Operative Strategies

Marriage Abdominoplasty:
A Short Scar Technique
Short scar abdominoplastythat is, a marriage of
aggressive superwet lipoplasty, rectus abdominis muscle plication, and excision of lower abdominal skin and
excess adipose tissuecan be used as an alternative to
conventional abdominoplasty in properly selected
patients. According to the authors, this technique
offers the advantages of less invasive surgery,
decreased pain, and faster return to work. (Aesthetic
Surg J 2002;22:294-301.)

he selection of technique for abdominal contouring

depends on the patients deformity. A logical classification of these deformities is described by Bozola
and Psillakis.1 For treatment of type II and III abdominal
deformities, which are marked by lower abdominal skin
excess, increased subcutaneous adipose tissue, and muscle
laxity, we use aggressive superwet lipoplasty with a rectus
abdominis muscle plication and excision of lower abdominal skin and excess adipose tissue.
This procedure combines lipoplasty of the entire abdomen
and adjacent anatomic regions, where indicated, with elevation of a lower abdominal skin flap to the level of the
umbilicus to plicate the musculofascial layer and permit
lower abdominal skin resection, preserving excellent circulation to the upper and lower abdominal skin flaps.
Circulation is interrupted to the central lower abdominal
tissues only. Therefore this technique, which incorporates
lipoplasty, musculofascial plication, and skin tightening,
can be performed without concern for blood supply,
achieving excellent results in many patients.

Preoperative Evaluation and Markings

Careful patient selection is the key to consistent success
with limited or short scar abdominoplasty. Close attention to the patients chief complaint and a detailed physical examination are of paramount importance. Examine
the abdominal area with the patient in both the supine

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and upright positions, noting the important aesthetic

relationships including distance between costal margin
and iliac crest, as well as the
topographic relationships
between xiphoid and umbilicus and umbilicus and pubic
area. Note the presence of
excess adipose tissue in the
abdomen, inframammary
region, and lower thoracic
region, as well as in the contours of the lateral
abdomen, waist area, and
flank region. It is important
to differentiate between subcutaneous adipose tissue
excess and intraperitoneal
adiposity. The latter is not
amenable to treatment with
any abdominoplasty technique.1

Kenneth C. Shestak, MD,

Pittsburgh, PA, is a board-

certified plastic surgeon and an

ASAPS member.

Klaus J. Walgenbach, MD,

Pittsburgh, PA, is a plastic

surgeon.

It is important to identify
the presence and location of
muscle laxity in the abdominal wall. Some degree of
laxity almost always exists
in the lower abdomen
because of the absence of
the posterior rectus fascia
below the arcuate line.
While the patient is standing
Kodi Azari, MD, Pittsburgh,
with a relaxed abdomen,
PA, is a plastic surgeon.
assess muscle laxity and its
contribution to the abdominal contour deformity.
Next, perform a maneuver to simulate correction of laxity (Figure 1, A). Apply gentle, posteriorly directed pressure, with the ulnar aspect of your hand, over the

Operative Strategies

Illustrations by William M. Winn, Atlanta, GA.

Figure 1. A, With the patient upright and supported against a wall, gentle pressure, directed posteriorly, is applied by the examiners hand.
Application of posteriorly directed pressure on the infraumbilical midline will simulate infraumbilical muscle plication. B, When performing manual
external simulation of lower abdominal (infraumbilical) rectus abdominus muscle plication, the examiner focuses on the upper abdomen to
assess the extent of the bulging. Significant bulging in the upper abdomen indicates the need for full-length rectus abdominis muscle plication.

infraumbilical midline with the patient standing supported against a wall or door. If complete correction of the
laxity occurs without producing an upper abdominal
bulge, then infraumbilical plication alone will produce
the necessary contour correction. If this maneuver produces bulging in the upper abdomen, a full rectus abdominis muscle plication is most likely needed (Figure 1, B).
Limited scar abdominoplasty addresses lower abdominal
skin excess but does not treat excess skin in the upper
abdomen. Patients with excess upper abdominal skin
must be treated with a full abdominoplasty in which the
area of skin excess is undermined and advanced. Finally,
photographs are taken of the frontal view and right and
left lateral and oblique views.

Operative Procedure
For marking, place the patient in a standing position
and delineate the areas that are to undergo lipoplasty
(Figure 2). Use the pinch test (while the patient is
standing) to accurately estimate the proposed skin
excision. Perform surgical preparation and draping
with the patient supine unless circumferential contour-

Marriage Abdominoplasty: A Short Scar

Technique

ing is planned, in which case a standing circumferential preparation is performed and the patient is placed
on a sterile operating room table. The procedure can
routinely be performed with the patient under local
anesthesia with deep conscious sedation and use of
wetting solution infiltration. Our preference is to add
lidocaine 125 mg (1% xylocaine 12.5 mL) plus 1 mL
epinephrine 1:1000 to each liter of normal saline solution.
Begin the procedure with subcutaneous infiltration of the
wetting solution and follow with conventional powerassisted or ultrasound-assisted lipoplasty of all the
marked areas. Expose the musculofascial layer of the
abdomen by elevating the lower skin flap according to
the marks established by the pinch test. Elevate the lower
abdominal flap with the electrocautery to maximize
hemostasis. Then resect the skin excess marked before the
operation (Figure 3). Make the incisions long enough to
excise any folds of overhanging skin. In many patients,
excess skin typically can be excised from the lower
abdomen, above the pubic area, for a distance of about 6
cm toward the umbilicus. It is important to maintain 11

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Figure 2. The patient is marked for lipoplasty of the abdomen, waist,

and adjacent contours, as necessary.

Figure 3. Limited undermining of the central lower abdominal flap.

cm of skin between the umbilicus and pubic hair to maximize abdominal wall aesthetics. The horizontal length of
the incision is determined by the presence, or absence, of
skin folds and the width of the skin ellipse to be
removed. Muscle laxity in the abdomen is then
addressed. In cases of infraumbilical muscle laxity, we
perform an infraumbilical muscle plication (Figure 4).
Begin by marking the position of the suture lines with
methylene blue. We then commonly use 0-Surgilon
sutures (Tyco International Ltd, New York, NY), placed
in a buried figure of 8 technique to plicate the anterior
rectus fascia. If laxity persists, further plication is performed. If supraumbilical musculofascial laxity exists, we
simply undermine a small area (8 to 10 cm wide), extending from the umbilicus to the xiphoid. When a full-length
plication of the abdominal musculature is necessary, an
endoscope can greatly facilitate muscle plication.2

Somerville, NJ). As noted previously, at least 11 cm of

skin between the umbilicus and pubis must be retained to
preserve an aesthetic relationship between these areas.
Introduce a single Jackson Pratt suction drain (Allegiance
Healthcare, McGraw Park, IL) through a small incision
in the pubic area and suture to the skin after muscle plication and premarked skin excision are completed. Close
the wound in layers with 3-0 PDS sutures to carefully
approximate Scarpas fascia or the superficial fascial system; close the deep dermis with buried sutures of 4-0 PDS
and approximate the skin with a running intradermal
suture. Apply a nonadherent foam and a compression
garment to conclude the procedure.

Additional lateral undermining of the abdominal tissues

adjacent to the midline may be required, after upper
abdominal muscle plication, for proper draping of the
upper abdominal tissues. In rare cases in which the
umbilicus is floated, we reapproximate the umbilicus
to the linea alba with 3-0 PDS sutures (Ethicon Inc,

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Discussion
The classic abdominoplasty operation was developed to
correct pronounced skin excess and significant musculoaponeurotic laxity seen most frequently in multiparous
women with significant weight loss. Frequently, these
patients present with Bozola and Psillakis1 type V category changes and require lengthy incisions to allow for
appropriate skin resection and muscle plication. Our
experience indicates that type V abdominal deformities

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Operative Strategies

Figure 4. Infraumbilical rectus abdominus muscle plication with 0-Surgilon sutures placed in a buried figure of 8 technique to plicate the anterior rectus fascia.

are found in a distinct minority of patients seeking aesthetic contouring.3 Yet the approach for type V patients
is often applied to many patients with lesser abdominal
deformities. The significant drawbacks associated with
the classic dermolipectomy procedure, such as lengthy
scar, skin sensory changes, and extended recovery period,
have prompted us to use a modified and less extensive
operative approach in patients with type II, III, and IV
category changes. This technique uses aggressive lipoplasty of the entire abdomen and adjacent anatomic regions

Marriage Abdominoplasty: A Short Scar

Technique

along with elevation of the lower abdominal skin to the

level of the umbilicus, preserving vascular perfusion to
the upper abdomen, while interrupting only the circulation to the central lower abdominal tissues.
Because the technique is a union of lipoplasty and standard
surgical techniques of lower abdominoplasties, we have
described this union as a marriage abdominoplasty.3
The marriage abdominoplasty differs from many previously described mini-abdominoplasty procedures4,5 by incor-

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Figure 5. A, C, E, Preoperative views of a 38-year-old woman with lower abdominal skin excess, excess adipose tissue in the upper abdomen,
and lower abdominal and infraumbilical musculofascial laxity. B, D, F, Postoperative views after 9 months without interval weight change after
marriage abdominoplasty. The procedure entailed an 8-cm vertical skin resection; lipoplasty of the upper and lower abdomen, waist, and inframammary regions with an aspiration of 2200 mL; and an infraumbilical rectus abdominis muscle plication.

porating aggressive lipoplasty of the fat layer in the

abdomen, as well as inframammary, waist, and flank
areas. It includes treatment of both the superficial and
deep adipose layers. This procedure places more emphasis
on lipoplasty to produce an aesthetic contour improvement than on surgical skin excision or muscle tightening.

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When simulating the effect of lower abdominal plication, there are patients in whom infraumbilical pressure
produces only a slight increase in fullness, or small
bulge, in the upper abdomen. If there is also substantial
subcutaneous adipose tissue thickness in the upper
abdominal tissue, aggressive lipoplasty in the upper

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Figure 6. A, C, E, Preoperative views of a 47-year-old woman with minimal lower abdominal skin excess, moderate adipose tissue excess, and
minimal musculofascial laxity in the intraumbilical region. B, D, F, Postoperative views 9 months after marriage abdominoplasty. The procedure
entailed a 7-cm vertical skin excision and suction-assisted lipoplasty of the abdomen, waist, and inframammary regions with an aspiration of
1600 mL. There was a 15-lb interval weight loss.

abdomen can effectively improve contour and compensate for the slight tendency to bulge produced by the
infraumbilical rectus abdominis muscle plication, obviating the need for full-length muscle plication. When such
simulation of the plication produces more of a bulge in

Marriage Abdominoplasty: A Short Scar

Technique

the upper abdomen, then full-length plication of the rectus abdominis is advised.
The marriage abdominoplasty procedure does not
address skin excess in the upper abdomen or even minor

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Operative Strategies

Commentary

skin excess located above the umbilicus. Certain patients

are not good candidates for this operation. This includes
patients with redundant upper abdominal skin. Such
patients must be treated with a procedure that undermines and advances skin excess located in the supraumbilical region. Additionally, patients who have
pronounced indentation of the skin at the waistline,
caused by long-term panty girdle use, have increased
subcutaneous tissue fibrosis and adhesions to the superficial fascial system. Such patients are better candidates for
a full abdominoplasty because extensive undermining
and release of this band (by dividing the fibrous bands on
the deep surface of the flap) are required to improve the
waist contour. Of course, patients with type V deformities are not candidates for marriage abdominoplasty.
The marriage of aggressive superwet lipoplasty of the
entire abdomen and adjacent anatomic regions with standard surgical techniques to treat skin excess and allow
infraumbilical abdominal muscle plication offers the
advantage of less invasive surgery, decreased pain, and
faster return to work as compared with a conventional
abdominoplasty. In addition, with appropriate patient
selection, significant contour improvement is consistently
achieved. Figures 5 and 6 demonstrate the results of this
procedure. Our experience indicates that this concept is
applicable to most patients presenting for abdominal
contouring, and it has markedly expanded the application of the mini-abdominoplasty concept.

by Foad Nahai, MD
Editor, Operative Strategies
It seems just a short while ago that our sole option for
improving abdominal contour was the standard
abdominoplasty entailing a long incision, full undermining, and full-length muscle and fascia plication. Today,
our options have increased considerably.
We now have a spectrum of alternatives including
lipoplasty, endoscopic abdominoplasty, and varied miniabdominoplasty techniques. The key is patient selection;
not everyone needs or should undergo a standard
abdominoplasty. The authors clearly define patient selection criteria, designating appropriate candidates as those
with excess skin and muscle laxity limited to the area
between the umbilicus and pubis. I would concur that
anyone with excess skin above the umbilicus, or even the
periumbilical area, should undergo full undermining,
umbilical translocation, and extensive skin excision.
The article describes a very useful maneuver to detect
upper abdominal laxity (Figure 1). In my experience,
most people with lower abdominal laxity, especially
parous women, have muscle laxity also between the
xiphoid and umbilicus, requiring the modification
described by the authors: umbilical float and limited
undermining, up to the xiphoid, to allow fascial repair.
The authors suggest that this procedure may be performed with the patient under local anesthesia with conscious sedation. However, I prefer general anesthesia
with muscle relaxation; I believe that this facilitates muscle repair by achieving a degree of muscle relaxation not
attainable by local anesthesia and sedation.

References
1. Bozola AR, Psillakis JM. Abdominoplasty: a new concept and classification for treatment. Plast Reconstr Surg 1988;82:983-993.
2. Eaves FF III, Nahai F, Bostwick J III. Endoscopic abdominoplasty and
endoscopically assisted mini-abdominoplasty. Clin Plast Surg
1996;23:599-616.
3. Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty concepts. Plast Reconstr Surg 1999;103:1020-1031.
4. Greminger RF. The mini-abdominoplasty. Plast Reconstr Surg
1987;79:356-365.
5. Wilkinson TS, Swartz BE. Individual modifications in body contour
surgery: the limited abdominoplasty. Plast Reconstr Surg
1986;77:779-784.
Reprint requests: Kenneth C. Shestak, MD, Magee-Womens Hospital, 3000
Halket St, Room 2541, Pittsburgh, PA 15213.

Marriage abdominoplasty provides a high degree of

safety in combining extensive lipoplasty with abdominoplasty because the undermining is very limited, preserving
the upper and lateral vascular supply to the abdominal
wall. As with any abdominoplasty, deep venous thrombosis prophylaxis is essential. Here are important pointers to remember:

Copyright 2002 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/2002/$35.00 + 0 70/1/124710
doi:10.1067/maj.2002.124710

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Patient selection is key to success.

Evaluate for skin excess and muscle laxity above and
below the umbilicus.

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Operative Strategies

To avoid suboptimal results and patient disappointment, differentiate between intraabdominal fat, subcutaneous fat, and abdominal wall laxity.
Avoid lowering the umbilicus or raising the pubic
hairline. Maintain a distance of 11 cm between the
umbilicus and pubic hair.
As both research and clinical experience have shown,1 the
combination of extensive lipoplasty and extensive undermining is associated with an increased risk of serious

Marriage Abdominoplasty: A Short Scar

Technique

complications including an increased mortality rate.

Marriage abdominoplasty effectively avoids this level of
increased risk through limited undermining, and it offers
plastic surgeons an additional option for enhancing surgical results and patient satisfaction from abdominoplasty.

Reference
1. Hughes CE III. Reduction of lipoplasty risks and mortality: an ASAPS
survey. Aesthetic Surg J 2001;21:120-125.

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