Role of Scarpa's Fascia Advancement in Waist Definition during Abdominoplasty

Egypt, J. Plast. Reconstr. Surg., Vol. 46, No. 2, April: 107-114, 2022
Role of Scarpa's Fascia Advancement in Waist Definition during
Abdominoplasty
MOHAMED T. YOUNIS, M.D.; SHIMAA E. MAHFOUZ, M.Sc.; GAMAL EL HABAA, M.D.;
ATEF A. YOUSEF, M.D. and AYMAN M. ABDELMOFEED, M.D.
Plastic & Reconstructive Surgery Unit, Department of General Surgery, Faculty of Medicine, Benha University
107
INTRODUCTION
Abdominoplasty is a type of plastic surgery
that has evolved through time. It has undergone
significant refining to meet the growing aesthetic
perception, as well as to address various issues
such as rectus abdominis muscle diastasis, trunk
rejuvenation, and the restoration of a normal defined
waistline [1-4].
The three essential defects of the abdominal
wall (redundant skin with concomitant striae, excess
subcutaneous fat, and musculoaponeurotic laxity)
must always be considered and managed by the
plastic surgeon while performing classic abdominoplasty.
The waist, which is a component of the
trunk's circumferential aesthetic unit, must be
considered similarly as well [5].
As a result, abdominoplasty has evolved from
focusing on the skin flap and underlying rectus
diastasis repair to include liposuction procedures
and minimal undermining to improve the outcome
[6].
Although plication of the midline diastasis
improves antero-posterior diameter, it has a limited
effect on waist definition. Furthermore, as shown
by Nahas and his colleagues in 2001, when the
plication of the anterior rectus sheath is expanded
in width, it might cause deformed abdominal shape,
resulting in undesirable and unnatural contour [6].
Various procedures have been recommended
in order to accomplish reliable waist modification.
Multi-directional abdominal musculature plication,
L-shaped external oblique plication, and muscle
flap advancement have also been documented [7].
Lockwood reported the interconnected fibrous
septa that extend from the dermal layer in different
directions to the Scarpa's fascia, allowing pulling
forces to be directed to the skin even after liposuction,
when tension is applied to the fascial flaps.
It may be modified to meet a variety of aesthetic
purposes, similar to SMAS in the facelifts [8].
The use of bilateral Scarpa advancement flaps
for waist definition during standard abdominoplasty
can alter the waistline and enhance the result of
waist liposuction [9].
When supra-Scarpal dissection was conducted,
roughly 17 percent of the lymph drainage of the
abdominal wall was retained, according to Friedman
and his colleagues [10]. Scarpa's fascia preservation
has also been shown to reduce the risk of
postoperative problems [11].
In comparison to traditional abdominoplasty,
the current study aimed to determine the value of
Scarpa's fascia inferomedial advancement during
abdominoplasty in patients with moderate to severe
actual or potential laxity of the skin, fat, and
muscles of the anterior abdominal wall in terms
of waist definition and seroma rates.
PATIENTS AND METHODS
Between January 2020 and September 2021,
40 female patients were included in the study at
the Plastic Surgery Unit, General Surgery Department,
Faculty of Medicine, Benha University, after
receiving clearance from the Ethics Research Committee.
According to the following criteria, all of
the patients had abdominal deformities indicated
by extra abdominal skin and fat tissue, as well as
musculoaponeurotic laxity.
Inclusion criteria:
• The candidate was not extremely overweight
(BMI 30kg/m2) and remained stable for more
than 6 months if considerable weight loss occurred.
• Females who are very motivated and realistic.
• Major uncontrolled medical conditions such as
labile hypertension, diabetes, coronary disease,
nutritional deficiencies, and bleeding disorders
are not present.
Exclusion criteria:
• BMI >30kg/m2.
• Multiple abdominal scars or a large amount of
abdominal protrusion (secondary to intraabdominal
fat accumulation).
• Females who are completely unrealistic.
• Patients on unreasonable diet, with excessive
smoking or alcohol consumption.
108 Vol. 46, No. 2 / Scarpa's Fascia Advancement in Waist Definition during Abdominoplasty
According to the infraumbilical plane of dissection,
either rectus sheath or Scarpa fascia plane,
they were divided into two equal groups:
- Group A: Abdominoplasty with Scarpa's fascia
inferomedial advancement was performed on
Group A.
- Group B: Traditional abdominoplasty was performed
on Group B.
They were given information regarding the
operation, the type of anesthetic used, the risks,
potential consequences, photos, and their participation
in the research. Before surgery, all patients
underwent a thorough medical history, general
examination, and local examination, with evaluation
of all layers of the abdominal wall, including
skin laxity, the presence of striae and scars, subcutaneous
fat and supraumbilical fullness by pinch
technique (cases with more than 3cm of subcutaneous
fat were targeted for supraumbilical liposuction),
recti diastasis, and hernias defects as indicators
of muscle weakness). In addition, the waist
circumference was measured 4cm above the umbilicus
prior to surgery and compared to the postoperative
measures.
Pre-operative photography and marking:
Digital pictures of the anterior and lateral profiles
were obtained in the standing posture before
and after surgery.
The initial incision was represented by a central
transverse line at the superior level of the symphysis
pubis, within the hair line about 7-8cm away from
the level of the vulval commissure, that line was
slightly curved while extending laterally in both
directions following the natural skin crease. In
some individuals, the supraumbilical area was
marked for liposuction to achieve sufficient contouring.
Surgical details:
In the traditional abdominoplasty group: In the
chosen patients, deep and superficial liposuction
(limited to the supraumbilical area) was done. The
surgery began with tumescent fluid infiltration
using the super-wet method (1mg adrenaline +
10ml 2% xylocaine per liter of saline). Xylocaine
was administered to offer post-operative analgesia
for a few hours. Lipoplasty was started using 4-
and 3-mm Mercedes tip cannulas after tumescent
infiltration. The thickness of the skin flap over the
cannula was used to determine when the lipoplasty
needed to be ended.
The skin incision was made according to the
pre-operative markings and proceeded through the
Egypt, J. Plast. Reconstr. Surg., April 2022 109
subcutaneous fat and Scarpa's fascia all the way
down to the rectus sheath level, the superficial
inferior epigastric vessels were identified and
managed. The flap was then elevated until it reached
the level of the umbilicus, which was vertically
excised and a sufficient amount of subcutaneous
fat was applied to its stalk. Limited dissection was
continued above that level up to the xiphoid process,
establishing a central tunnel about 10cm wide
to protect the lateral perforators. Following that,
diastasis of the recti was repaired vertically from
above with continuous locking Polypropylene 1
suture. With upper body flexed at (30°), excess
abdominal flap was resected and the umbilicus
was repositioned in its new site. Proper homeostasis
was obtained throughout the whole procedure and
two closed-system suction drains were placed under
the abdominal flaps, fixed and secured. Then,
interrupted 0 Vicryl suture was used for the Scarpa's
closure which is the key layer for closure. It was
closed under high tension, which allows for final
skin closure to be performed under minimal tension
and yields a high-quality fine-line scar. Finally,
skin closure was done in two layers with deep
dermal 2/0 Vicryl suture placed every centimeter
and continuous intradermal polypropylene 4/0
suture was used for final closure.
In Scarpa's fascia advancement group: We
followed the same steps as the other group, but
with the following changes:
The initial incision was limited to the Scarpa's
fascia level, which was identified by its gleaming
white look. We continued the incision laterally
over Scarpa's fascia after its central exposure,
keeping its lateral parts and adjacent sub-Scarpal
fatty areolar layer to preserve the lymphatics.
Scarpa's fascia flaps were designed below the
umbilicus by separating the fascia along the midline
until it reached the level of the rectus muscle fascia.
To prevent supra-pubic bulge, a bilateral wedgeshaped
excision from the Scarpa's central part was
performed (with the base pointed upward or downward
for better contour, measuring around 4 to
6cm width between its two limbs) after the Scarpa's
were separated from the underlying loose tissues.
The fascial flaps were then sutured together and
to the linea alba or the underlying rectus fascia
with continuous non-absorbable sutures under
tension (Fig. 1).
Fig. (1): Intraoperative view showing suprascarpal dissection till the umbilicus, Scarpa's fascia flaps are created below the
umbilicus down to the rectus muscle fascia (right). The Scarpa's fascia inferomedial advancement flaps are sutured
under tension together and to the rectus muscle fascia without overlap.
Post-operative management and follow-up:
Early ambulation was started after anesthesia
recovery, a post-operative prophylactic parenteral
third generation cephalosporin antibiotic (2gm/day)
was given, patients were asked to keep their legs
semi-flexed for the first week to ten days after
surgery, hemoglobin levels were measured after
surgery and repeated the next day for follow-up,
and suction drains were noticed and removed when
24-hour collection was less than 30cc.
In all participants, a 6-month follow-up was
performed to evaluate the aesthetic outcomes, the
patient's feedback, and to detect and address any
problems.
RESULTS
On 40 females, we conducted our study to
assess waist definition. Both groups were similar
in terms of general characteristics: Age (p-value
=0.673), weight (p-value=0.479), height (p-value
=0.679), and BMI (p-value=0.548). (Table 1).
When comparing multiple pregnancies to other
factors such as weight gain, post bariatric, and
weight reduction. It was identified as the most
prevalent etiological factor in both research groups
(Fig. 2).
According to operative details, liposuction cases
(p-value=difference. 0.736) and operating time (pvalue=
0.922) were practically same in both groups.
The p-value for post-operative blood transfusion
was (0.231). The drain time in group B (10 days)
was substantially longer than in group A (6 days);
the p-value was 0.001 (Table 2).
Regarding aesthetic Outcome: (Table 4)
Waist definition was estimated objectively [by
measuring pre and post-operative waist circumference
(Table 3), the study reported that the mean
postoperative waist circumference was significantly
higher in group B (92) than group A (87); p-value
was 0.02], and subjectively [by the interaction
between the surgical team's judgment and patient
satisfaction as good, fair, and bad]; most patients
in group A (80%) were highly satisfied with their
good waist definition while (15%) in group A
reported fair result compared to 50% in group B.
There was a difference in post-operative waist
circumference between the candidates of Scarpa's
fascia advancement group who had liposuction
(mean 89) and those who didn't (mean 87), but
there was no significant variation in the outcome
(p-value 0.541), since liposuction was restricted
to the supraumbilical area.
Patients evaluated their satisfaction with the
outcome as extremely dissatisfied, dissatisfied,
happy, and extremely satisfied. There was a considerable
difference in patient satisfaction, with
three quarters of patients in group A being extremely
happy, compared to just 15% in group B.
Accepted scar, hypertrophic, dog ear, or asymmetrical
scars were documented as scar outcomes.
For hypertrophic scars, an intralesional steroid was
injected, and silicone gel was recommended. Three
cases of small dog ear scars were recorded in group
B, and two cases in group A, with only two of
them requiring local anesthetic repair.
The umbilicus was seen and classified as complicated
or not complicated based on its shape and
location. In addition, two instances in group A and
three cases in group B were recorded to have
contour irregularities reported according to the
presence of ill-defined midline depression from
the xiphoid to the umbilicus, distorted thickness
of subcutaneous fat above and below the scar and
poorly defined waist.
110 Vol. 46, No. 2 / Scarpa's Fascia Advancement in Waist Definition during Abdominoplasty
The following complications were documented
and managed: (Table 5)
After the suction drains were removed, there
was clinically obvious seroma. Only one case of
the 20 patients (5%) in group (A), compared to six
cases among group (B). All of the patients were
treated conservatively, with needle aspiration every
4-5 days and an average volume of 20cc to 200cc.
After 2-3 aspirations.
At day 15 post-operative, only two individuals
from each group experienced wound infection, and
three cases of wound dehiscence were recorded in
group B, two of which were healed by secondary
intention and the third of which required scar
revision under local anesthetic.
In one case in the Scarpa's group, a little hematoma
developed and was resolved following
continuous compression with another fitted garment.
In both groups, there was no evidence of
flap necrosis.
Table (1): General characteristics in both groups.
Age (years)
Weight (kg)
Height (cm)
BMI
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
37±6
77±5
163±4
28.9±1.5
Group A
(n=20)
38±7
76±8
162±6
28.6±1.5
Group B
(n=20)
0.673
0.479
0.679
0.548
pvalue
Independent t-test was used.
Table (2): Operative and post-operative details in both groups.
Liposuction
Operative time (h)
Post op. blood
transfusion
Drain duration
(days)
n (%)
Mean ± SD
n (%)
Mean ± SD
6 (30.0)
3.5±0.5
0 (0.0)
6±1
Group A
(n=20)
7 (35.0)
3.5±0.5
3 (15.0)
10±2
Group B
(n=20)
0.736
0.922
0.231
<0.001
pvalue
Independent t-test was used for numerical variables.
Fisher's exact test was used for categorical variables.
Table (3): Waist circumference pre and post-operative in both
groups.
WC Pre-operative
WC Post-operative
Mean ± SD
Mean ± SD
103±7
87±6
Group A
(n=20)
103±9
92±7
Group B
(n=20)
0.954
0.02
pvalue
Independent t-test was used.
Egypt, J. Plast. Reconstr. Surg., April 2022 111
Table (4): Aesthetic outcome in both groups.
Scar
Umbilicus
Abdominal contour irregularity
Waist definition
Patient Satisfaction
Accepted scar
Hypertrophic
Dog ear
Asymmetric scar
Uncomplicated
Complicated
Bad
Fair
Good
Highly unsatisfied
unsatisfied
Satisfied
Highly satisfied
15 (75.0)
2 (10.0)
2 (10.0)
1 (5.0)
16 (80.0)
4 (20.0)
2 (10.0)
1 (5.0)
3 (15.0)
16 (80.0)
0 (0.0)
3 (15.0)
2 (10.0)
15 (75.0)
Group A
(n=20)
11 (55.0)
4 (20.0)
3 (15.0)
2 (10.0)
17 (85.0)
3 (15.0)
3 (15.0)
6 (30.0)
10 (50.0)
4 (20.0)
5 (25.0)
8 (40.0)
4 (20.0)
3 (15.0)
Group B
(n=20)
0.631
1.0
1.0
0.001
<0.001
pvalue
Chi-square or Fisher's exact test was used.
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
Table (5): Complications in both groups.
Seroma
Hematoma
Wound dehiscence
Wound infection
Flap Necrosis
n (%)
n (%)
n (%)
n (%)
n (%)
1 (5.0)
1 (5.0)
0 (0.0)
2 (10.0)
0 (0.0)
Group A
(n=20)
6 (30.0)
0 (0.0)
3 (15.0)
2 (10.0)
0 (0.0)
Group B
(n=20)
0.037
1.0
0.231
1.0
–
pvalue
Fisher's exact test was used.
Fig. (3): Group (A) 29 yeas f. patient Pre-operative photographs, (Above) and post-operative good waist definition, (Below).
Fig. (2): General characteristics in both groups.
180
160
140
120
100
80
60
40
20
0
Mean
Age
(years)
Weight
(kg)
Height
(cm)
BMI
Group A
Group B
37 38
77 76
163 162
28.9 28.6
DISCUSSION
One of the aims of trunk rejuvenation during
abdominoplasty is to define the waist. Many variables,
including abdominal shape, fat deposits, and
the degree of muscular tension, which is frequently
impacted by the combined effects of pregnancy
and aging [4,6], influence it.
112 Vol. 46, No. 2 / Scarpa's Fascia Advancement in Waist Definition during Abdominoplasty
In order to enhance the waist, several writers
have published numerous procedures to deal with
the deformities produced by excess fat and laxity
of the skin and muscle structure of the anterior
abdominal wall [5]. Avelar (1985) and Bozola
(1988) were the first to introduce rectus plication
and its variations. This plication has become a
standard feature of abdominoplasty procedures to
Fig. (4): Group (A) 38 yeas f. patient Pre-operative photographs, (Above) and post-operative good waist definition, (Below).
Fig. (5): Group (B) 42 yeas f. patient Pre-operative photographs, (Right) and post-operative waist definition, (Left).
Egypt, J. Plast. Reconstr. Surg., April 2022 113
reduce waist circumference and improving its
definition [12,13]. However, this can be a difficult
process.
Midline plication of the musculoaponeurotic
layer seldom has the desired impact on the waist,
and direct plication of this layer across the waist
is frequently out of reach, due to restricted dissection
over this area. Excess fat in the flanks can be
easily removed with liposuction procedures; however,
improving skin redundancy without further
incisions and subsequent scarring, is more difficult
[14].
Nahas and his colleagues went on to describe
L-shaped external oblique muscle plication, multidirectional
abdominal wall plication, and advancement
of the external oblique muscle flaps for
achieving reliable waist modification [7].
Many studies have been published on the Scarpa's
fascia as a component of the superficial fascial
system (SFS), because it allows pulling forces to
be translated to the skin when tension is applied
to the fascia flaps, even after liposuction [8], and
its advancement has a significant effect on waistline
improvement [9,15,16]. According to the aesthetic
outcome of the current study, the majority of Scarpa's
advancement group had good waist definition
with a considerable improvement in the postoperative
waist circumference.
When it comes to post-abdominoplasty scar
quality, some writers suggest that preserving the
Scarpa fascia leads in better wound healing and
better scars [17]. Many factors influence the final
scar outcomes, including the patient's posture, the
symmetry of the abdominal deformity, and the
symmetry of the dissection and excision. It should
be remembered that a scar that is perfectly symmetrical
immediately after surgery may become
asymmetrical later [15]. Therefore, all our patients
were warned that it may be necessary to perform
scar revision after six months. The scar result was
classified as acceptable scar, hypertrophic, dog
ear, or asymmetrical scars in the current study. For
hypertrophic scars, an intralesional steroid was
injected, and silicone gel was recommended. Three
cases of small dog ear scars were recorded in group
B, and two cases in group A, with only two of
them requiring repair with local anesthesia. Novais
in his randomized controlled trial proved that
abdominoplasty with Scarpa fascia preservation
could be used safely without compromising the
aesthetic result [18]. Regarding umbilicus and
abdominal contour irregularity in our study, no
evident differences between both groups were
found.
For the previously mentioned good aesthetic
outcome, patient satisfaction showed three quarters
of patients in group A were highly satisfied, compared
to only 15% in group B.
Supra-scarpal dissection, according to Friedman
and other writers, is critical for lymphatic preservation
of the abdominal wall [10], and lowering
the risk of post-operative problems [11]. While
several studies have shown that the conventional
approach is associated with a number of problems,
the most prevalent of which is seroma [19,20]. In
our study, almost no difference was recorded between
both groups regarding hematoma and wound
infection, but wound dehiscence was reported in
three cases of group B. The resulted widening
required revision under local anaesthesia. That
may be occurred because we ignored to reattach
the Scarpa's fascia layer during wound closure in
these cases. We had three cases of postoperative
blood transfusion recorded in group B, the preoperative
Hb % was borderline about 11 and half
in two of them, as the need of blood transfusion
after surgery can be affected by patient medical
condition before surgery and his body inflammatory
response. Also, there was no flap necrosis in any
group was detected.
Regarding seroma formation, various authors
found that preserving Scarpa fascia during an
abdominoplasty reduced seroma incidence significantly
[9,19], as did Koller and his colleagues, who
found that preserving Scarpa's fascia during an
abdominoplasty reduced seroma incidence significantly
[21,22], based on a prospective study with
50 patients (25 undergoing abdominoplasty with
Scarpa fascia preservation and 25 undergoing
classical abdominoplasty). Seroma was recorded
after drain removal in our study, and it was shown
to be greater in group B (p0.037). It happened in
early cases because the suction drains were removed
too soon after surgery.
In a study comparing the traditional rectus
sheath dissection plane with the supra Scarpa
dissection plane, Elwakeel and his colleagues
found that using the supra Scarpa dissection plane
was associated with a significant reduction in
drainage volume and early drain removal when
compared to the other group [23]. The drain duration
results in the study were greater in group B than
in group A.
Conclusion:
During abdominoplasty, Scarpa's fascia inferomedial
advancement flap is an effective way to
improve the waistline. As part of SFS, it relieves
strain on skin flaps while also elevating and shaping
the waist region. With just a few small issues and
no serious difficulties, this technique was shown
to be safe. It maintains the natural fascia system
and can enhance surgical outcomes while preserving
the benefits of abdominal wall lymphatic preservation,
resulting in lower seroma rates.
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