Continuing Education Activity

Abdominoplasty, commonly referred to as a “tummy tuck,” is a widely performed cosmetic procedure that improves abdominal contour by removing redundant skin and excess subcutaneous fat and, when indicated, addressing rectus muscle laxity. The procedure has seen increasing demand, with over 170,000 cases reported in the United States in 2023, a 37% rise from pre–COVID-19 rates. Techniques vary from full abdominoplasty to mini or lipoabdominoplasty, with attention to flap design, vascular preservation, and aesthetic balance. Complications can include hematoma, seroma, wound dehiscence, infection, and contour irregularities, highlighting the need for careful patient selection, meticulous surgical planning, and structured postoperative management. Consideration of patient comorbidities, prior abdominal surgeries, and expectations is essential for optimizing functional and cosmetic outcomes.

Participants in this activity gain comprehensive knowledge of abdominoplasty, including anatomy, surgical approaches, strategies to mitigate complications, and postoperative care. Emphasis is placed on minimally invasive techniques, flap design principles, and evidence-based refinements to enhance safety and aesthetic results. Clinicians also learn to integrate preoperative assessment, operative planning, and postoperative management with interprofessional collaboration among anesthesia, nursing, nutrition, and rehabilitation teams. Coordinated communication supports patient education, risk reduction, and longitudinal follow-up, ultimately improving outcomes, reducing complications, and promoting patient satisfaction across the continuum of care.

Objectives:

• Identify early signs of complications postoperatively and implement timely interventions to mitigate adverse events.
• Evaluate intraoperative outcomes and adjust surgical technique to accommodate anatomical variations or unexpected findings.
• Select appropriate operative techniques (eg, full abdominoplasty, mini-abdominoplasty, or adjunctive liposuction) based on patient anatomy and aesthetic goals.
• Collaborate with the interprofessional healthcare team, including surgeons, anesthesiologists, nurses, nutritionists, and rehabilitation specialists, to achieve optimal patient recovery and long-term outcomes.

Introduction

Abdominoplasty, commonly referred to as a “tummy tuck,” is a surgical procedure designed to improve the contour and aesthetic appearance of the abdominal wall by removing excess skin and subcutaneous fat (panniculus) and, when indicated, tightening the underlying musculature (see Image. Abdominal Panniculus). Since its first descriptions in the early twentieth century, abdominoplasty has evolved through numerous refinements in technique to enhance safety, minimize complications, and optimize both functional and cosmetic outcomes. Today, it is one of the most frequently performed body-contouring procedures worldwide, addressing concerns related to massive weight loss, postpartum changes, and aging.[1][2][3][4] With the increasing prevalence of bariatric surgery, the widespread use of glucagon-like peptide-1 (GLP-1) agonists, and evolving societal trends, abdominoplasty offers an important opportunity for individuals to address and reduce excess abdominal tissue.[5][6][7]

Anatomy and Physiology

Abdominal Wall Layers

The abdominal wall consists of seven principal layers, arranged from superficial to deep: the skin, Camper fascia (superficial loose subcutaneous tissue), Scarpa fascia (deep fibrous subcutaneous tissue), subscarpal fat, anterior rectus sheath (dense fibrous layer formed by aponeuroses of the external and internal oblique muscles), rectus abdominis muscle, and posterior rectus sheath (dense fibrous layer posterior to rectus abdominis above the arcuate line) (see Image. Abdominal Wall Muscles).[8][9]

Vasculature

The vascular supply of the abdominal wall can be divided into 3 distinct zones. Zone I, the central abdomen, extends from the xiphoid process to the pubis and lies between the lateral borders of the rectus abdominis muscles. The deep superior and inferior epigastric arteries primarily supply this zone. Zone II, the lower abdomen, is located below the level of the anterior superior iliac spines (ASIS) and receives its blood supply from 3 branches of the femoral artery: the superficial epigastric, superficial circumflex iliac, and superficial external pudendal arteries. Zone III, the lateral abdominal wall, is supplied by the subcostal, intercostal, and lumbar arteries.[10] 

Additionally, the vascular supply to the umbilicus is particularly important, as inadequate preservation during dissection may lead to postoperative necrosis. The umbilicus derives its blood flow from the subdermal plexus, the remnant of the ligamentum teres, and perforators from the deep inferior epigastric arteries.[11] A thorough understanding of the vascular zones is essential in abdominoplasty, as surgical dissection often devascularizes zone II and a significant portion of zone I, depending on the extent of the procedure. Consequently, preserving the blood supply from zone III is critical to ensure the viability of the abdominal flap.[8][9][10][9][12]

Nerves

Four primary nerves traverse the abdominal wall and are at risk of injury during abdominoplasty: the lateral femoral cutaneous (LFCN), iliohypogastric, ilioinguinal, and intercostal nerves. Among these, the LFCN is most frequently injured, resulting in paresthesia along the anterolateral thigh. To minimize the risk of LFCN injury, dissection should be limited near the inguinal ligament, where the nerve typically passes approximately 1 cm medial to the ASIS.

The iliohypogastric and ilioinguinal nerves, which provide sensory innervation to the lower abdomen and groin, are most vulnerable near the inguinal canal and pubic region, and should be carefully preserved during lower abdominal flap elevation. Intercostal nerves, responsible for motor innervation of the upper abdominal wall musculature, can be protected by avoiding overly aggressive lateral dissection. Awareness of these anatomical pathways and meticulous surgical technique is essential to prevent sensory deficits and preserve abdominal wall function.[12][13]

Indications

Abdominoplasty is indicated for patients seeking improved abdominal contour, resolution of functional impairment due to skin or muscle laxity, or correction of abdominal wall defects. Aesthetically, the procedure addresses abdominal skin laxity, excess subcutaneous fat, and laxity of the abdominal musculature, which are commonly seen in multiparous women seeking to restore a youthful profile. Functionally, abdominoplasty corrects rectus diastasis, improves core strength, and alleviates issues caused by redundant skin, such as irritation, rashes, or hygiene difficulties, particularly in bariatric individuals after massive weight loss. Reconstructively, abdominoplasty can restore abdominal wall integrity following trauma, surgery, or congenital deformities, and may be combined with hernia repair when necessary. Across these populations, the procedure addresses both functional and aesthetic concerns, providing a tailored approach to achieving an aesthetic abdominal profile.[14]

Patient selection is a critical step for achieving successful abdominoplasty outcomes and begins with a thorough history and physical examination. A detailed medical history should assess personal or family histories of bleeding or clotting disorders and review medications, including anticoagulants and immunosuppressants. Social history is equally important, particularly tobacco or vaping use, which significantly affects postoperative wound healing. Smoking cessation is recommended for at least 4 weeks before and after surgery, and some surgeons may verify compliance with a cotinine test on the day of the procedure. During the physical examination, careful assessment of skin quality, the presence of rashes, and the extent of abdominal pannus descent is essential, as variations in skin laxity and position guide intraoperative technique and influence postoperative results. Laboratory evaluation may be performed based on clinical judgment to assess nutritional status, including markers such as albumin, prealbumin, vitamins, and routine blood counts and chemistry panels.[9][15][16]

Contraindications

Abdominoplasty is contraindicated in patients with conditions that substantially increase surgical or anesthetic risk. Absolute contraindications include active infection, uncontrolled medical disease, unstable coagulopathies, poorly controlled diabetes, pregnancy, inadequate abdominal wall support, and psychological conditions such as unrealistic expectations or body dysmorphic disorder. Relative contraindications include tobacco use, obesity, immunosuppression, poor nutritional status, and prior abdominal surgeries, which can compromise flap vascularity. Particularly open procedures like cholecystectomy, liver surgery, or nephrectomy performed via Chevron or Kocher incisions can devascularize the superior abdominal wall. Careful evaluation and optimization of these factors are essential to minimize complications and achieve favorable postoperative outcomes.[15][16]

Equipment

The equipment required for abdominoplasty includes supplies for local and/or regional anesthesia, standard surgical instruments for dissection and hemostasis, and closure products. Preoperative preparation involves a sterile surgical skin marker and local anesthetic for dermal infiltration, often supplemented with a transversus abdominis plane block. Essential instruments include a surgical scalpel and a Bovie electrocautery unit, with a second unit available when an assistant or resident participates at the appropriate level.

Suture selection varies by layer: rectus diastasis imbrication typically uses Ethibond, polydioxanone (PDS), or Stratafix; Scarpa fascia closure and progressive tension sutures employ Vicryl or PDS; deep dermal closure uses Monocryl; and skin closure and umbilical inset are completed with Monocryl or Prolene, sometimes using Stratafix. Incision dressings include Steri-Strips, Prineo, or Dermabond, while the umbilicus is managed with Bacitracin, Xeroform, and occasionally topical nitroglycerin. Drains and an abdominal binder are not mandatory but are routinely employed postoperatively.[14] Optional specialized instruments include the Lockwood underminer and abdominal flap demarcator to facilitate flap elevation and contouring.[17]

Personnel

Performing an abdominoplasty typically requires a multidisciplinary team, including an anesthesiologist, the primary surgeon, scrub technician, circulating operating room nurse, and possibly a resident surgeon (or surgical assistant).

Preparation

Operative Marking

Preoperative marking is a critical step in abdominoplasty, and it should be performed with the patient standing, undressed, and with the arms relaxed at their sides to allow accurate assessment of soft-tissue laxity and contour. Patient privacy must be maintained throughout the process. Before exposure, the surgeon should introduce themselves and the team members present, and, given the sensitive nature of the examination, a chaperone is strongly recommended.

Marking techniques vary among surgeons, but key anatomical landmarks typically include the midline, pubic bone, and bilateral anterior superior iliac spines. Additional reference points may include the costal margins and, when blunt dissection is planned, the inframammary fold. Because many patients exhibit posterior skin redundancy and adiposity beyond the anterior superior iliac spine, it is essential to counsel patients regarding areas that the procedure will not address.[14][18][19]

A pinch test should be performed to assess skin laxity and guide the extent of planned resection. The inferior incision is then marked, with the superior margin defined either preoperatively or intraoperatively, depending on the surgeon's preference. The lower incision should remain at least 5 to 7 cm superior to the vulvar commissure to avoid genital elevation or distortion.[20]

When liposuction is planned concomitantly, the intended areas should be clearly marked. For patients undergoing a Fleur-de-Lis abdominoplasty, the vertical component of resection is outlined by gently pinching the skin and soft tissue overlying the rectus abdominis to estimate the amount of redundant tissue. The excision pattern should remain symmetric, with each limb of the vertical ellipse equidistant from the midline, as asymmetry can result in an off-midline scar.[14][21]

Operative Positioning

The patient should be placed supine, with the ASIS at the bed's break. The bed should be capable of flexing to at least 30 to 45 degrees, as the patient will be placed in a semirecumbent or beach chair position.[14][20] Usually, the patient's arms are placed on padded arm boards to protect bony prominences and nerves, and then secured to prevent movement when the bed position is changed intraoperatively. 

Anesthesia Considerations 

General endotracheal anesthesia with complete neuromuscular paralysis is recommended for abdominoplasty to facilitate optimal muscle relaxation and operative exposure. If the surgeon is not proficient or unable to perform fascial plane blocks, an anesthesia provider may perform an ultrasound-guided TAP and/or rectus sheath block for enhanced perioperative analgesia.[8] Because of the large exposed surface area during surgery, use of a forced-air warming device is advised to maintain normothermia, with a target core temperature above 36 °C throughout the procedure.

Urinary (Foley) catheterization is generally unnecessary but may be considered for procedures exceeding 3 to 4 hours or when significant fluid shifts are anticipated. Patients should receive appropriate prophylactic antibiotics. Per the Surgical Care Improvement Project (SCIP), patients should receive antibiotic prophylaxis between 30 and 59 minutes before incision. Typical antibiotics selected include cefazolin or clindamycin if a patient has a beta-lactam allergy.[22]

Technique or Treatment

Traditional Abdominoplasty

Flap dissection

Local anesthetic is first infiltrated along the marked incision line. A #10 scalpel is used to incise through the epidermis and dermis, after which electrocautery is employed to divide Camper and Scarpa fascia. Electrocautery should be avoided within the dermis to minimize thermal injury. During dissection, the superficial epigastric vessels should be identified and controlled either with electrocautery or ligated with 2-0 Vicryl sutures. Near the anterior superior iliac spine, a small layer of fat should be preserved over the dissection bed to protect the lateral femoral cutaneous nerve.[12][13] Elevation of the abdominal flap proceeds by separating the skin and subcutaneous fat from the underlying fascia, leaving a thin layer of fat on the fascia, a step believed to reduce the risk of postoperative seroma formation.[23] The superior limit of dissection extends to the costal margin and xiphoid process, and laterally to the anterior axillary line. Overdissection laterally should be avoided, as it increases dead space and compromises perfusion without enhancing flap mobility. Care must also be taken to preserve the umbilical stalk and its surrounding tissue to prevent devascularization.[11][14][20][21]

Umbilical dissection

The orientation of the umbilicus should first be identified and marked. Traction sutures may be placed 180 degrees apart to aid in exposure. The umbilicus and surrounding periumbilical tissue are then carefully dissected using an atraumatic technique. One option is to use single-tooth skin hooks to gently elevate the umbilicus, followed by a circumferential skin incision with the surgeon's preferred scalpel. Electrocautery should be avoided during umbilical dissection; if required, only low-energy settings are recommended to minimize thermal injury. Sharp dissection is continued through the subcutaneous tissue surrounding the umbilicus, taking care to preserve vascular integrity. Over-skeletonization of the umbilical stalk increases the risk of devascularization and postoperative umbilical necrosis. Additionally, surgeons should remain vigilant for small periumbilical hernias that may not have been identified preoperatively and proceed with dissection cautiously.[11][12][14]

Rectus diastasis plication 

After elevation of the abdominal flap, attention is directed to correction of rectus diastasis and, when present, concomitant hernia repair. Complete neuromuscular relaxation should be confirmed with anesthesia before proceeding. The medial borders of the rectus sheath are marked bilaterally using either a cotton-tipped applicator dipped in methylene blue or a sterile surgical marker. Rectus plication is performed with permanent or long-acting absorbable sutures, employing techniques that may include single- or double-layer closure with interrupted or running patterns (see Image. Abdominoplasty After Plication of the Rectus Muscle).[14][24] 

Abdominal soft tissue excision

Flex the bed to a position with the hips flexed at approximately 30 degrees. Next, confirm the superior excision line of excess skin and subcutaneous tissue. Marking can be performed preoperatively using a pinch test or intraoperatively once the flap has been elevated. If performed intraoperatively, the excess skin can be marked by hand or with a Lockwood demarcator, then excised.[14][17]

Additional Consideration: Clinician-Administered TAP Block

At this point in the dissection, the abdominal wall musculature is identified. A clinician-administered TAP block can be performed via landmarks or with ultrasound guidance.[8]

Drain Placement, Irrigation, and Hemostasis 

Typically, 1 or 2 surgical drains are placed for this procedure. One resting along the belt line and incision, and the second over the umbilicus. They can be brought out through the lateral portion of the incision or be placed through separate skin incisions. They should be secured to the skin with a permanent suture. After all dissection is complete, the site should be copiously irrigated and meticulous hemostasis obtained.[9][14] 

Progressive tension sutures can be used in place of abdominal drains. In progressive tension sutures, the abdominal flap is advanced onto the muscular fascia using an interrupted absorbable or running continuous barbed suture. Once the flap is secured, progressive tension is applied to each suture to offload the incision. Decreased tension prevented necrosis and hypertrophic scars. Additionally, dead space diminished the prevention of seroma and hematoma formation.[15][23][25][26]

Umbilical Inset

Use a marking pen to mark the level of the new umbilicus, and the umbilicus is inset. There are numerous techniques for umbilical inset. In women, studies have found that a T-shaped or vertically shaped umbilicus with superior hooding consistently scores highest in aesthetic appeal. While in men, a horizontal oval is preferred.[27]

Closure 

Temporarily approximating the abdominal incision with surgical staples before suture closure is a common practice.[20] The superior skin should be medialised to avoid dog ears and relieve tension on the triple point.[15] The incision is then closed in layers, approximating Scarpa fascia, followed by a dermal and subcuticular approximation. In the medial portion of the incision, the superficial fascial system may be secured to the abdominal fascia to prevent migration of the incision.[14][20][23]

Variations in Abdominoplasty

The traditional abdominoplasty remains the most common (described above), addressing both supra- and infraumbilical excess through a horizontal incision and umbilical transposition; however, there are additional treatment types that can be performed based on patient preference and characteristics:

• Mini abdominoplasty

  • Uses a shorter, lower incision and does not involve umbilical repositioning. This technique is best suited for patients with excess lower abdominal skin but with minimal upper abdominal excess.
• Fleur-de-Lis

  • This approach involves a vertical midline incision to correct both horizontal and vertical laxity. A known complication of this approach is wound-healing problems at the "T-point" junction, where the horizontal and vertical incisions intersect. 
• Circumferential abdominoplasty (belt lipectomy)

  • This approach provides 360-degree contouring by combining abdominoplasty with a lateral thigh lift and a buttock lift (beyond the scope of this paper). 
• Reverse abdominoplasty

  • Addresses isolated upper abdominal skin excess via an inframammary incision

Complications

The overall complication rate following abdominoplasty ranges from 10% to 20%, but can rise to 30% to 50% in patients after massive weight loss. The most common complications include seroma (5%–43%), infection (3%–14%), hematoma (3%–7%), skin necrosis (1.6%), deep vein thrombosis (<1%), and local complications such as scarring, pain, umbilical issues, and suture extrusion.[15][26] A seroma is the accumulation of clear serous fluid beneath the abdominal flap within a surgical cavity. Preservation of the Scarpa fascia during flap elevation and the use of progressive-tension sutures have been found to significantly decrease the risk of seroma compared with drains alone.[23] Risk factors for seroma include high body mass index, extensive weight loss, prior abdominal surgery, low protein intake, wide tissue undermining, and elevated flap thickness.[14][23][26][23][28]

Surgical site infections most commonly arise from skin flora, though enteric organisms may also be implicated. Risk factors include intraoperative issues such as hypothermia, inadequate antibiotic prophylaxis, breaches in sterile technique, and prolonged operative time, as well as patient factors including immunosuppression, malnutrition, smoking, and obesity. Rare but life-threatening infections, such as necrotizing fasciitis, can also occur.[15][28]

Hematomas, or collections of blood in the subcutaneous or subfascial space, typically result from inadequately controlled bleeding vessels. Intraoperative vasospasm or hypotension may mask bleeding sites that subsequently manifest postoperatively. Hematomas increase the risk of flap necrosis by exerting pressure, provide a medium conducive to bacterial growth, and prolong the inflammatory phase of wound healing.[15] 

Skin necrosis is a serious complication, often resulting from intraoperative injury to perforators or excessive tension from skin resection. The area of highest risk is the inferior midline “triple point” where lateral skin flaps converge. Other risk factors include smoking, obesity, diabetes, and hypertension. Necrosis of the umbilicus is particularly concerning because it can compromise the central aesthetic of the abdomen and significantly affect overall results.[29] Meralgia paresthetica is another rare but notable complication, resulting from injury to the lateral femoral cutaneous nerve. Patients may experience numbness, tingling, burning, prickling, or hyperesthesia of the lateral thigh, with an estimated incidence of 1.36% to 1.94%.[30]

Clinical Significance

Abdominoplasty is one of the most frequently performed body-contouring procedures worldwide, addressing concerns related to massive weight loss, postpartum changes, and aging. With the increasing prevalence of bariatric surgery, the widespread use of GLP-1 agonists, and evolving societal trends, abdominoplasty offers individuals an important opportunity to address and reduce excess abdominal tissue. The incidence of abdominoplasty is continuing to increase.

In 2023, approximately 170,110 abdominoplasties were performed. This is a 5% increase from the year prior and a 37% increase compared to pre-pandemic levels. As this procedure becomes increasingly common, clinicians will need to become familiar with its anatomy, indications, contraindications, technique, and complications.[1][2]

Enhancing Healthcare Team Outcomes

Abdominoplasty is a major elective operation with the potential for significant perioperative complications; therefore, meticulous preoperative risk stratification and patient optimization are essential. Identification of modifiable risk factors, including cardiopulmonary disease, nutritional deficiencies, smoking status, and psychosocial readiness, should precede surgical planning. An integrative, team-based model reduces morbidity by incorporating pulmonary and cardiology evaluation through primary care to optimize respiratory and cardiac function, formal anesthesiology assessment to determine fitness for general anesthesia, psychological evaluation to ensure realistic expectations (particularly in post–massive weight loss patients), and nutrition consultation to promote sustained postoperative health behaviors.[31] This structured, multidisciplinary preoperative strategy aligns with evidence-based perioperative planning and risk mitigation principles.[32]

Postoperatively, coordinated interprofessional care enhances early recognition and management of complications, thereby directly improving prognosis and safety.[33] Surgeons and advanced practitioners must lead surveillance for hematoma, seroma, venous thromboembolism, flap compromise, and wound infection. At the same time, nurses provide vigilant monitoring, early mobilization support, education on drain management, and reinforcement of discharge instructions.

Diagnostic laboratories play a critical role in guiding targeted antimicrobial therapy through culture and susceptibility data when infection is suspected. Pharmacists contribute to multimodal analgesia planning, antimicrobial stewardship, and thromboprophylaxis optimization. Clear communication, shared decision-making, and standardized handoffs across inpatient and outpatient settings ensure continuity of care, reinforce patient education, particularly for home drainage management, and promote patient-centered recovery within an evidence-based framework.[32][33]

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Disclosure: Kwesi Dawson-Amoah declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Kelecy declares no relevant financial relationships with ineligible companies.

Disclosure: Karen Szymanski declares no relevant financial relationships with ineligible companies.