The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. Traditionally, abdominoplasty has been a hospital procedure requiring general anesthesia, with partial or full rectal muscle plication to ensure tightening of the abdomen. Although delivering impressive results, this procedure has also required significant post-operative healing time, as well as significant operative risk.1,2 The mini-abdominoplasty is a modification of the classic abdominoplasty. Mini-abdominoplasty is ideal for patients who lack the severe abdominal contouring problems requiring full abdominoplasty, but who are burdened by abnormalities too extensive to be corrected through lipoplasty alone. Under conscious sedation, tumescent liposuction is first performed to the lower abdomen, followed by excision and removal of redundant skin. The mini-abdominoplasty, therefore, has many advantages. The procedure can be performed in an outpatient surgical setting, with decreased pain, morbidity, healing time and scarring; most patients are discharged home within 3 hours of the completion of the procedure and are able to resume regular activities in 2 to 3 weeks. PATIENT SELECTION Determining Appropriate Candidates Optimal candidates for the procedure include those who have small amounts of skin laxity of the lower abdomen, but who have retained moderate lower abdominal musculoskeletal tone. It is therefore critical to perform a pre-operative physical exam of the abdominal region with the patient in multiple different positions: supine, upright and bent forward at the waist (diver’s position). This allows the surgeon to effectively determine skin elasticity, rebound and looseness. Certain maneuvers can further elucidate whether the mini-abdominoplasty is indicated for a selected patient. Physical Exam Components To assess degree of skin laxity and adiposity: • Pinch test: By pinching the fat between the thumb and index finger, the amount of subcutaneous fat is measured. When there is good skin tone, no overhanging redundant skin, and a pinch test of more than 1 inch, liposuction alone may correct the disfigurement. To assess integrity of the lower abdominal musculoaponeurotic system: • Diver’s position: Moving from an upright standing position to bending forward at the waist elucidates weakened abdominal musculature with an evident bulge. • Head raise: In a supine position, the patient is asked to raise his/her head and shoulders to tighten the abdominal muscles. Muscular weakness, hernias, and/or diastasis of the rectus muscles will become obvious. Poor Candidates Grossly obese individuals with a high degree of centripetal adiposity, or those with excess muscular flaccidity or skin laxity are poor candidates. It should be emphasized that mini-abdominoplasty is not a weight loss procedure. Smokers and those with a history of thrombophlebitis, should also be strongly discouraged from undergoing the procedure, as complication risks are increased.2,3 Patient Expectations/Informed Consent In addition to completing a pre-operative physical exam and obtaining medical clearance, the surgeon should also thoroughly review patients’ expectations. Conversation should revolve around the patient’s preferences concerning the degree of skin tightening, scarring, stretch marks, and post-operative recovery and morbidity. THE CONTOURING PROCEDURE Tumescent Liposuction • The first phase of mini-abdominoplasty is tumescent liposuction during which a dilute lidocaine solution is infused through cannulas into the lower abdominal fat, hydrodissecting the tissue plane. The infusion takes place via two small (1.0-cm to 1.5-cm) incisions, just superior to the mons pubis. • Subsequently, suction-assisted cannulas are introduced through the same incisions used for tumescent anesthesia delivery. Remaining superficial to the abdominal aponeurotic system, the syringe-assisted cannulas tunnel through the fat, and remove excess fat from the area. This phase of fat debulking also helps to better define localized skin redundancy. Connecting Liposuction Incisions • The second phase involves creation of a transverse incision (15 blade) along the horizontal sub umbilical crease. (Figures 3A and 3B) • Metzenbaum scissors are then used to undermine the tissue to a level midway to one-third below the umbilicus, thereby connecting all of the horizontal tunnels previously created by the liposuction cannulas. • The excess skin is pulled inferiorly with an appropriate degree of tension, and bifurcations are made to approximate the amount of redundant skin to be excised. • Unipolar electrocautery is used to achieve hemostasis. Plication of the Rectus Muscle • In select cases, limited plication of the rectus muscle is next accomplished placing a non-absorbable monofilament suture. • Multiple absorbable tacking sutures may be placed from the subcutaneous tissue to the musculofascial layer to help advance the flap downward, decreasing tension on the final closure line. These sutures help to bring the tissue planes together, thus also decreasing dead space and helping prevent the most common complication of the procedure: seroma/hematoma formation.1 No drains are placed. Closing and Dressing the Wound • The wound is then closed with an absorbable, subcuticular pull-out suture or small skin staples. • Finally the wound is covered with surgical tape strips and the patient is dressed in a compressive, elastic binder to provide support. DISCUSSION Advantages for Appropriate Patients Patients with increased adiposity who have a modest amount of redundant skin, scarring, or striae of the lower abdomen, along with reasonable underlying musculofascial tone, are likely to benefit most from mini-abdominoplasty. This “variation on a theme” also creates another option for abdominal contouring in those patients who have already lost weight or desire to have children, who are poor surgical risks, or who have already had a full abdominoplasty.4 Clearly, neither morbidly obese patients nor patients with significant lower abdominal flaccidity are candidates. However, in the appropriately selected patient, this form of “mini-abdominoplasty” has resulted in excellent contour improvement and a more rapid return to life activities than is seen with the traditional “full” abdominoplasty. Decreased costs, due to the physician’s ability to perform the procedure utilizing conscious sedation in an outpatient, surgical center setting, and decreased operative risks, add to the procedure’s appeal.5 Classic Abdominoplasty Complications The classic abdominoplasty is fraught with surgical complications. Local complications such as hematoma, seroma, wound dehiscence, and skin necrosis, occur in up to 32% of nonsmokers and as many as 52% of smokers.6 Generalized complications include deep vein thrombosis, pulmonary embolus, ileus, sensation disorder of the skin of the thighs, nerve palsies of the upper extremity and death.7 Decreased Risks with Mini-Abdominoplasty The limited abdominal flap undermining in the mini-abdominoplasty technique significantly decreases these risks by minimizing dead space and preserving sensory and vascular supply to the abdominal skin.2 Scar formation and flap necrosis are also minimized secondary to smaller incisions and diminished tension of the skin closure edges.4 Dehiscence can be avoided by limiting excessive tension on the closure. Fortunately, the mini-abdominoplasty offers the added advantage of minimized tension at the closure site due to decreased abdominal girth, created by prior liposuction. Selecting appropriate surgical candidates (severe coughing spells are common in smokers) and preventing constipation-associated strain also further help to reduce tension. Despite these decreased risks in comparison to full abdominoplasty, dehiscence, infections, transient hypesthesia, and hypertrophic scarring are still potential complications. SUMMARY In a day and age when so many of life’s “wants” have become down-sized, the mini-abdominoplasty appears to be following suit; the procedure is less than a full abdominoplasty, but more than a suction lipectomy alone. Mini-abdominoplasty has consistently and significantly reduced many of the problems that have been associated with classic abdominoplasty, allowing for faster patient recovery and better cosmesis.2 Despite its many advantages, it should be stressed that the success of this type of abdominal wall surgery is highly dependent upon appropriate preoperative selection of patients. Overall, the mini-abdominoplasty is a safe and effective alternative approach to body contouring and can offer a more youthful abdominal silhouette with decreased risk, minimal downtime, and a shorter scar. Dr. Bisaccia is a practicing dermatologist and Professor of Clinical Dermatology at the Columbia University College of Physicians and Surgeons in New York City. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Eickhorst is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. DISCLOSURES: Drs. Bisaccia, Rogachefsky, Eickhorst and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
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Mini-Abdominoplasty
The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. Traditionally, abdominoplasty has been a hospital procedure requiring general anesthesia, with partial or full rectal muscle plication to ensure tightening of the abdomen. Although delivering impressive results, this procedure has also required significant post-operative healing time, as well as significant operative risk.1,2 The mini-abdominoplasty is a modification of the classic abdominoplasty. Mini-abdominoplasty is ideal for patients who lack the severe abdominal contouring problems requiring full abdominoplasty, but who are burdened by abnormalities too extensive to be corrected through lipoplasty alone. Under conscious sedation, tumescent liposuction is first performed to the lower abdomen, followed by excision and removal of redundant skin. The mini-abdominoplasty, therefore, has many advantages. The procedure can be performed in an outpatient surgical setting, with decreased pain, morbidity, healing time and scarring; most patients are discharged home within 3 hours of the completion of the procedure and are able to resume regular activities in 2 to 3 weeks. PATIENT SELECTION Determining Appropriate Candidates Optimal candidates for the procedure include those who have small amounts of skin laxity of the lower abdomen, but who have retained moderate lower abdominal musculoskeletal tone. It is therefore critical to perform a pre-operative physical exam of the abdominal region with the patient in multiple different positions: supine, upright and bent forward at the waist (diver’s position). This allows the surgeon to effectively determine skin elasticity, rebound and looseness. Certain maneuvers can further elucidate whether the mini-abdominoplasty is indicated for a selected patient. Physical Exam Components To assess degree of skin laxity and adiposity: • Pinch test: By pinching the fat between the thumb and index finger, the amount of subcutaneous fat is measured. When there is good skin tone, no overhanging redundant skin, and a pinch test of more than 1 inch, liposuction alone may correct the disfigurement. To assess integrity of the lower abdominal musculoaponeurotic system: • Diver’s position: Moving from an upright standing position to bending forward at the waist elucidates weakened abdominal musculature with an evident bulge. • Head raise: In a supine position, the patient is asked to raise his/her head and shoulders to tighten the abdominal muscles. Muscular weakness, hernias, and/or diastasis of the rectus muscles will become obvious. Poor Candidates Grossly obese individuals with a high degree of centripetal adiposity, or those with excess muscular flaccidity or skin laxity are poor candidates. It should be emphasized that mini-abdominoplasty is not a weight loss procedure. Smokers and those with a history of thrombophlebitis, should also be strongly discouraged from undergoing the procedure, as complication risks are increased.2,3 Patient Expectations/Informed Consent In addition to completing a pre-operative physical exam and obtaining medical clearance, the surgeon should also thoroughly review patients’ expectations. Conversation should revolve around the patient’s preferences concerning the degree of skin tightening, scarring, stretch marks, and post-operative recovery and morbidity. THE CONTOURING PROCEDURE Tumescent Liposuction • The first phase of mini-abdominoplasty is tumescent liposuction during which a dilute lidocaine solution is infused through cannulas into the lower abdominal fat, hydrodissecting the tissue plane. The infusion takes place via two small (1.0-cm to 1.5-cm) incisions, just superior to the mons pubis. • Subsequently, suction-assisted cannulas are introduced through the same incisions used for tumescent anesthesia delivery. Remaining superficial to the abdominal aponeurotic system, the syringe-assisted cannulas tunnel through the fat, and remove excess fat from the area. This phase of fat debulking also helps to better define localized skin redundancy. Connecting Liposuction Incisions • The second phase involves creation of a transverse incision (15 blade) along the horizontal sub umbilical crease. (Figures 3A and 3B) • Metzenbaum scissors are then used to undermine the tissue to a level midway to one-third below the umbilicus, thereby connecting all of the horizontal tunnels previously created by the liposuction cannulas. • The excess skin is pulled inferiorly with an appropriate degree of tension, and bifurcations are made to approximate the amount of redundant skin to be excised. • Unipolar electrocautery is used to achieve hemostasis. Plication of the Rectus Muscle • In select cases, limited plication of the rectus muscle is next accomplished placing a non-absorbable monofilament suture. • Multiple absorbable tacking sutures may be placed from the subcutaneous tissue to the musculofascial layer to help advance the flap downward, decreasing tension on the final closure line. These sutures help to bring the tissue planes together, thus also decreasing dead space and helping prevent the most common complication of the procedure: seroma/hematoma formation.1 No drains are placed. Closing and Dressing the Wound • The wound is then closed with an absorbable, subcuticular pull-out suture or small skin staples. • Finally the wound is covered with surgical tape strips and the patient is dressed in a compressive, elastic binder to provide support. DISCUSSION Advantages for Appropriate Patients Patients with increased adiposity who have a modest amount of redundant skin, scarring, or striae of the lower abdomen, along with reasonable underlying musculofascial tone, are likely to benefit most from mini-abdominoplasty. This “variation on a theme” also creates another option for abdominal contouring in those patients who have already lost weight or desire to have children, who are poor surgical risks, or who have already had a full abdominoplasty.4 Clearly, neither morbidly obese patients nor patients with significant lower abdominal flaccidity are candidates. However, in the appropriately selected patient, this form of “mini-abdominoplasty” has resulted in excellent contour improvement and a more rapid return to life activities than is seen with the traditional “full” abdominoplasty. Decreased costs, due to the physician’s ability to perform the procedure utilizing conscious sedation in an outpatient, surgical center setting, and decreased operative risks, add to the procedure’s appeal.5 Classic Abdominoplasty Complications The classic abdominoplasty is fraught with surgical complications. Local complications such as hematoma, seroma, wound dehiscence, and skin necrosis, occur in up to 32% of nonsmokers and as many as 52% of smokers.6 Generalized complications include deep vein thrombosis, pulmonary embolus, ileus, sensation disorder of the skin of the thighs, nerve palsies of the upper extremity and death.7 Decreased Risks with Mini-Abdominoplasty The limited abdominal flap undermining in the mini-abdominoplasty technique significantly decreases these risks by minimizing dead space and preserving sensory and vascular supply to the abdominal skin.2 Scar formation and flap necrosis are also minimized secondary to smaller incisions and diminished tension of the skin closure edges.4 Dehiscence can be avoided by limiting excessive tension on the closure. Fortunately, the mini-abdominoplasty offers the added advantage of minimized tension at the closure site due to decreased abdominal girth, created by prior liposuction. Selecting appropriate surgical candidates (severe coughing spells are common in smokers) and preventing constipation-associated strain also further help to reduce tension. Despite these decreased risks in comparison to full abdominoplasty, dehiscence, infections, transient hypesthesia, and hypertrophic scarring are still potential complications. SUMMARY In a day and age when so many of life’s “wants” have become down-sized, the mini-abdominoplasty appears to be following suit; the procedure is less than a full abdominoplasty, but more than a suction lipectomy alone. Mini-abdominoplasty has consistently and significantly reduced many of the problems that have been associated with classic abdominoplasty, allowing for faster patient recovery and better cosmesis.2 Despite its many advantages, it should be stressed that the success of this type of abdominal wall surgery is highly dependent upon appropriate preoperative selection of patients. Overall, the mini-abdominoplasty is a safe and effective alternative approach to body contouring and can offer a more youthful abdominal silhouette with decreased risk, minimal downtime, and a shorter scar. Dr. Bisaccia is a practicing dermatologist and Professor of Clinical Dermatology at the Columbia University College of Physicians and Surgeons in New York City. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Eickhorst is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. DISCLOSURES: Drs. Bisaccia, Rogachefsky, Eickhorst and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. Traditionally, abdominoplasty has been a hospital procedure requiring general anesthesia, with partial or full rectal muscle plication to ensure tightening of the abdomen. Although delivering impressive results, this procedure has also required significant post-operative healing time, as well as significant operative risk.1,2 The mini-abdominoplasty is a modification of the classic abdominoplasty. Mini-abdominoplasty is ideal for patients who lack the severe abdominal contouring problems requiring full abdominoplasty, but who are burdened by abnormalities too extensive to be corrected through lipoplasty alone. Under conscious sedation, tumescent liposuction is first performed to the lower abdomen, followed by excision and removal of redundant skin. The mini-abdominoplasty, therefore, has many advantages. The procedure can be performed in an outpatient surgical setting, with decreased pain, morbidity, healing time and scarring; most patients are discharged home within 3 hours of the completion of the procedure and are able to resume regular activities in 2 to 3 weeks. PATIENT SELECTION Determining Appropriate Candidates Optimal candidates for the procedure include those who have small amounts of skin laxity of the lower abdomen, but who have retained moderate lower abdominal musculoskeletal tone. It is therefore critical to perform a pre-operative physical exam of the abdominal region with the patient in multiple different positions: supine, upright and bent forward at the waist (diver’s position). This allows the surgeon to effectively determine skin elasticity, rebound and looseness. Certain maneuvers can further elucidate whether the mini-abdominoplasty is indicated for a selected patient. Physical Exam Components To assess degree of skin laxity and adiposity: • Pinch test: By pinching the fat between the thumb and index finger, the amount of subcutaneous fat is measured. When there is good skin tone, no overhanging redundant skin, and a pinch test of more than 1 inch, liposuction alone may correct the disfigurement. To assess integrity of the lower abdominal musculoaponeurotic system: • Diver’s position: Moving from an upright standing position to bending forward at the waist elucidates weakened abdominal musculature with an evident bulge. • Head raise: In a supine position, the patient is asked to raise his/her head and shoulders to tighten the abdominal muscles. Muscular weakness, hernias, and/or diastasis of the rectus muscles will become obvious. Poor Candidates Grossly obese individuals with a high degree of centripetal adiposity, or those with excess muscular flaccidity or skin laxity are poor candidates. It should be emphasized that mini-abdominoplasty is not a weight loss procedure. Smokers and those with a history of thrombophlebitis, should also be strongly discouraged from undergoing the procedure, as complication risks are increased.2,3 Patient Expectations/Informed Consent In addition to completing a pre-operative physical exam and obtaining medical clearance, the surgeon should also thoroughly review patients’ expectations. Conversation should revolve around the patient’s preferences concerning the degree of skin tightening, scarring, stretch marks, and post-operative recovery and morbidity. THE CONTOURING PROCEDURE Tumescent Liposuction • The first phase of mini-abdominoplasty is tumescent liposuction during which a dilute lidocaine solution is infused through cannulas into the lower abdominal fat, hydrodissecting the tissue plane. The infusion takes place via two small (1.0-cm to 1.5-cm) incisions, just superior to the mons pubis. • Subsequently, suction-assisted cannulas are introduced through the same incisions used for tumescent anesthesia delivery. Remaining superficial to the abdominal aponeurotic system, the syringe-assisted cannulas tunnel through the fat, and remove excess fat from the area. This phase of fat debulking also helps to better define localized skin redundancy. Connecting Liposuction Incisions • The second phase involves creation of a transverse incision (15 blade) along the horizontal sub umbilical crease. (Figures 3A and 3B) • Metzenbaum scissors are then used to undermine the tissue to a level midway to one-third below the umbilicus, thereby connecting all of the horizontal tunnels previously created by the liposuction cannulas. • The excess skin is pulled inferiorly with an appropriate degree of tension, and bifurcations are made to approximate the amount of redundant skin to be excised. • Unipolar electrocautery is used to achieve hemostasis. Plication of the Rectus Muscle • In select cases, limited plication of the rectus muscle is next accomplished placing a non-absorbable monofilament suture. • Multiple absorbable tacking sutures may be placed from the subcutaneous tissue to the musculofascial layer to help advance the flap downward, decreasing tension on the final closure line. These sutures help to bring the tissue planes together, thus also decreasing dead space and helping prevent the most common complication of the procedure: seroma/hematoma formation.1 No drains are placed. Closing and Dressing the Wound • The wound is then closed with an absorbable, subcuticular pull-out suture or small skin staples. • Finally the wound is covered with surgical tape strips and the patient is dressed in a compressive, elastic binder to provide support. DISCUSSION Advantages for Appropriate Patients Patients with increased adiposity who have a modest amount of redundant skin, scarring, or striae of the lower abdomen, along with reasonable underlying musculofascial tone, are likely to benefit most from mini-abdominoplasty. This “variation on a theme” also creates another option for abdominal contouring in those patients who have already lost weight or desire to have children, who are poor surgical risks, or who have already had a full abdominoplasty.4 Clearly, neither morbidly obese patients nor patients with significant lower abdominal flaccidity are candidates. However, in the appropriately selected patient, this form of “mini-abdominoplasty” has resulted in excellent contour improvement and a more rapid return to life activities than is seen with the traditional “full” abdominoplasty. Decreased costs, due to the physician’s ability to perform the procedure utilizing conscious sedation in an outpatient, surgical center setting, and decreased operative risks, add to the procedure’s appeal.5 Classic Abdominoplasty Complications The classic abdominoplasty is fraught with surgical complications. Local complications such as hematoma, seroma, wound dehiscence, and skin necrosis, occur in up to 32% of nonsmokers and as many as 52% of smokers.6 Generalized complications include deep vein thrombosis, pulmonary embolus, ileus, sensation disorder of the skin of the thighs, nerve palsies of the upper extremity and death.7 Decreased Risks with Mini-Abdominoplasty The limited abdominal flap undermining in the mini-abdominoplasty technique significantly decreases these risks by minimizing dead space and preserving sensory and vascular supply to the abdominal skin.2 Scar formation and flap necrosis are also minimized secondary to smaller incisions and diminished tension of the skin closure edges.4 Dehiscence can be avoided by limiting excessive tension on the closure. Fortunately, the mini-abdominoplasty offers the added advantage of minimized tension at the closure site due to decreased abdominal girth, created by prior liposuction. Selecting appropriate surgical candidates (severe coughing spells are common in smokers) and preventing constipation-associated strain also further help to reduce tension. Despite these decreased risks in comparison to full abdominoplasty, dehiscence, infections, transient hypesthesia, and hypertrophic scarring are still potential complications. SUMMARY In a day and age when so many of life’s “wants” have become down-sized, the mini-abdominoplasty appears to be following suit; the procedure is less than a full abdominoplasty, but more than a suction lipectomy alone. Mini-abdominoplasty has consistently and significantly reduced many of the problems that have been associated with classic abdominoplasty, allowing for faster patient recovery and better cosmesis.2 Despite its many advantages, it should be stressed that the success of this type of abdominal wall surgery is highly dependent upon appropriate preoperative selection of patients. Overall, the mini-abdominoplasty is a safe and effective alternative approach to body contouring and can offer a more youthful abdominal silhouette with decreased risk, minimal downtime, and a shorter scar. Dr. Bisaccia is a practicing dermatologist and Professor of Clinical Dermatology at the Columbia University College of Physicians and Surgeons in New York City. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH. Dr. Rogachefsky is a practicing dermatologist and is the Program Director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ. Dr. Eickhorst is a Fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ. DISCLOSURES: Drs. Bisaccia, Rogachefsky, Eickhorst and Scarborough disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
