INTRODUCTION
Obesity is initially characterized by a body mass index (BMI) ≥30kg/m2, it is a condition that has grown in many countries, and today it has become a serious
public health problem in most of them; around 2.1 billion adults are obese1,2. In Europe, the United Kingdom has the largest population of obese people on the
continent, reaching a rate of 28%; in the United States of America, there are about
150 million obese adults, while in Brazil, according to the Brazilian Institute of
Geography and Statistics (IBGE), 41.2 million people over 18 years old are obese3,4,5,6.
The National Health System in the United Kingdom invests 5.3 billion pounds a year
in actions to control obesity, as it understands the seriousness of this problem,
as it is linked to the development of several comorbidities, such as hypertension,
cardiovascular diseases, hyperlipidemia, stroke, osteoarthritis, obstructive sleep
apnea, diabetes mellitus, and carcinomas. All can directly affect the health of these
people and reduce their life expectancy3,7.
The first step in treating patients with a BMI of 30kg/m2 to 34.9kg/m2 is lifestyle changes, physical exercise, and nutritional and endocrinological follow-up7. Those with a BMI >40kg/m2 or >35kg/m2 with severe comorbidities are eligible for bariatric surgery7.
The search for treating type II obesity with comorbidities and type III obesity has
been increasing, considering that gastroplasties can be associated with reducing weight
and secondary comorbidities to this disease8,9. Of course, always in conjunction with changes in lifestyle, habits, and nutritional
and endocrine monitoring, making it the most effective way to accelerate weight loss9.
However, this intense and rapid loss of adipose tissue can also involve adverse effects.
The main disadvantages are dermoadipose ptosis caused by collagen changes in post-bariatric
patients, characterized by dimorphism in regions of the thighs, arms, breasts, and
abdomen7,10,11. In addition to the psychological damage caused, poor hygiene, skin infection, dermatitis,
and difficulty walking are also observed, which can aggravate the psychological condition11.
Plastic surgery then plays a fundamental role in tissue replacement and psychological
and social reintegration of these individuals who underwent gastroplasty and with
weight loss, and abdominoplasty is the most requested procedure for treating post-bariatric
treatment patients. According to the International Society of Plastic Surgery, 112,116
abdominoplasties were performed in 2020, representing 8.6% of all plastic surgeries
in Brazil12.
However, there are indication criteria: a minimum of 12 to 18 months after bariatric
surgery, weight stability for at least 3 to 4 months, and BMI below 30kg/m2. These parameters are important, as nutritional homeostasis is a positive nitrogen
balance necessary to heal large surgical wounds13. Thus, the theme’s relevance and its main and most current techniques for the scientific
society are highlighted.
OBJECTIVE
This systematic review aims to present the main abdominoplasty techniques in post-bariatric
patients, their main postoperative complications, and the improvement in the patient’s
quality of life and psychosocial status after the surgery.
METHOD
A systematic literature review was carried out following the PRISMA statement using
epidemiological data from the Brazilian Institute of Geography and Statistics (2019)
and the International Society of Plastic Surgery (2020) in order to answer the PICO
question -What are the main techniques used of abdominoplasty in post-bariatric patients
after massive weight loss? -.
The search was carried out on 07/19/2022 in the PubMed, BVS, SciELO, and Cochrane
databases, applying the following descriptors, respectively: “Abdominoplasty” AND
“Patients” OR “Bariatric surgery” AND “Plastic surgery” AND “Body contouring. “ All
descriptors were validated in DeCS/MeSH. Time limitation between 2017 and 2022 and
articles in Portuguese, English, Spanish, Italian, and French were used.
Therefore, studies that met the following criteria were included in this review: (1)
case reports, randomized or quasi-randomized clinical trials, prospective/ retrospective
case series, retrospective/prospective cohorts; (2) in humans; (3) revisions; (4)
post-bariatric patients; (5) the most used abdominoplasty techniques in post-bariatric
patients. Finally, all papers that did not meet the inclusion criteria were excluded.
The main techniques to be addressed in this review are traditional or classic horizontal
abdominoplasty, fleur-de-lis or anchor, circumferences, and with Scarpa’s fascia.
These four techniques can be associated with other surgeries, for example, neophalloplasty
and liposculpture; however, they are not addressed in this research8,12,13,14.
Traditional or classic horizontal abdominoplasty
Vernon, Callia, Pitanguy, Regnaul, Grazer, and Baroudi described it. The markings
of this technique may have anatomical variations. In general, a straight line begins
above the pubic symphysis and extends parallel to the height of the iliac crest, then
the clamping test occurs to delimit the region to be removed, and it is then possible
to delimit the upper marking, which can have variation concerning its positioning.
At the end of the marking, something similar to an ellipse is expected8,14 (Figure 1).
Figure 1 - Markings of Abdominoplasty techniques. (A) Fleur-de-lis; (B) Classical; (C) Fleur-de-lis
with Scarpa’s fascia; (D) Classic with Scarpa’s fascia. Copyright image.
Figure 1 - Markings of Abdominoplasty techniques. (A) Fleur-de-lis; (B) Classical; (C) Fleur-de-lis
with Scarpa’s fascia; (D) Classic with Scarpa’s fascia. Copyright image.
Fleur-de-lis or anchor abdominoplasty
Castanhares and Goethel described it. The markings begin at the xiphoid process and
extend to the pubic symphysis region, forming a large ellipse. In sequence, the inferior
marking is performed in the region of the pubic symphysis through the “pinch test”
for marking the base of the T, containing a slight convexity, which will extend from
one iliac crest to the other. In this way, the markings will overlap, forming a single
marking with the shape of a fleur-de-lis8,14 (Figure 1).
Circumferential abdominoplasty
Gonzalez Ulloa described it. Markings must be performed with the patient in a supine
position. In the anterior part, the standards of the classical technique must be followed,
respecting the anatomical variations already described above. In the posterior part,
the intergluteal groove must be identified to start the marking where a point just
above it is indicated, called the “A” point. Superior to point “A”, a new point is
marked, which is called point “B”, which is the upper limit of the resection14 (Figure 2).
Figure 2 - Marking of the Circumferential technique. (A) Anterior portion of the marking; (B)
Posterior portion.
Figure 2 - Marking of the Circumferential technique. (A) Anterior portion of the marking; (B)
Posterior portion.
Abdominoplasty with preservation of Scarpa’s fascia
Described by Saldanha. Patient marking is the same as the fleur-de-lis and traditional
technique8,9,14. However, there are differences regarding the surgical technique (Figure 1).
RESULTS
In the identification of studies via databases and registrations, the electronic search
carried out in PubMed (n=111), Medline (n=30), LILACS (n=5), SciELO (n=1), Cochrane
(n=102), Binacis (n=1). Two hundred fifty references were found, and duplicated, or
ineligible records or records that did not open were excluded before screening (n=11).
Soon after, screening was performed, divided into three phases. All 239 titles were
read in the first, and 119 were excluded, as they did not contemplate the theme. In
phase 2, all 120 abstracts were analyzed, and 89 references, which were not relevant
to the study, were excluded. In phase 3, the 31 full texts were deeply examined, and
6 articles were removed because they did not pass the eligibility criteria: Portuguese,
English, Spanish, Italian, French, and last 5 years. This resulted in an n=25.
In addition, studies were identified using other methods at the Brazilian Institute
of Geography and Statistics - IBGE (n=44) and the International Society of Plastic
Surgery (n=7). In the screening, 48 records were excluded, as they were not surveys
carried out in the last 5 years and did not address the subject of abdominoplasty
or obesity, which resulted in three findings. Therefore, 28 references were included
in this systematic review (Figure 3).
Figure 3 - Organization chart of the results obtained in this systematic review, which used the
PRISMA method.
Figure 3 - Organization chart of the results obtained in this systematic review, which used the
PRISMA method.
DISCUSSION
Post-bariatric patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass
can usually develop a lack of vitamin B12, folic acid, iron, calcium, vitamin D and
vitamin K, minerals, and protein-caloric malnutrition, with iron deficiency and nutritional
deficiency the most frequent7,8,13,15,16,17,18,19. It is noteworthy that vitamin K is necessary for normal blood clotting; its deficiency
can lead to major secondary bleeding8.
Therefore, follow-up with the nutritional team is essential to improve the parameters
before the abdominoplasty mentioned in the present study8,20.
Most patients with marked weight loss after bariatric surgery seek body contouring
surgery due to excess skin in various body regions (arms, thighs, lower abdomen, breasts,
and inguinal region). This loss of skin elasticity can cause skin folds, resulting
in fungal infections, eczema, ulcers, and edema, in addition to a worsening in the
quality of life, leaving them socially isolated, without practicing daily activities
and with low self-esteem, feeling even dissatisfied with their aesthetic image after
the bariatric procedure3,7,15,20,21,22.
In this sense, body contouring surgery improves the quality of life and promotes psychosocial
reintegration17,20. A study in the United Kingdom showed that patients who underwent abdominoplasty
significantly improved their body image and quality of life. 92% of these patients
recommended plastic surgery to their friends, and 96% have no regrets3.
Patients with the so-called “apron abdomen” are recommended to undergo abdominoplasty
due to the possible complications generated by this condition23. It is clear that the plastic surgeon must perform a thorough physical examination
to identify all deformities and detect comorbidities, BMI, body type, amount of adipose
tissue, localized fat deposits, the existence of diastasis of the abdominal muscles,
folds, and the presence of hernias24,25,26.
The body fat distribution in these patients is variable, influencing the surgical
options24. To facilitate the analysis of deformities in each anatomical region of the body,
Luján applied a four-point scale called the Pittsburgh Scale, which serves as a guide
for choosing the best abdominoplasty technique related to the specificities of the
patients7,20. Abdominoplasty techniques have their specificities for each indication23.
The conventional one is indicated for the correction of abdominal diastasis, as well
as correction of ptosis, removal of stretch marks, and dermoadipose panicle in the
lower abdomen8. The traditional fleur-de-lis technique for patients with medium-sized scars on the
abdomen, abdominal hernias, and/or excess horizontal/ vertical dermoadipose panicle8,24. The circumferential technique, in cases where, even after a great loss of body mass,
there is a trace of adipose tissue together with excess skin in the lower abdomen,
flanks, and back and in the elevation of the trochanteric fossa11,17. Finally, the one that maintains Scarpa’s fascia is still not very clear9,25.
The applicability of abdominoplasty techniques may contain some similarities and differences.
The classic one begins with a scalpel incision in the delimited area, without a specific
order, and can then occur in the suprapubic region up to the anterior superior iliac
spine, bilaterally as the fleur-de-lis. With the preservation of Scarpa’s fascia,
since in the circumferential one, the incision occurs in the posterior region of the
patient, the anterior part is a traditional abdominoplasty9,13,14,24,25,27.
In sequence, the first part of the adipose tissue dissection takes place in its entirety
until the depth of the aponeurosis of the abdominal muscles, following the height
of the navel in the traditional technique, fleur-de-lis; in contrast, the circumferential
one starts from point “A” and goes towards the flanks, leaving only the deep fat fascia
as in the abdominoplasty with preservation of Scarpa’s fascia9,20,25,26.
The second part of the subcutaneous dissection occurs up to the height of the xiphoid
process (vertical) and costal margin (horizontal) in the classic and anchor8. In the
latter and the technique of preserving Scarpa’s fascia, an incision is made from the
navel to the xiphoid process, forming a flower8. So, at this moment, it is evident that the abdominoplasty with the preservation
of the deep subcutaneous tissue is very similar to the classic fleur-de-lis; however,
it differs only in terms of the maintenance of the deep fat layer. In all techniques,
the flaps are resected, and diatheses are treated8,9,27.
A detailed analysis of possible surgical complications between the techniques above
is essential8. In this way, the plastic surgeon can potentially reduce risks and determine the
most convenient choice for post-bariatric surgery8. De Macedo et al.28 divided post-bariatric patients into two groups (n=207) with BMI ≥30kg/m2 and <30kg/m2. The authors observed that patients with a BMI ≥30kg/m2 did not have a higher risk of postoperative complications than those with a BMI <30
kg/m2; however, there is no exposure of which abdominoplasty techniques were used.
Schlosshauer et al.8, in a retrospective study at the Agaplesion Markus Hospital, Frankfurt, Germany,
with 406 post-bariatric patients undergoing abdominoplasty, compared the three techniques
-traditional abdominoplasty, fleur-de-lis, and miniabdominoplasty with preservation
of Scarpa’s fascia - and just like Macedo et al. they were also divided according
to the same BMI criteria. The two most used techniques were the traditional one (64%;
n=261), followed by fleur-de-lis (27%; n=141), and with preservation of deep adipose
tissue (8.4%; n=4)8. The total number of complications was 42%; the main ones observed were scarring,
skin dehiscence, infection, and necrosis; the three added up to 32%. The horizontal
had fewer total complications than the anchor (38.7% and 47.7%, respectively)8. Therefore, the importance of reducing BMI is notorious, regardless of the technique
used, because, in this way, the patient is less susceptible to postoperative complications
As mentioned above, the most reported complication was skin healing; however, it is
not understood whether seroma formation is directly related to quality9,25. For this reason, two other studies that compare the anchor and classic techniques
with and without preservation of Scarpa’s fascia observed that the maintenance of
deep adipose tissue is beneficial, simply because drainage is more efficient because
in both studies in the postoperative bariatric patients, there was no development
of seroma and complications. However, when evaluating scar satisfaction using the
Pittsburgh Scale, there was no difference between the two groups9,25. It is understood, then, that seroma, when analyzed in isolation, does not directly
interfere with the quality of healing.
Finally, circumferential abdominoplasty has little statistical data to compare it
with complications. In a retrospective study with 180 post-bariatric patients, only
four patients underwent surgery; Bunting also cited only two patients out of a total
of 1611,17.
CONCLUSION
It is concluded that the improvement in the quality of life of patients submitted
to any abdominoplasty is evident; however, there is still a lack of research that
relates abdominoplasty techniques in post-bariatric patients with their postoperative
complications. It is extremely important to use evidence-based medicine in the applicability
of techniques in these patients, as surgeons can reduce this way risks and complications.
1. Sociedade Brasileira de Cirurgia Plástica, São Paulo, SP, Brazil
2. Universidade Santo Amaro, Faculdade de Medicina, São Paulo, SP, Brazil
Corresponding author: Matheus Lucena Miranda Meroni Faculdade de Medicina da Universidade Santo Amaro, Rua Prof. Enéas de Siqueira Neto,
340, Jardim das Imbuias, São Paulo, SP, Brazil. Zip code: 04829-300 E-mail: matheusmiranda742@gmail.com
