11 Horseshoe Abdominoplasty Richard Moufarr`ege

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11 Horseshoe Abdominoplasty

Richard Moufarr`ege

11.1

Introduction

Surgeons who perform abdominoplasties today typi- cally use one of three general approaches: a horizontal incision through which it is possible to deal with the ptotic and excess skin in the vertical dimension, a vertical resection that allows access for treating the horizontal excess of skin at the level of the waist, or certain techniques that deal with both the vertical and horizontal excess. However, these techniques leave opera- tive scars that prevent the patient from wearing a high- cut bathing suit or high-cut underwear. The horseshoe abdominoplasty combines the advantages of the horizontal and vertical techniques. Although a vertical component to the scar is unavoidable in certain cases, the procedure respects the need to limit incisions to sites where they will not be visible when the patient wears a high-cut bathing suit.

11.2 History

The first abdominoplasty was described by Demars in 1890 [1]. In 1899 Kelly [2] described a technique in which an ellipse of skin and subcutaneous tissue was

Fig. 11.1. a–g Horizontal tech- niques for the treatment of ptosis [1 – 7]. a Kelly, b Tho- rek, c Gonzalez-Ulloa

excised through a transverse incision. However, the umbilicus was sacrificed (Fig. 11.1a). Gaudet and Mo- restin in 1905 [3] were the first to describe preservation of the umbilicus. Many authors have since described a variety of incisions and techniques to improve the con- tour of the abdomen, including Weinhold in 1905 [4]

(cloverleaf incision) (Fig. 11.3c), Desjardins in 1911 [5], and Babcock in 1916 [6] (vertical elliptical resection) (Fig. 11.2a). In 1939 Thorek [7, 8] described a crescent horizontal resection without undermining (Fig. 11.1b).

In 1955 Galtier [9] reported resection in four quadrants (Fig. 11.3b); this was followed by reports of circular abdominoplasty techniques by Gonzalez-Ulloa in 1960 [10] and Vilain and Dubousset in 1964 [11] (Fig. 11.1c).

In 1965 Spadafora [12] described a curved transverse incision, and this was followed by reports of a low transverse incision technique by Pitanguy in 1967 [13, 14], 1971 [15] and 1974 [16] (Fig. 11.1e). This technique was modified by Grazer [17], who contoured the upper lateral incisions to hide them in the confines of bathing suits that were in vogue at that time (Fig. 11.1f). R´egnault used a “W” incision (described in 1972 [18] and 1975 [19]) (Fig. 11.1g), and Baroudi’s [20, 21] “bicycle handles” technique (Fig. 11.1d) was used in a further attempt to place the incisions so that they were less visible.

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Fig. 11.1. d Baroudi, e Pitanguy, f Grazer, g R´egnault

11.3

Classification

Abdominoplasties can be divided into the following three categories:

1. Horizontal resections that treat the skin excess and abdominal ptosis (Fig. 11.4) without treating the waist expansion (Kelly, Gonzalez-Ulloa, Thorek, Grazer, Pitanguy, R´egnault, and Baroudi) (Fig. 11.1a–g) 2. Vertical resections (Babcock, Kuster, Schepelmann,

and Desjardins) (Fig. 11.2a–c ) to improve waist expansion (Fig. 11.5)

3. Combined abdominoplasties that deal with both the transverse and vertical components of the problem (Fig. 11.3a–e)

Unfortunately, the majority of the combined techniques result in a significant and frequently unaccept- able scar. The “horseshoe abdominoplasty” that I have developed is a combined technique that permits resection of an amount of skin equivalent to that resected

Fig. 11.2 a–c. Vertical tech- niques for treating the waist [24, 25]. a Babcock, b Schepel- mann, c Kuster

with other techniques currently in use. The horseshoe abdominoplasty treats both the transverse and horizontal components of the problem while the incision remains within the confines of high-cut bathing suits and underwear (Fig. 11.6).

11.4

The Horseshoe Abdominoplasty Technique

The short inferior incision used in the horseshoe abdominoplasty technique is similar in placement to that described by El Baz (Fig. 11.7) and Flageul. But El Baz recommended that method for a very small resection in the inferior area of the abdomen, without displace- ment of the umbilicus. Through this incision the Mou- farr`ege technique will realize a complete radical abdominoplasty with a resection of enough skin to obtain a real abdominoplasty result and reconstitution of a new umbilicus in the right position. To obtain such a result, we have to undermine as far as the hips, correct the dia- 122 11 Horseshoe Abdominoplasty

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Fig. 11.3. a–e Mixed techniques for treating both waist and pto- sis problems [22, 23]. a Pick, Barsky, b Galtier, c Weinhold, d Flesh-Thebesius, Weisheimer, e Moufarr`ege

stasis, and resect the excess of skin between the pubis and the umbilicus, subsequently reconstituting the umbilicus at its proper level.

We begin by drawing the horseshoe incision around the pubis with a downward notch centrally, which gives it a heart-shaped appearance. With this maneuver, vertical contracture of the central portion of the incision is avoided (Fig. 11.8a). A second similarly shaped incision that passes over the umbilicus is then drawn (Fig. 11.8b) and the skin between the two incisions is excised. We then undermine in the subcutaneous plane upward over the inferior two to three ribs, as well as lat- erally, undermining further than with other techniques

Fig. 11.4. Vertical stretching causes skin ptosis

Fig. 11.5. Horizontal stretching causes waist enlargement

(as far as 10 cm) on the sides of the abdomen. The dia- stasis is then corrected (Fig. 11.8b). With subsequent closure, force is exerted in a direction that helps to ad- dress the waistline and vertical excesses (Fig. 11.9).

Fig. 11.6. The horseshoe abdo- minoplasty treats the transverse and horizontal compo-

nents while the incision remains within the confines of high- cut bathing suits and underwear (Moufarr`ege)

Fig. 11.7. Short inferior inci- sion of El Baz [26, 27]

Closure is accomplished with considerable shirring of the upper incision to the lower incision (Fig. 11.10).

Puckering improves over 3 – 6 months.

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Fig. 11.8. A Begin by drawing the horseshoe incision around the pubis with a central downward notch to avoid vertical contracture of the central portion of the inci- sion. B A second sim- ilar-shaped incision that passes over the umbilicus is then drawn, the skin is re- moved between the lines, and the diasta- sis repaired after dis- section

d Fig. 11.10. a–c Progressive closure; d final result

11.5 Discussion

The Moufarr`ege horseshoe abdominoplasty is not the panacea for all abdomens. Its utilization should be lim- ited to a very strict category of patients. Abdominopla- sty patients are divided into four main categories.

Category I: The slim patient who has a very small pad of under cutaneous fat

Category II: The patient is relatively slim but has a certain amount of fat in the subcutaneous layer (until 2 cm). But skin does not hang in front of the pubic area in an overlap fashion (no apron).

Category III: The patient, without being obese, has a big amount of excess of skin, which drops in front of the pubic area (the apron).

Category IV: The obese patient.

Fig. 11.9. Orientation of trac- tion for closure

11.5.1

Patient Selection

The selection of candidates for the horseshoe is very important and must obey very strict rules. When the patient is not the ideal candidate for the technique, one will realize that the corrective procedure has to be per- formed more often than with average techniques.

From 1991 to 1993, our incidence of revision was about 40 % of cases. Since we tightened the criteria in the choice of candidates, our revision ratio has dropped to less than 10 %. In any circumstances, correction pro- cedures should not take place before 1 year after the first surgery.

I limit the horseshoe abdominoplasty procedure to Category I patients. Even in these, we have to avoid per- forming the procedure in patients presenting stretch marks in the upper incision line. These stretch marks will prevent the upper flap from adapting to the lower edge of the wound, which is by far shorter. All in all, we consider that only 10 % of our abdominoplasty patients can undergo the horseshoe abdominoplasty.

In Category I patients with stretch marks at the sec- 124 11 Horseshoe Abdominoplasty

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a b

Fig. 11.11. a Supplemental wedge resection in Category II pa- tients and Category I patients with stretch marks; b final result with supplemental wedge resection

tion line of the upper flap and in Category II patients, the horseshoe could be used with a triangular supple- mentary resection in the upper flap. This consists of a wedge resection having its summit at the umbilicus and its base on the free edge of the upper flap (Fig. 11.11a).

The final result will consist in a horseshoe surrounding the pubic area with a medial vertical incision, which will go from the umbilicus down to the horseshoe (Fig. 11.11b).

In Category III patients one should use one of the classical low horizontal incisions, e.g., Baroudi’s. One

a b

Fig. 11.12a,b. Horseshoe ab- dominoplasty, Patient no. 1, Category 1. a Front view, preoperative. b Front view, postoperative

a b

Fig. 11.13a,b. Horseshoe ab- dominoplasty, Patient no. 1, Category 1. a Lateral view, preoperative. b Lateral view, postoperative

should avoid operating on Category IV patients (obese) until they lose their excess fat and become Category III patients.

11.6 Conclusions

The horseshoe abdominoplasty is an interesting and advantageous alternative to other types of abdominoplasty. Its short and well-placed incision makes it easily hidden in a high-cut bathing suit and underwear. The horseshoe is a mixed technique, improving the ptosis of the skin as much as the waist enlargement. But one should be very conservative and not permissive in the selection of patients. The surgeon must also always pre- sent to the patient the possibility of a scar revision a year after the procedure, even for those who constitute an ideal candidate.

11.7

Illustrations of Different Patient Categories

The following photographs provide illustrative pre- and postoperative images of different categories of patients with occasional comments with regard to technique (Figs. 11.12 – 11.27).

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a b

Fig. 11.14a,b. Horseshoe ab- dominoplasty, Patient no. 1, Category 1. a Right oblique view, postoperative. b Left oblique view, postoperative.

Please note the definition of the rectus abdominis muscle

a b

Fig. 11.17a,b. Horseshoe ab- dominoplasty, Patient no. 2, Category 1. a Oblique view, preoperative. b Oblique view, postoperative

126 11 Horseshoe Abdominoplasty

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a b Fig. 11.18a,b. Horseshoe ab-

dominoplasty, Patient no. 3, Category 2. a Front view, preoperative. b Front view, postoperative

a b

Fig. 11.20a,b. Horseshoe ab- dominoplasty, Patient no. 3, Category 2. a Oblique view, preoperative. b Oblique view, postoperative. This Category 2 patient was operated on in the mid-1990s using a horseshoe technique. If I had to operate on her now, I would choose either the horseshoe with a medial vertical wedge resection or the bicycle han- dle incision

a b

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a b

Fig. 11.23a,b. Horseshoe ab- dominoplasty, Patient no. 4, Category 2. a Right oblique view, postoperative. b Left oblique view, postoperative.

Once again, this Category 2 patient was operated on in the mid-1990s using a horseshoe technique. If I had to operate on her now, I would choose either the horseshoe with a medial vertical wedge resection or the bicycle han- dle incision

a b

128 11 Horseshoe Abdominoplasty

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a b Fig. 11.26a,b. Horseshoe ab-

dominoplasty, Patient no. 5, Category 2. a Right oblique view, postoperative. b Left oblique view, postoperative.

This Category 2 patient has been treated using the modified horseshoe abdominoplasty with a the medial vertical wedge resection ending with a medial vetical incision over the horseshoe incision

Fig. 11.27. The horseshoe incision at the end of the surgical procedure

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