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 re-
gion by means of abdominoplasty surgery. 2. Describe the current modalities
for preventing and managing perioperative pain associated with abdomino-
plasty surgery. 3. Discuss proper techniques for safely performing simultane-
ous 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 periopera-
tive complications in abdominoplasty patients.
Summary: Abdominoplasty continues to be one of the most popular cosmet-
ic surgeries performed by plastic surgeons throughout the world. Advance-
ments 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 abdomi-
noplasty surgery. (Plast. Reconstr. Surg. 133: 1214, 2014.)

CLINICAL SCENARIO “C-section,” “scars,” “antibiotic prophylaxis,”

A 47-year-old woman with a body mass index
of 23 comes to see you in consultation for abdom-
inoplasty surgery. She also complains of excess
fatty tissues on her flanks bilaterally. She has a his-
tory 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 occa-
sional acetaminophen. She has no medical prob-
lems 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 abdomino-
plasty, 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: “abdomi-
noplasty,” “risk factors,” “smoking,” “tobacco,”
“venous thrombosis,” “venous thromboembo-
lism,” “DVT,” “diabetes,” “obesity,” “gynecology,”
From Aesthetic and Reconstructive Plastic Surgery; and the
Aesthetic and Plastic Surgery Institute, University of Cali-
fornia, 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
“psychosocial,” “seroma,” “infection,” “outcome,”
“BMI,” “psychosocial,” “pulmonary embolism,”
“PE,” “outpatient,” “lipoabdominoplasty,” “quilt-
ing sutures,” “liposuction,” “combined,” “tummy
tuck,” “mommy makeover,” and “breast augmen-
tation.” The search was limited to human studies
and articles published between 2008 and 2013 as
an update to the 2010 abdominoplasty Mainte-
nance of Certification article published by Buck
and Mustoe (Level of Evidence: Therapeutic, V).1
Studies were excluded if the full text was not avail-
able or the article was of non-English language.
Studies were assessed for quality and assigned a
level of evidence according to the American Soci-
ety 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 thor-
ough history and physical examination, which is
essential for identifying potential risks during sur-
gery. As previously discussed by Buck and Mustoe,
abdominoplasty carries a higher risk of wound
Disclosure: None of the authors has a financial in-
terest in any of the products, devices, or drugs men-
tioned in this article.

1214 www.PRSJournal.com
Volume 133, Number 5 • Abdominoplasty
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 infec-
tions.6 Araco et al. found that even after smokers
quit tobacco 4 weeks before abdominoplasty, the
risk of infection was 14.3 percent versus 1.2 per-
cent 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
Wound infection continues to be the second
most common complication in abdominoplasty
surgery.7 In 2007, Sevin et al. showed that abdom-
inoplasty patients with a single dose of antibiotic
prophylaxis preoperatively had fewer infections
than those patients that did not receive antibiot-
ics (Level of Evidence: Therapeutic, II).8 These
results emphasize the need for prophylactic pre-
operative antibiotic administration in abdomi-
noplasty 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 cover-
age against resistant bacteria (e.g., methicillin-
resistant 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 determin-
ing the exact course for antibiotic administration
in abdominoplasty surgery.
EVIDENCE ON DEEP VENOUS
THROMBOSIS PROPHYLAXIS
Although there is substantial evidence in the
orthopedic literature regarding prevention of
venous thromboembolism with chemoprophylaxis
during elective operations, there is no consensus
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 Assess-
ment 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 abdomi-
noplasty (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 abdomino-
plasty was combined with any other plastic surgery
procedure, the risk was only 0.76 percent.10
Newall et al. presented data on the use of
­low-molecular-weight heparin in their patients fol-
lowing 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 com-
plications and no patients developed deep vein
thrombosis or pulmonary embolism.
Somogyi et al. developed a protocol to reduce
venous thromboembolism in abdominoplasty
without chemoprophylaxis.12 This regimen con-
sisted of graded compression stockings worn pre-
operatively and 7 days postoperatively, intermittent
pneumatic compression devices placed before
surgery and until discharge, strict intraopera-
tive 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 chemopro-
phylaxis 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 PAIN MANAGEMENT
AND OUTPATIENT SURGERY
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
1215
 Plastic and Reconstructive Surgery • May 2014

using pain blocks. In a retrospective review of Abdominoplasty has been shown to be safe
abdominoplasty patients over a 10-year period, when performed in the outpatient setting. Gray
Feng compared outcomes of 20 patients who et al. reported an 8-year retrospective review of
received no blocks versus 77 patients who received 206 patients undergoing abdominoplasty who
a combination of nerve blocks. He found that were discharged to home the same day without
using nerve blocks (both intercostal and pararec- any incidence of pulmonary embolism, venous
tus blocks) in conjunction with general anesthe- thromboembolism, need for blood transfusion,
sia was associated with less pain medication use intraabdominal perforation, or death.19 All opera-
(3.1 mg of morphine in the treatment group ver- tions were performed in outpatient ambulatory
sus 12.8 mg of morphine in the control group; p facilities accredited by the American Association
< 0.0001).13 In addition, less time was needed in for Accreditation of Ambulatory Surgery Facili-
the recovery room, lower pain scores (using the ties. All patients had an American Society of Anes-
visual analogue scale ranging from 0 to 10) were thesiologists class of 1 or 2. No chemoprophylaxis
noted at home (3 for the treatment group versus was given, and discharge criteria included void-
7.5 for the control; p < 0.0001), and a shorter time ing, tolerating oral intake, and early ambulation.
to resume normal activities was also noted in the All patients were discharged the same day and
nerve block group.13 patients were seen in the clinic on postopera-
A separate study comparing intercostal rib tive day 2 for follow-up.19 Despite our extensive
blocks plus intravenous sedation versus general literature search of this topic, we were unable to
anesthesia alone had similar results.14 In this locate any articles or data pertaining to the safety
study, all abdominoplasty cases performed by a of performing abdominoplasty in the office set-
single surgeon from 1999 to 2006 were evaluated ting outside of an accredited operating room. At
retrospectively and divided into two groups: those this time, based on a complete lack of evidence in
operations that had been performed under gen- our current literature, we cannot make any rec-
eral anesthesia (group 1, n = 39) and those that ommendations on office-based abdominoplasties
had been performed using rib blocks and intra- until substantial, credible evidence arises to sup-
venous sedation (group 2, n = 29). Group 2 treat- port this practice.
ment was associated with a statistically significant
decrease in recovery room time, postoperative EVIDENCE ON SURGICAL
narcotics, pain, nausea, and vomiting. This study
was performed in an outpatient setting, with no
TREATMENT PLAN
reported hospital admissions, no increase in oper- The general concept behind abdominoplasty
ative time, and no major complications or deaths surgery has remained fairly constant over the
in 29 operations in the treatment group.
In a prospective, randomized, double-blind
study, Sforza et al. 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 anesthesia–infused pain pumps placed
after abdominoplasty have also been shown to
decrease perceived pain and oral narcotic use.16
Smith et al. 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 Fig. 1. Depiction of traditional low-lying incision placement for
without the use of local anesthetic pain pumps.18 abdominoplasty surgery.

1216
Volume 133, Number 5 • Abdominoplasty

years. The overall idea is to improve the contour

of the abdominal wall by means of rectus abdomi-
nis 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 innova-
tion in abdominoplasty. Advancements in the fol-
lowing areas of abdominoplasty will be the core of
discussion in this section: the addition of simulta-
neous suction lipoplasty, limited flap undermin-
ing, preservation of tissue on the rectus fascia,
use of tension quilting sutures at closure, man-
agement of the umbilicus, and combination of
abdominoplasty with other surgical procedures.
The goal of this discussion is to help surgeons in Fig. 2. Recommended limited midline suprafascial dissection of
determining a safe surgical treatment plan for the abdominal wall during abdominoplasty surgery.
new abdominoplasty patients presenting to the
office for consultation.
One major advance in the area of abdomino- liposuction tunnels create a sliding plane for the
plasty has been the increasing addition of liposcu- abdominal wall flap by disrupting skin retaining
lpture. Patient satisfaction rates for the combined ligaments yet sparing large essential perforator
lipoabdominoplasty procedure have been shown vessels needed for circulation.26
to be better when compared with traditional The level of dissection in abdominoplasty has
abdominoplasty alone.20 Heller et al.21 performed been examined as having an effect on seroma
a 114-patient retrospective analysis of patients formation and drain maintenance. Traditionally,
undergoing abdominal contouring procedures abdominal flap dissection was carried out directly
and found lower complication rates in patients on the anterior surface of the muscle fascia in
who underwent lipoabdominoplasty compared all regions. In addition to limiting the total sur-
with traditional abdominoplasty. In the past, there face area of dissection as discussed above, it has
was caution emphasized when combining abdom- been advocated that a thin layer of tissue be left
inoplasty with aggressive liposuction for fear of on the fascia to decrease the incidence of post-
abdominal flap vascular compromise and subse- operative seroma and reduce the total length of
quent flap necrosis. This was based on the tradi- time that drains are needed.27 More recent stud-
tional wide lateral dissection abdominoplasties ies have examined leaving even more tissue on
with extensive undermining, which would often the muscle fascia by performing the dissection
sacrifice important abdominal wall perforator ves- above the Scarpa fascia in the lower abdomen
sels and lymphatics. There are significant recent and only then transitioning to the prefascial layer
data that clearly show success with aggressive
liposuction in combination with abdominoplasty
(Level of Evidence: Reference 22: Therapeutic,
II; Reference 24: Therapeutic, III).22–24 However,
careful modifications in technique must be fol-
lowed to safely preserve vascular supply to the skin
flaps. One key to success with this combination
technique is in only creating a limited suprafas-
cial tunnel from the umbilicus up to the xiphoid
process for the full rectus fascia plication. Dissec-
tion laterally from the midline is generally limited
to 7.5 cm (Fig. 2).22 This method preserves major
lateral abdominal wall perforators that would oth-
erwise be sacrificed with traditional techniques. In
addition, liposuction is generally performed deep
to the Scarpa fascia except in the lower abdomen Fig. 3. Illustration of placement of tension quilting sutures dur-
in the area of pannus to be excised.20,25 The deep ing inset of the abdominal flap during abdominoplasty surgery.

1217

in the epigastrium and infraumbilical midline,
where plication of the rectus fascia needs to be
performed.28,29 These studies have shown signifi-
cant 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 main-
tenance.31 Some advocate no need for drains when
tension quilting sutures are used. Of 597 cases per-
formed using progressive tension sutures on clo-
sure, 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 heal-
ing 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
et al. performed careful intraoperative measure-
ments on 40 consecutive patients and concluded
the ideal location for the umbilicus to be 15 cm
from the midpubis in patients 145 to 178 cm in
height.34 Using a system of formulas and regres-
sion analysis, Pallua et al. 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 ori-
ented, concave structure.36–38 To achieve these
goals at inset, different surgical techniques have
been offered. Use of an inverted V- or U-type inci-
sion in the abdominoplasty flap has resulted in
high patient and surgeon satisfaction rates.35,36 In
2011, Mazzocchi et al. published their technique
using vertical double-opposing Y flaps on 111
abdominoplasty patients.39 Their results after 5
1218
Plastic and Reconstructive Surgery • May 2014
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 pro-
posed 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, Cló and
Nogueira published their results of 306 consecu-
tive 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 abdomi-
noplasty 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 abdomino-
plasty may cause some hesitation for fear of infec-
tion. Sinno et al. 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 hysterec-
tomies with and without ­salpingo-oophorectomies.
Twenty-five patients were followed. There were no
differences in complication rates of the combined
abdominoplasty/hysterectomy patients when com-
pared with control abdominoplasty patients. The
only significant difference was duration of opera-
tion, 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 liposuc-
tion versus lipoabdominoplasty versus traditional
Volume 133, Number 5 • Abdominoplasty
abdominoplasty in a prospective evaluation of
360 patients.20 He found that patients who under-
went 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 tech-
niques were compared: wide flap undermining
with wet liposuction, wide flap undermining with
superwet liposuction, and limited flap under-
mining with liposuction and suture tension clo-
sure technique (Table 1). Seroma formation was
less common with the group 3 technique and was
highest with group 1. Group 1 also had the high-
est 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 et al. 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 requir-
ing antibiotics was 7.5 percent, and the seroma
rate was 3.4 percent. There was only a 1.1 per-
cent rate of skin flap necrosis that required read-
vancement 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 et al. 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 previ-
ous abdominal surgery that resulted in signifi-
cant supraumbilical scarring. They found no
difference in perfusion-related complications
Table 1. Comparison of Three Different Treatment
Techniques
Surgical
­Technique Description
Group 1 Wide abdominal undermining; wet
­liposuction
Group 2 Wide abdominal undermining with
extended lower lateral dissection;
superwet liposuction; ultrasound-assisted
liposuction of flanks
Group 3 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 lipoabdomino-
plasty, which included direct liposuctioning of the
abdominal flap.
In a case-control study of combined gyneco-
logic surgery and abdominoplasty surgery, Sinno
et al. reported reduction in operative time and
blood loss, and a decrease in total days of hospi-
talization when comparing the combined surgical
procedures with the sum of the two separate pro-
cedures.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 esti-
mated blood loss was 350 ml compared with 551 ml
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 deliv-
ery with abdominoplasty, the results were not so
promising. Fifty patients were reviewed with 6
months of follow-up after cesarean delivery com-
bined with abdominoplasty.44 Results revealed
a wound infection rate of 18 percent, a wound
dehiscence rate of 9 percent, and lower abdom-
inal 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 et al. 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 cho-
lesterol levels.46
Sensory changes also occur as a result of
abdominoplasty. Lapid et al. evaluated postopera-
tive 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 stan-
dard abdominoplasty.
In addition to the physical changes that occur
with abdominoplasty surgery, there are also posi-
tive emotional ones that arise. Papadopulos et al.
1219

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 et al. showed that
even patients who experienced complications
after undergoing abdominoplasty surgery were
generally not negatively impacted by the occur-
rence.49 On the contrary, they were satisfied with
the procedure and would recommend the sur-
gery to a friend.
SUGGESTED TREATMENT FOR THE
CLINICAL SCENARIO
Based on the available evidence, the best treat-
ment 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 ambu-
lation.13 Abdominoplasty combined with lipo-
suction, 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.21,25–27
Following fascial plication, closure would be per-
formed with tension suture technique to mini-
mize seroma formation.37 Suction drains might be
placed, but would be removed in an expeditious
manner if used. This procedure would be per-
formed 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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Plastic and Reconstructive Surgery • May 2014
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