along the lateral trunk. Experience with the lower-body lift procedure has shown that significant lateral truncal skin resection results in epigastric tightening. In these patients, the ideal abdominoplasty pattern would resect as much or more laterally than centrally, leading to more natural abdominal contours. Fifty patients who underwent high-lateral-tension abdominoplasty with and without significant truncal liposuction and other aesthetic procedures were followed for 4 to 16 months. The primary indication for surgery was moderate to severe laxity of abdominal skin and muscle with or without truncal fat deposits. Complication rates were equal to or less than those of historical controls and did not increase with significant adjunctive liposuction. The key technical elements of this procedure include direct undermining limited to the paramedian area, discontinuous undermining to costal margins and flanks as needed, skin resection pattern with significant lateral resection and highest-tension wound closure placed laterally, superficial fascial system repair with permanent sutures along the entire incision, and liberal use of adjunctive liposuction in the upper abdomen and the lateral and posterior trunk.