My Way Abdominoplasty with Scarpa s Fascia Advancement Flap to Enhance the Waistline Aesthetic Surgery Journal 2016, Vol 36(7) 852 857 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com DOI: 10.1093/asj/sjv254 www.aestheticsurgeryjournal.com David Whiteman, MD; and Gabriele C. Miotto, MD Accepted for publication November 19, 2015; online publish-ahead-of-print March 15, 2016. Abdominoplasty for body contouring has evolved from focusing primarily on modification of the skin flap and underlying rectus diastasis repair, to the association of liposuction and limited undermining techniques. While plication of the midline diastasis reliably improves anterior posterior dimensions, it has a more limited effect on the waist contour. Nahas suggested that increasing the width of the plication of the anterior rectus sheath may be responsible for displacement of the contours of the abdomen, yielding unnatural results. 1 In an attempt to achieve reliable waist modification, different techniques have been published. L-shaped external oblique muscle plication, multidirectional abdominal wall plication, and advancement of the external oblique muscle flaps have been described. 2 Plication of the external obliques demonstrates limited mobility and the creation of widely undermined external oblique flaps is typically beyond the scope of the standard outpatient procedure. It has been suggested that the preservation of Scarpa s fascia during abdominoplasty may lead to a decrease in postoperative complications. 3,4 Friedman et al suggested that up to 17% of the lymphatic drainage of the abdominal wall is maintained if dissection is performed above Scarpa s fascia. 5 The use of Scarpa s fascia to enhance the waist line definition during abdominoplasty has been limited. Mossaad et al used a medial directional pull on Scarpa s fascia in an effort to define the waistline as a modification of the lipoabdominoplasty technique described by Saldanha et al. 6-9 Mossaad s technique removes a full thickness midline strip of subcutaneous tissue below the umbilicus down to the rectus sheath, extending approximately 4 cm lateral to the midline on each side. Tissue advancement was achieved only through lipo-mobilization using standard liposuction techniques with o undermining above the umbilicus other than the midline. Mallucci presented a refinement to traditional abdominoplasty using a superficial fascial glide technique. In this technique, a full thickness abdominoplasty flap is elevated. 10 During the excision of skin excess, a flap of superficial fascia 3 cm distal to the skin is created and pulled in an oblique direction towards the midline while the abdominal skin is pulled downward. This is not a technique in which there is maintenance of the continuity of Scarpa s fascia lymphatic system. This paper presents the use of bilateral infero-medially directed Scarpa s fascia advancement flaps as an adjunct to waistline definition during traditional abdominoplasty, miniabdominoplasties, as well as the Saldanha lipoabdominoplasty technique. The Scarpa s fascia advancement flaps can be easily performed and supplements the effect of liposuction in the waistline. It also modifies the waistline in the thin patient where liposuction is not indicated. Since the description of the superficial fascial system of the upper trunk by Lockwood it is known that interconnecting fibrous septa run from the dermal layer in multiple directions to the Scarpa s fascia. 11 Those strong interconnections allow for pulling forces to be translated to the skin when tension is placed on the fascia flaps, even after liposuction. The Scarpa s fascia flaps work in a similar way in which the SMAS flaps in facelifts can be used to carry the skin flap. As in the facelift, the fascia and the skin do not have to move in the same vector and can be modified for different aesthetic goals. In both cases, the flaps are substantial and can bear tension. Dr Whiteman is the Chairman of Surgical Services, Gwinnett Medical Center, Duluth, GA. Dr Miotto is an Intern, Department of Surgery, Emory University School of Medicine, Atlanta, GA. Corresponding Author: Dr Gabriele C. Miotto, 1065 Peachtree Street Northeast, #3705, Atlanta, GA 30309, USA. E-mail: gabrielemiotto@hotmail.com
Whiteman and Miotto 853 Figure 1. This illustration shows the plane of the abdominal flap dissection above the Scarpa s fascia in the area below the umbilicus. TECHNICAL DETAILS Preoperative consultations were used to focus on patient goals. All patients seeking waist narrowing or waist modification were considered candidates for the use of the Scarpa s fascia flaps. Patients were examined for the degree to which subcutaneous fat was contributing to the fullness above the anterior superior iliac spine and translating posteriorly into the flank. Using a pinch technique, patients with greater than 3 cm of subcutaneous fat were considered candidates for lateral abdominal wall liposuction as well as Scarpa s fascia flap. In those with less than 3 cm of fat, no sub-scarpa s liposuction is performed, only the Scarpa s fascia flap. Attention was then turned to the supraumbilical subcutaneous fat thickness. Patients with fullness in this area underwent the Saldanha s (Brazilian) lipoabdominoplasty. In patients with significant skin laxity, skin ptosis or multiple supraumbilical skin folds, a wide dissection technique above the umbilicus was used instead of lipoabdominoplasty. All patients were marked standing in the preoperative area. A low mildly curved suprapubic abdominal incision and all areas for liposuction were defined. Procedures were completed under general anesthesia with the patient supine on the operating table. When indicated, a tumescent fluid 1:1 was added for standard liposuction of the lateral abdominal wall, flank, and anterior supraumbilical sites. Following the liposuction with three or four millimeters Mercedes cannulas above the Scarpa s fascia, the abdominoplasty proceeded. The incision is carried down to the level of Scarpa s fascia(figure 1), which can be easily identified by its shiny white color. The abdominal flap is elevated above the Scarpa s fascia using electrocautery up to the umbilicus, which is circumscribed. Figure 2. Flap elevation including the central portion of Scarpa s fascia below the umbilicus on a 45-year-old woman. Above the umbilicus, the abdominal flap is undermined below Scarpa s fascia up to the xiphoid process. A limited central tunnel is created with preservation of lateral perforators in individuals requiring extensive liposuction during the Saldanha s lipoabdominoplasty, or a wide undermining is performed when a traditional abdominoplasty is indicated. Below the umbilicus, Scarpa s fasciaflaps are created.the fascia is grasped by two clamps and divided over the linea alba down to the rectus muscle fascia. Then, a 4 to 5 cm wide triangular shaped excision of the midline fascia is performed to avoid overlapping of the inferior border of the flaps when advanced medially. Optionally, we can elevate and excise this central triangular medial portion of the Scarpa s
854 Aesthetic Surgery Journal 36(7) Figure 3. (A) Scarpa s fascia flaps are pulled in an infero-medial direction to improve the definition of the waistline. (B-E) Intraoperative photographs of a 54-year-old woman with previous hysterectomy undergoing Scarpa s fascia flap abdominoplasty with wide supraumbilical undermining and two-layer vertical plication of the rectus muscle. No liposuction was performed. (B) The initiation of the procedure with an arrow demonstrating proposed direction of flap advancement. (C, D) Demonstrating the proposed direction of flap advancement to create waist definition. (E) Demonstrating Scarpa s fascia flap advancement with suture of the fascia to the underlying of abdominal wall using a 2-0 Monocryl suture and resultant waistline.
Whiteman and Miotto 855 fascia at the time of initial flap elevation, preserving the lateral flaps for advancement (Figure 2). Shaping the medial flap edges as the sides of a triangle or a J shape avoids a centralized bulk after plication. The triangle can be excised either at the superior or inferior edge of the flap for better contour. The lateral Scarpa s fascia and sub-scarpa s fatty areolar layer are preserved. We do not perform infraumbilical liposuction below the Scarpa s fascia. The plication of the rectus muscle diastasis above and below the umbilicus is performed by a running V-Loc (Covidien, Mansfield, MA), just enough to re-approximate the rectus muscles. After diastasis plication, the Scarpa s fascia flaps are grasped with clamps and pulled in an inferomedial direction while inspecting the skin above the anterior superior iliac spine for waist contour change (Figure 3) (Video 1, available as Supplementary Material at www.aestheticsurgeryjournal. com). Once the appropriate vector is identified, the fascia flaps are sutured under tension to the rectus muscle fascia or to the linea alba with a 2-0 Monocryl depending on the quality of the flaps and degree of advancement needed (Figure 4). With the patient in a 35 back-elevated position, excess skin is removed. The abdominal skin can now be advanced for closure from lateral to medial. Attention to proper suturing is necessary to avoid excessive suprapubic wrinkling. Wound closure is completed in two layers of 2-0 and 3-0 Monocryl suture. Two 7 mm Jackson Pratt drains were used for the first 165 cases and a change from use of drains to use of quilting sutures over the last months is part of the main author s technique evolution. Pain pumps are used upon patient request and were placed entirely within the rectus sheaths. Tegaderm surgical dressings (3 M, St. Paul, MN) and abdominal binder are always applied. Antithrombotic prophylaxis included venous compression hose and intermittent compression device applied preoperatively and intraoperatively. Postoperative prophylaxis included Lovenox (Sanofi, Bridgewater, NJ) 40 mg beginning a.m. postoperative day one and continued for 7 days. Patients were administered preoperative cefazolin 1 g, or clindamycin 600 g IV for penicillin allergic individuals. MY EXPERIENCE This technique has been used in 348 consecutive female patients that underwent abdominal procedures including 217 (62%) traditional abdominoplasties, 108 (31%) lipoabdominoplasties, and 23 (7%) miniabdominoplasties. The mean age of the patients was 42 years (range, 21-63 years), the mean body mass index (BMI) was 29 kg/m 2 (range, 20-32 kg/m 2 ), and the average associated volume of liposuction of the abdominal wall was 468 cc (range, 0-3700 cc). The patient population consisted of 174 (50%) Caucasian, 120 (34%) African American, 50 (14%) Hispanic, 2 (0.3%) Asian, and 2 (0.3%) Middle Eastern patients. Figure 4. This illustration shows the shape and the vector of ideal mobilization of the Scarpa s fascia flaps once the flaps are sutured in place. This technique can be performed in patients of all body habitus. The versatility exists as long as the infraumbilical elevation of the abdominal flap is completed above Scarpa s fascia. The plane of dissection above the umbilicus is deep to Scarpa s fascia to address the need for diastasis plication. In patients with a BMI above 30, the results may not be as profound due to a lack of mobility of the fascial flaps. It seems that the greatest indication for the use of the Scarpa s fascia flaps is in the thin patient that does not require liposuction at all. In these patients, the effect of flap advancement through the connections between fascia and skin is easily visible and highly defines the waistline. OUTCOMES This technique has been used successfully in 348 consecutive female patients. Figure 5 shows a typical postoperative result of the use of the Scarpa s fascia flap at 14 months after surgery, with good definition of the waistline. Supplementary Figure 1 shows another patient 13 months after surgery. Both patients had mastopexies at the time of the abdominoplasty. Out of the 348 cases, seven (4.2%) patients required scar revision either for dog ears or scar asymmetry. Six (3.6%) patients developed postoperative seromas. Four of the six seromas occurred above the umbilicus in the patients who had wide undermining of the flap. Five of the six seromas occurred in the traditional abdominoplasty group with wide undermining and one in a lipoabdominoplasty patient. This complication seems to have decreased with the use of more extensive quilting sutures in the upper abdomen, eliminating the need for drains. Three of the seromas resolved with
856 Aesthetic Surgery Journal 36(7) Figure 5. This 34-year-old woman underwent a traditional abdominoplasty with wide superior undermining, and liposuction of the hip roll and superolateral abdomen with Scarpa s fascia advancement flaps. She also underwent mastopexy with use of superomedial pedicles. (A, C) Preoperative and (B, D) postoperative photographs taken at 14 months. aspiration while the remaining three required placement with placement of a SeromaCath (Greer Medical, Santa Barbara, CA). Five patients (2.9%) required removal of suture material from the wound following development of symptomatic suture granulomas. These patients were in the group in which a running subcuticular barbed suture closure was completed. Four (2.4%) patients experienced minimal wound necrosis that resolved with local care. Four (2.4%) patients underwent steroid injection for scar hypertrophy. Three (1.8%) patients developed superficial wound infection and were treated with oral antibiotics or antibiotic ointment for suspected minor infections characterized by wound redness or drainage. One (0.6%) patient developed a MRSA infection, which required reoperation for drainage and six weeks of intravenous antibiotics. One (0.6%) patient with a history of diabetes had major wound necrosis and required reoperation for debridement with secondary healing. One (0.6%) patient developed a hematoma within three hours of drain removal and required reopening of the wound under local anesthetic. One (0.6%) patient developed a significant
Whiteman and Miotto 857 complication secondary to bupivacaine toxicity due to malfunction of her pain pump. 12 COSTS There were no extra costs involved in this procedure. There is a potential for a cost saving over standard techniques because of the ability to address waist modification without liposuction in one procedure in selected cases. CONCLUSIONS The Scarpa s fascia bilateral advancement flap is a multilayer approach to enhance the waistline during all forms of abdominoplasty. The easy elevation of the superolateral based Scarpa s fascia flaps makes it a simple maneuver that can be widely applicable for all forms of abdominoplasties. It preserves the original fascia system and can improve surgical results while maintaining the benefits of the preservation of abdominal wall lymphatics. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Nahas FX. Advancement of the external oblique muscle flap to improve the waistline: a study in cadavers. Plast Reconstr Surg. 2001;108(2):550-555. 2. Nahas FX, Ferreira LM. Concepts on correction of the musculoaponeurotic layer in abdominoplasty. Clin Plast Surg. 2010;37(3):527-538. 3. Costa-Ferreira A, Rebelo M, Vásconez LO, Amarante J. Scarpa fascia preservation during abdominoplasty: a prospective study. Plast Reconstr Surg. 2010;125(4):1232-1239. 4. Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation in a more superficial plane: decreasing the need for drains. Plast Reconstr Surg. 2010;125(2):677-682. 5. Friedman T, Coon D, Kanbour-Shakir A, Michaels J 5th, Rubin JP. Defining the lymphatic system of the anterior abdominal wall: an anatomical study. Plast Reconstr Surg. 2015;135(4):1027-1032. 6. Mossaad BM, Frame JD. Medial advancement of infraumbilical Scarpa s fascia improves waistline definition in Brazilian abdominoplasty. Aesthetic Plast Surg. 2013;37 (1):3-10. 7. Saldanha OR, Pinto EB, Matos WN Jr, Lucon RL, Magalhães F, Bello EM. Lipoabdominoplasty without undermining. Aesthet Surg J. 2001;21(6):518-526. 8. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg. 2003;27(4):322-327. 9. Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg. 2009;124 (3):934-942. 10. Mallucci P, Pacifico MD, Waterhouse N, Sabbagh W. The differential fascial glide: a technical refinement in abdominoplasty. J Plast Reconstr Aesthet Surg. 2007;60(8):929-933. 11. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87(6):1009-1018. 12. Whiteman DM, Kushins SI. Successful Resuscitation With Intralipid After Marcaine Overdose. Aesthet Surg J. 2014;34(5):738-740.