An individualized approach to abdominoplasty in the presence of bilateral subcostal scars after open gastric bypass

BACKGROUND: Patients requiring surgical skin excision after massive weight loss are challenging and require an individualized approach. The characteristic abdominal deformity includes a draping apron of panniculus, occasionally associated with previous transverse surgical scars from open gastric bypass surgery in the upper abdomen, which compromise blood supply of the abdominal skin. METHODS: We propose four different surgical techniques for safe abdominal body contouring in the presence of such scars: (1) a limited abdominoplasty of the lower abdomen is performed, and then contouring is completed by a reversed abdominoplasty with scar positioning in the submammary folds; (2) a one-stage procedure characterized by skin resection in the upper and lower abdomen, in which blood supply of the skin island between the submammary and suprapubic incisions is ensured by periumbilical perforators; (3) a perforator-sparing abdominoplasty with selective dissection of periumbilical abdominal wall perforators to secure flap blood supply and allow complete flap undermining up to the xyphoid process; (4) for patients with extensive excess skin, a modified Fleur-de-Lys abdominoplasty performed in such a way that the old transverse scar is transformed into a vertical scar. RESULTS: The treatment of four exemplary patients is described. All techniques yielded good esthetic and functional results through preservation of abdominal blood supply. CONCLUSION: Through an individualized approach, adequate abdominal body contouring can be performed safely, even in the presence of transverse surgical scars in the upper abdomen.