MOC-CME

Evidence-Based Medicine: Abdominoplasty

Keith A. Hurvitz, M.D.
Windy A. Olaya, M.D.
Audrey Nguyen, B.S.
James H. Wells, M.D
Long Beach and Orange, Calif.

Learning Objectives: After studying this article, the participant should be able
to: 1. Develop a surgical plan for improving the contour of the abdominal region by means of abdominoplasty surgery. 2. Describe the current modalities
for preventing and managing perioperative pain associated with abdominoplasty surgery. 3. Discuss proper techniques for safely performing simultaneous abdominal wall liposuction and abdominoplasty surgery. 4. Determine the
means of decreasing seroma formation and drain duration in abdominoplasty
patients. 5. Apply current concepts in preventing and minimizing perioperative complications in abdominoplasty patients.
Summary: Abdominoplasty continues to be one of the most popular cosmetic surgeries performed by plastic surgeons throughout the world. Advancements in the area continue to surface which can help improve outcomes.
We present an extensive review of the most current literature on this topic.
This article offers readers an up-to-date and organized approach to abdominoplasty surgery. (Plast. Reconstr. Surg. 133: 1214, 2014.)

CLINICAL SCENARIO
A 47-year-old woman with a body mass index
of 23 comes to see you in consultation for abdominoplasty surgery. She also complains of excess
fatty tissues on her flanks bilaterally. She has a history of smoking for 10 years, but quit 4 weeks ago.
She has chronic pain in her back after a motor
vehicle accident 3 years ago that requires occasional acetaminophen. She has no medical problems other than a penicillin allergy that gives her
a rash. What is the best treatment plan according
to available evidence?

METHODS FOR IDENTIFYING

EVIDENCE
A literature search of PubMed was performed
to obtain the best available evidence on abdominoplasty, with emphasis on preoperative assessment,
antibiotic and deep vein thrombosis prophylaxis,
anesthesia, analgesia, treatment, and outcomes.
In addition, we combined the following terms in
the PubMed search when appropriate: abdominoplasty, risk factors, smoking, tobacco,
venous thrombosis, venous thromboembolism, DVT, diabetes, obesity, gynecology,
From Aesthetic and Reconstructive Plastic Surgery; and the
Aesthetic and Plastic Surgery Institute, University of California, Irvine Medical Center.
Received for publication April 1, 2013; accepted May 17,
2013.
Copyright 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000088

1214

C-section, scars, antibiotic prophylaxis,

psychosocial, seroma, infection, outcome,
BMI, psychosocial, pulmonary embolism,
PE, outpatient, lipoabdominoplasty, quilting sutures, liposuction, combined, tummy
tuck, mommy makeover, and breast augmentation. The search was limited to human studies
and articles published between 2008 and 2013 as
an update to the 2010 abdominoplasty Maintenance of Certification article published by Buck
and Mustoe (Level of Evidence: Therapeutic, V).1
Studies were excluded if the full text was not available or the article was of non-English language.
Studies were assessed for quality and assigned a
level of evidence according to the American Society of Plastic Surgeons Evidence Rating Scales.
Evidence ratings were not assigned to studies with
inadequately described methods or to references
included for discussion purposes only.

EVIDENCE ON PREOPERATIVE
ASSESSMENT
The preoperative assessment of any potential
abdominoplasty patient should include a thorough history and physical examination, which is
essential for identifying potential risks during surgery. As previously discussed by Buck and Mustoe,
abdominoplasty carries a higher risk of wound
Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

www.PRSJournal.com

Volume 133, Number 5 Abdominoplasty

Wound infection continues to be the second

most common complication in abdominoplasty
surgery.7 In 2007, Sevin etal. showed that abdominoplasty patients with a single dose of antibiotic
prophylaxis preoperatively had fewer infections
than those patients that did not receive antibiotics (Level of Evidence: Therapeutic, II).8 These
results emphasize the need for prophylactic preoperative antibiotic administration in abdominoplasty surgery; however, there is no consensus
as to the duration or choice of antibiotics to be
given. Many questions arise with antibiotic use
regarding the need for extended broad coverage against resistant bacteria (e.g., methicillinresistant Staphylococcus aureus), length of time
to cover the patient, or the need for antibiotic
coverage while surgical drains are still in place.
With our extensive literature search, we did not
find any updated quality information regarding
duration of postoperative antibiotic use, choice
of antibiotic, or use of antibiotics in conjunction
with surgical drain use. Future studies in this area
would be very helpful for surgeons in determining the exact course for antibiotic administration
in abdominoplasty surgery.

in the recent plastic surgery literature about

use of pharmacologic prophylaxis specifically in
abdominoplasty surgery. A higher incidence of
venous thromboembolism has been reported in
patients with a body mass index greater than 30,
those that use hormone therapy, and patients with
higher risk scores using the Caprini Risk Assessment Model.5,9 Another review that evaluated
the risk for venous thromboembolism in various
abdominal contouring procedures found that
circumferential abdominoplasty was associated
with the highest venous thromboembolism rate
(3.4 percent) compared with traditional abdominoplasty (0.35 percent; p < 0.001).10 The risk of
venous thromboembolism when abdominoplasty
was combined with any intraabdominal procedure
was 2.17 percent. In contrast, when abdominoplasty was combined with any other plastic surgery
procedure, the risk was only 0.76 percent.10
Newall etal. presented data on the use of
low-molecular-weight heparin in their patients following body contouring procedures.11 High-risk
patients were given an injection immediately after
surgery and then every 12 hours for 3 days. They
did not experience any unforeseen bleeding complications and no patients developed deep vein
thrombosis or pulmonary embolism.
Somogyi etal. developed a protocol to reduce
venous thromboembolism in abdominoplasty
without chemoprophylaxis.12 This regimen consisted of graded compression stockings worn preoperatively and 7 days postoperatively, intermittent
pneumatic compression devices placed before
surgery and until discharge, strict intraoperative and perioperative warming, and ambulation
within the first hour of the operation. In addition,
their protocol specified that patients were to be
discharged to home the same day. No chemoprophylaxis was given. In this retrospective review of
404 abdominoplasty patients from 2000 to 2010,
297 were high risk and 17 were highest risk for
venous thromboembolism based on the Caprini
score. Smokers were required to stop smoking 1
month before surgery, and patients on hormone
therapy were allowed to continue. There was only
one reported case of venous thromboembolism in
their case series.

EVIDENCE ON DEEP VENOUS

THROMBOSIS PROPHYLAXIS

EVIDENCE ON PAIN MANAGEMENT

AND OUTPATIENT SURGERY

Although there is substantial evidence in the

orthopedic literature regarding prevention of
venous thromboembolism with chemoprophylaxis
during elective operations, there is no consensus

Pain control is an important factor that affects

patient satisfaction related to the abdominoplasty
experience. A number of studies have evaluated
ways of improving pain control, many of them

infection in smokers, and higher rates of wound

complications and seromas in obese patients with
a body mass index greater than 30 (Reference 2:
Level of Evidence: Risk, II).2,3 Obese patients are
also at much higher risk of experiencing a venous
thromboembolic event.4,5
Not only is active smoking a risk factor for
wound complications, but the overall number
of cigarettes smoked in a lifetime can also have
an effect on the development of wound infections.6 Araco etal. found that even after smokers
quit tobacco 4 weeks before abdominoplasty, the
risk of infection was 14.3 percent versus 1.2 percent in nonsmokers (p < 0.05).6 They also found
that higher infection rates were associated with a
higher number of cigarettes smoked per day, more
years of smoking, and a higher estimated overall
number of cigarettes smoked over a lifetime.6

EVIDENCE OF ANTIBIOTIC
PROPHYLAXIS

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Plastic and Reconstructive Surgery May 2014

using pain blocks. In a retrospective review of
abdominoplasty patients over a 10-year period,
Feng compared outcomes of 20 patients who
received no blocks versus 77 patients who received
a combination of nerve blocks. He found that
using nerve blocks (both intercostal and pararectus blocks) in conjunction with general anesthesia was associated with less pain medication use
(3.1mg of morphine in the treatment group versus 12.8mg of morphine in the control group; p
< 0.0001).13 In addition, less time was needed in
the recovery room, lower pain scores (using the
visual analogue scale ranging from 0 to 10) were
noted at home (3 for the treatment group versus
7.5 for the control; p < 0.0001), and a shorter time
to resume normal activities was also noted in the
nerve block group.13
A separate study comparing intercostal rib
blocks plus intravenous sedation versus general
anesthesia alone had similar results.14 In this
study, all abdominoplasty cases performed by a
single surgeon from 1999 to 2006 were evaluated
retrospectively and divided into two groups: those
operations that had been performed under general anesthesia (group 1, n = 39) and those that
had been performed using rib blocks and intravenous sedation (group 2, n = 29). Group 2 treatment was associated with a statistically significant
decrease in recovery room time, postoperative
narcotics, pain, nausea, and vomiting. This study
was performed in an outpatient setting, with no
reported hospital admissions, no increase in operative time, and no major complications or deaths
in 29 operations in the treatment group.
In a prospective, randomized, double-blind
study, Sforza etal. randomly assigned 28 women
who were undergoing abdominoplasty by means
of a lower abdominal incision to standard therapy
plus a transversus abdominis plane block (n = 14)
or to standard therapy alone (n = 14).15 Treatment
with the block was associated with a significant
reduction in morphine requirements and allowed
for earlier ambulation. Operations were again
performed on an outpatient basis, and no major
complications were encountered.
Local anesthesiainfused pain pumps placed
after abdominoplasty have also been shown to
decrease perceived pain and oral narcotic use.16
Smith etal. published a case report concerning
a postoperative seroma in association with pain
pump use.17 However, a larger 3-year retrospective
chart analysis including 159 patients undergoing
abdominoplasty revealed no correlation between
the development of seromas in patients with or
without the use of local anesthetic pain pumps.18

1216

Abdominoplasty has been shown to be safe

when performed in the outpatient setting. Gray
etal. reported an 8-year retrospective review of
206 patients undergoing abdominoplasty who
were discharged to home the same day without
any incidence of pulmonary embolism, venous
thromboembolism, need for blood transfusion,
intraabdominal perforation, or death.19 All operations were performed in outpatient ambulatory
facilities accredited by the American Association
for Accreditation of Ambulatory Surgery Facilities. All patients had an American Society of Anesthesiologists class of 1 or 2. No chemoprophylaxis
was given, and discharge criteria included voiding, tolerating oral intake, and early ambulation.
All patients were discharged the same day and
patients were seen in the clinic on postoperative day 2 for follow-up.19 Despite our extensive
literature search of this topic, we were unable to
locate any articles or data pertaining to the safety
of performing abdominoplasty in the office setting outside of an accredited operating room. At
this time, based on a complete lack of evidence in
our current literature, we cannot make any recommendations on office-based abdominoplasties
until substantial, credible evidence arises to support this practice.

EVIDENCE ON SURGICAL
TREATMENT PLAN
The general concept behind abdominoplasty
surgery has remained fairly constant over the

Fig. 1. Depiction of traditional low-lying incision placement for

abdominoplasty surgery.

Volume 133, Number 5 Abdominoplasty

years. The overall idea is to improve the contour
of the abdominal wall by means of rectus abdominis fascia plication and removal of excess skin and
fat from the region. This is all achieved using a
low-lying suprapubic incision that can be hidden
under the bikini line (Fig.1). Refinements of this
concept in recent years are the bases of innovation in abdominoplasty. Advancements in the following areas of abdominoplasty will be the core of
discussion in this section: the addition of simultaneous suction lipoplasty, limited flap undermining, preservation of tissue on the rectus fascia,
use of tension quilting sutures at closure, management of the umbilicus, and combination of
abdominoplasty with other surgical procedures.
The goal of this discussion is to help surgeons in
determining a safe surgical treatment plan for
new abdominoplasty patients presenting to the
office for consultation.
One major advance in the area of abdominoplasty has been the increasing addition of liposculpture. Patient satisfaction rates for the combined
lipoabdominoplasty procedure have been shown
to be better when compared with traditional
abdominoplasty alone.20 Heller etal.21 performed
a 114-patient retrospective analysis of patients
undergoing abdominal contouring procedures
and found lower complication rates in patients
who underwent lipoabdominoplasty compared
with traditional abdominoplasty. In the past, there
was caution emphasized when combining abdominoplasty with aggressive liposuction for fear of
abdominal flap vascular compromise and subsequent flap necrosis. This was based on the traditional wide lateral dissection abdominoplasties
with extensive undermining, which would often
sacrifice important abdominal wall perforator vessels and lymphatics. There are significant recent
data that clearly show success with aggressive
liposuction in combination with abdominoplasty
(Level of Evidence: Reference 22: Therapeutic,
II; Reference 24: Therapeutic, III).2224 However,
careful modifications in technique must be followed to safely preserve vascular supply to the skin
flaps. One key to success with this combination
technique is in only creating a limited suprafascial tunnel from the umbilicus up to the xiphoid
process for the full rectus fascia plication. Dissection laterally from the midline is generally limited
to 7.5cm (Fig.2).22 This method preserves major
lateral abdominal wall perforators that would otherwise be sacrificed with traditional techniques. In
addition, liposuction is generally performed deep
to the Scarpa fascia except in the lower abdomen
in the area of pannus to be excised.20,25 The deep

Fig. 2. Recommended limited midline suprafascial dissection of

the abdominal wall during abdominoplasty surgery.

liposuction tunnels create a sliding plane for the

abdominal wall flap by disrupting skin retaining
ligaments yet sparing large essential perforator
vessels needed for circulation.26
The level of dissection in abdominoplasty has
been examined as having an effect on seroma
formation and drain maintenance. Traditionally,
abdominal flap dissection was carried out directly
on the anterior surface of the muscle fascia in
all regions. In addition to limiting the total surface area of dissection as discussed above, it has
been advocated that a thin layer of tissue be left
on the fascia to decrease the incidence of postoperative seroma and reduce the total length of
time that drains are needed.27 More recent studies have examined leaving even more tissue on
the muscle fascia by performing the dissection
above the Scarpa fascia in the lower abdomen
and only then transitioning to the prefascial layer

Fig. 3. Illustration of placement of tension quilting sutures during inset of the abdominal flap during abdominoplasty surgery.

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Plastic and Reconstructive Surgery May 2014

in the epigastrium and infraumbilical midline,
where plication of the rectus fascia needs to be
performed.28,29 These studies have shown significant reductions in drain output and quicker drain
removal time.
Inset of the abdominoplasty flap with tension
quilting sutures has gained significant support.
These sutures anchor the Scarpa fascia directly to
the anterior abdominal wall fascia (Fig.3). The
exact placement pattern of sutures varies among
surgeons; however, the concept remains the same.
The suture technique obliterates dead space and
minimizes abdominal flap movement and friction,
which can lead to seroma formation.30 The sutures
hold the skin flap to the abdominal wall and have
been shown to significantly reduce the incidence
of seroma and the length of time for drain maintenance.31 Some advocate no need for drains when
tension quilting sutures are used. Of 597 cases performed using progressive tension sutures on closure, Pollock and Pollock32 had only one seroma.
No drains were placed in any of their study patients.
Another proposed benefit of these sutures is that
they may take the tension of closure off of the
lower incision and instead disperse it across the
entire flap. This should theoretically reduce the
incidence of incisional necrosis and wound healing problems. When placed above and below the
umbilicus, they are believed to relieve tension on
the umbilicus and preserve its blood flow as well.30
One of the smaller but more scrutinized details
of abdominoplasty surgery is the final appearance
and location of the umbilicus. Long ago, Dubou
and Ousterhout found that the ideal position in
the majority of their patients was level with the
superior border of the iliac crest.33 Rodriguez-Feliz
etal. performed careful intraoperative measurements on 40 consecutive patients and concluded
the ideal location for the umbilicus to be 15cm
from the midpubis in patients 145 to 178cm in
height.34 Using a system of formulas and regression analysis, Pallua etal. concluded that the true
position rests at two-thirds the distance from the
pubis to the xiphoid process.35
Despite the variances in opinion on true
umbilical location, it is widely accepted that the
preferred final shape is that of a vertically oriented, concave structure.3638 To achieve these
goals at inset, different surgical techniques have
been offered. Use of an inverted V- or U-type incision in the abdominoplasty flap has resulted in
high patient and surgeon satisfaction rates.35,36 In
2011, Mazzocchi etal. published their technique
using vertical double-opposing Y flaps on 111
abdominoplasty patients.39 Their results after 5

1218

years showed no significant change in shape and

a low rate of stenosis (4.5 percent). To achieve a
concave and scarless umbilicus, Dogan has proposed shortening the stalk of the umbilicus almost
down to its base.40 This simple technique allows
the final scar to be drawn into the depression
of the umbilicus, out of sight. In 2012, Cl and
Nogueira published their results of 306 consecutive abdominoplasties.41 Unlike other articles, this
one describes amputating the native umbilicus
at its base, marking its true preexisting location,
and then creating a completely new umbilicus de
novo using an X-shaped design from the abdominoplasty flap. This pattern, once incised, creates
four pie-shaped flaps that are then sutured to the
abdominal fascia at the location of the preexisting
umbilicus. Of 306 patients, however, only 50 were
randomly selected for a postoperative satisfaction
survey. Of these 50 patients, only 43 responded.
Ninety percent of responders, however, felt the
result of the new umbilicus was good to excellent.
Combination surgery in the realm of plastic
surgery is not uncommon. Above, we discussed the
combination of abdominoplasty with liposuction
and reviewed significant successes that have been
reported. In our private practice, we are seeing a
particular demand for gynecologic patients who
want to combine an abdominoplasty with their
elective transabdominal hysterectomy procedure.
The fear of combining a potentially contaminated
gynecologic operation with a clean abdominoplasty may cause some hesitation for fear of infection. Sinno etal. looked at this exact issue in 2011
and evaluated the safety and efficacy of combining
these two specialties in a single operating room
event (Level of Evidence: Therapeutic, III).42 The
study was limited to only transabdominal hysterectomies with and without salpingo-oophorectomies.
Twenty-five patients were followed. There were no
differences in complication rates of the combined
abdominoplasty/hysterectomy patients when compared with control abdominoplasty patients. The
only significant difference was duration of operation, blood loss, and length of hospital stay, which
was understandably higher for the combined
group because two operations were performed.
Importantly, there were no significant differences
found with respect to infection or seroma rates
between the two groups.

EVIDENCE OF POSTOPERATIVE
OUTCOMES
Swanson evaluated the outcomes of liposuction versus lipoabdominoplasty versus traditional

Volume 133, Number 5 Abdominoplasty

abdominoplasty in a prospective evaluation of
360 patients.20 He found that patients who underwent combined liposuction and abdominoplasty
experienced the highest level of satisfaction (99.2
percent).
In a 20-year retrospective review, outcomes
from combined liposuction with abdominoplasty
were evaluated.24 Three different treatment techniques were compared: wide flap undermining
with wet liposuction, wide flap undermining with
superwet liposuction, and limited flap undermining with liposuction and suture tension closure technique (Table1). Seroma formation was
less common with the group 3 technique and was
highest with group 1. Group 1 also had the highest blood loss. When photographs were reviewed
by an independent party, group 3 had the best
aesthetic outcome ratings. The overall infection
rate was less than 2 percent for all groups.
Weiler etal. performed a retrospective review
evaluating outcomes from direct liposuction of
the abdominal flap during abdominoplasty.43
They reviewed 173 consecutive cases over a 4-year
period. The partial dehiscence and skin necrosis
rate was 6.9 percent, the rate of infection requiring antibiotics was 7.5 percent, and the seroma
rate was 3.4 percent. There was only a 1.1 percent rate of skin flap necrosis that required readvancement of the abdominal flap. The venous
thromboembolism rate was 2.8 percent and the
pulmonary embolism rate was 1.1 percent. Their
conclusion was that this practice of direct flap
liposuction was safe.
An earlier review by Samra etal. looked at
liposuction of the abdominal wall in high-risk
patients.22 High-risk patients were defined as
active smokers or those with a history of previous abdominal surgery that resulted in significant supraumbilical scarring. They found no
difference in perfusion-related complications
Table 1. Comparison of Three Different Treatment
Techniques
Surgical
Technique
Group 1
Group 2

Group 3

Description
Wide abdominal undermining; wet
liposuction
Wide abdominal undermining with
extended lower lateral dissection;
superwet liposuction; ultrasound-assisted
liposuction of flanks
Limited central abdominal undermining
with maintenance of sub-Scarpa t issue
on the abdominal wall; ultrasound
liposuction of the central abdomen and
flanks; high superior tension technique

(e.g., skin necrosis, wound infection, and wound

dehiscence) in high-risk patients when comparing
traditional abdominoplasty versus lipoabdominoplasty, which included direct liposuctioning of the
abdominal flap.
In a case-control study of combined gynecologic surgery and abdominoplasty surgery, Sinno
etal. reported reduction in operative time and
blood loss, and a decrease in total days of hospitalization when comparing the combined surgical
procedures with the sum of the two separate procedures.42 Hospital stay was decreased to 2.7 days
from 3.9 days, operative time was reduced from
277 minutes to 221 minutes (p < 0.001), and estimated blood loss was 350ml compared with 551ml
when the surgical procedures were performed in
combination (p < 0.005). Wound infection was
similar in all groups at 4 percent. The seroma rate
was 4 percent in the combined procedure group
and 5.5 percent in a bdominoplasty-alone group.
In contrast, when combining cesarean delivery with abdominoplasty, the results were not so
promising. Fifty patients were reviewed with 6
months of follow-up after cesarean delivery combined with abdominoplasty.44 Results revealed
a wound infection rate of 18 percent, a wound
dehiscence rate of 9 percent, and lower abdominal skin necrosis in 12 percent of patients. In
addition, aesthetic outcomes were often of poor
quality. Patients experienced residual abdominal
skin (18 percent), lack of waist definition (32
percent), and outward bulging of the umbilicus
(24 percent).
There have been questions regarding the
long-term effects of abdominoplasty. Many have
postulated that there is a decrease in lung volume
after plication; however, Perin etal. evaluated
30-day spirometry values and found no change
compared with preoperative values.45 Swanson
found a significant reduction in triglyceride levels
after abdominoplasty, but saw no change in cholesterol levels.46
Sensory changes also occur as a result of
abdominoplasty. Lapid etal. evaluated postoperative patient sensation in 16 different abdominal
and thigh zones 1 year after abdominoplasty and
compared them with preoperative sensation.47
The authors found no decrease in sensation in
the thighs or upper abdomen; however, there was
a decrease in sensation from the umbilicus to the
infraumbilical area for patients undergoing standard abdominoplasty.
In addition to the physical changes that occur
with abdominoplasty surgery, there are also positive emotional ones that arise. Papadopulos etal.

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Plastic and Reconstructive Surgery May 2014

surveyed 63 of their abdominoplasty patients
and found improvement in overall quality of life
and emotional stability and higher levels of body
image satisfaction.48 Momeni etal. showed that
even patients who experienced complications
after undergoing abdominoplasty surgery were
generally not negatively impacted by the occurrence.49 On the contrary, they were satisfied with
the procedure and would recommend the surgery to a friend.

SUGGESTED TREATMENT FOR THE

CLINICAL SCENARIO
Based on the available evidence, the best treatment for our patient would be the following. We
should delay the surgical procedure for at least
4 more weeks to decrease the complications of
tobacco use.6 The patient should be advised that
she is still at increased risk of infection because of
her tobacco history.6 Given her penicillin allergy,
a prophylactic dose of nonpenicillin preoperative
antibiotics should be given to reduce her risk of
infection.8 Intraoperatively, rib blocks could be
used to assist with pain control and early ambulation.13 Abdominoplasty combined with liposuction, especially of the flank area, would be
performed. We would perform limited central
abdominal flap undermining with maintenance
of sub-Scarpa tissue on the abdominal wall.21,2527
Following fascial plication, closure would be performed with tension suture technique to minimize seroma formation.37 Suction drains might be
placed, but would be removed in an expeditious
manner if used. This procedure would be performed on an outpatient basis in an accredited
surgery facility with an early ambulation protocol,
sequential compression devices, and compression
stockings to avoid venous thromboembolism.46
Keith A. Hurvitz, M.D.
2880 Atlantic Avenue, Suite 290
Long Beach, Calif. 90806
khurvitz.plasticsurgery@gmail.com

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23. Rodby KA, Stepniak J, Eisenhut N, Lentz CS III.

Abdominoplasty with suction undermining and plication of

Volume 133, Number 5 Abdominoplasty

the superficial fascia without drains: A report of 113 consecutive patients. Plast Reconstr Surg. 2011;128:973981.
24. Trussler AP, Kurkjian TJ, Hatef DA, Farkas JP, Rohrich

RJ. Refinements in abdominoplasty: A critical outcomes
analysis over a 20-year period. Plast Reconstr Surg. 2010;126:
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25. Le Louarn C, Pascal JF. The high-superior-tension tech
nique: Evolution of lipoabdominoplasty. Aesthetic Plast Surg.
2010;34:773781.
26. Brauman D, Capocci J. Liposuction abdominoplasty: An

advanced body contouring technique. Plast Reconstr Surg.
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27. Fang RC, Lin SJ, Mustoe TA. Abdominoplasty flap elevation
in a more superficial plane: Decreasing the need for drains.
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28. Costa-Ferreira A, Rebelo M, Vasconez LO, Amarante J.

Scarpa fascia preservation during abdominoplasty: A prospective study. Plast Reconstr Surg. 2010;125:12321239.
29. Koller M, Hintringer T. Scarpa fascia or rectus fascia in

abdominoplasty flap elevation: A prospective clinical trial.
Aesthetic Plast Surg. 2012;36:241243.
30. Antonetti JW, Antonetti AR. Reducing seroma in outpatient
abdominoplasty: Analysis of 516 consecutive cases. Aesthet
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31. Di Martino M, Nahas FX, Barbosa MV, etal. Seroma in lipoabdominoplasty and abdominoplasty: A comparative study
using ultrasound. Plast Reconstr Surg. 2010;126:17421751.
32. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: A review of 597 consecutive cases. Aesthet Surg J.
2012;32:729742.
33. Dubou R, Ousterhout DK. Placement of the umbilicus in an
abdominoplasty. Plast Reconstr Surg. 1978;61:291293.
34. Rodriguez-Feliz JR, Makhijani S, Przybyla A, Hill D, Chao J.
Intraoperative assessment of the umbilicopubic distance: A
reliable anatomic landmark for transposition of the umbilicus. Aesthetic Plast Surg. 2012;36:817.
35. Pallua N, Markowicz MP, Grosse F, Walter S. Aesthetically
pleasant umbilicoplasty. AnnPlast Surg. 2010;64:722725.
36. Malic CC, Spyrou GE, Hough M, Fourie L. Patient satisfaction with two different methods of umbilicoplasty. Plast
Reconstr Surg. 2007;119:357361.

37. Craig SB, Faller MS, Puckett CL. In search of the ideal female
umbilicus. Plast Reconstr Surg. 2000;105:389392.
38. Rozen SM, Redett R. The two-dermal-flap umbilical transposition: A natural and aesthetic umbilicus after abdominoplasty. Plast Reconstr Surg. 2007;119:22552262.
39. Mazzocchi M, Trignano E, Armenti AF, Figus A, Dessy LA.
Long-term results of a versatile technique for umbilicoplasty
in abdominoplasty. Aesthetic Plast Surg. 2011;35:456462.
40. Dogan T. Umbilicoplasty in abdominoplasty: A new

approach. AnnPlast Surg. 2010;64:718721.
41. Cl TC, Nogueira DS. A new umbilical reconstruction technique used for 306 consecutive abdominoplasties. Aesthetic
Plast Surg. 2012;36:10091014.
42. Sinno S, Shah S, Kenton K, etal. Assessing the safety and efficacy of combined abdominoplasty and gynecologic surgery.
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43. Weiler J, Taggart P, Khoobehi K. A case for the safety and
efficacy of lipoabdominoplasty: A single surgeon retrospective review of 173 consecutive cases. Aesthet Surg J.
2010;30:702713.
44. Ali A, Essam A. Abdominoplasty combined with cesarean
delivery: Evaluation of the practice. Aesthetic Plast Surg.
2011;35:8086.
45. Perin LF, Saad R Jr, Stirbulov R, Helene A Jr. Spirometric
evaluation in individuals undergoing abdominoplasty. JPlast
Reconstr Aesthet Surg. 2008;61:13921394.
46. Swanson E. Prospective clinical study reveals significant

reduction in triglyceride level and white blood cell count
after liposuction and abdominoplasty and no change in cholesterol levels. Plast Reconstr Surg. 2011;128:182e197e.
47. Lapid O, Plakht Y, van der Horst CM. Prospective evaluation
of the sensory outcome following abdominoplasty. AnnPlast
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48. Papadopulos NA, Staffler V, Mirceva V, etal. Does abdominoplasty have a positive influence on quality of life,
self-esteem, and emotional stability? Plast Reconstr Surg.
2012;129:957e962e.
49. Momeni A, Heier M, Torio-Padron N, Penna V, Bannasch
H, Stark BG. Correlation between complication rate and
patient satisfaction in abdominoplasty. AnnPlast Surg. 2009;
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