Reverse Abdominoplasty in a Patient Presenting with Subcostal Nephrectomy Scar and Transverse Muscle Incisional Hernia

Summary:

Abdominoplasty and its different approaches have been widely described to improve abdominal wall contour. However, the role of reverse abdominoplasty, a less commonly performed technique, and its indications are not fully understood. Recent advances in the understanding of the vascular supply to the anterior abdominal wall have made this technique more popular, but there is still limited information available in the literature. In this report, we present the case of a 52-year-old woman who underwent a reverse abdominoplasty using an existing subcostal scar from a previous nephrectomy. No surgical complications were observed, and the patient achieved both aesthetic and functional improvement after 6 months of follow-up. Reverse abdominoplasty can be a reliable option for maintaining adequate blood supply and achieving a satisfactory cosmetic result in cases where there is a pre-existing subcostal scar.

INTRODUCTION

The reverse abdominoplasty technique differs from traditional abdominoplasty in that the incision is placed differently. Initially described by Rebello and Franco in 1972, this technique was primarily used for upper abdominal wall contouring.¹ In 1979, Baroudi et al described the combination of reverse abdominoplasty with reduction mammoplasty using the same incision for upper trunk contouring.²

In recent years, this procedure has been typically performed after weight loss surgery to remove excess fat remaining in the upper abdominal wall.³ Despite this being the main indication, reverse abdominoplasty has also been described as an adjunct for breast reconstruction.⁴ In addition, this technique has been used to provide tissue coverage in burn patients⁵ and to cover massive chest wall defects resulting from breast cancer surgical procedures.^6,7

CASE PRESENTATION

A 52-year-old female patient was referred to our department in November 2022 for a 1.5-cm right subcostal incisional hernia in the L1 area, according to the European Hernia Society classification, and excess dermal adipose tissue in the abdominal region.⁸ She had a medical history of clear cell renal carcinoma treated with nephrectomy and right adrenalectomy by bi-subcostal laparotomy in 2018, and adjuvant immunotherapy between 2018 and 2020. A computed tomography scan was performed during preoperative assessment. We recommended a combined procedure involving a reverse abdominoplasty and an anterior ventral hernia repair. The patient was informed of the surgical principles and potential complications and her free and informed consent was obtained.

The preoperative assessment was performed with the patient in the standing position, during which one inframammary sulcus and one sulcus on the existing scar were marked (Fig. 1). (See figure, Supplemental Digital Content 1, which shows preoperative assessment, semilateral view, http://links.lww.com/PRSGO/C784.) A vertical reference line was also marked in the midline of the torso, and these markings were used to plan a “T” incision from left to right.

Fig. 1.

Preoperative assessment, anterior view.

Incisions were then realized according to the preoperative markings (Fig. 2). The scar from the subcostal laparotomy was excised using a cold blade, and dissection was performed carefully from cranial to distal, remaining above the muscular fascial plane. The incisional hernia was identified and treated with an anterior approach and interposition of a mesh in the sublay position by a colleague from visceral surgery, using a 15 cm × 8 cm Optilene retromuscular mesh (B. Braun Medical AG, Switzerland) glued with Glubrand (GEM srl, Italy) and fixed with a transaponeurotic Maxon 2.0 stitch. The fascia was closed with two hemioverlaps of Maxon 2.0.

Fig. 2.

Perioperative status following the “T” incision.

Excess skin and fat were then resected, and closure was checked by placing the patient in a sitting position. The flap was resected and weighed at 567 g, followed by abundant washing with betadine serum, rinsing with sodium chloride, and careful hemostasis (Fig. 3). The flap was then replaced, and the superficial fascia was closed with Vicryl 2.0 (Ethicon Inc., USA). Two Redon drains were placed and attached to the skin. The supracostal incision was closed with Monocryl 3.0 reverse stitches, and intradermal suturing was performed with Monocryl 4.0 (Ethicon Inc, USA).

Fig. 3.

Perioperative status before flap closure.

Subsequently, liposuction was performed on the flanks using the Bodyjet, with small 5-mm incisions. Before the liposuction, infiltration of 660 mL of sodium chloride 0.9% with adrenaline was administered on the flanks, the saddlebags, and the inner face of the thighs. The liposuction was then carried out, and 75 g of pure fat was extracted. Liposuction holes were closed with simple Prolene 5.0 stitches. Finally, steristrips were placed on the incision sites and the patient was equipped with an abdominal belt.

No postoperative complications occurred, drains were removed on postoperative day 2, and the patient was discharged on postoperative day 3. Stitches were removed 14 days after surgery. Both aesthetic and functional improvement were obtained after 6 months of follow-up (Fig. 4). (See figure, Supplemental Digital Content 2, which shows the postoperative assessment, semilateral view, http://links.lww.com/PRSGO/C785.)

Fig. 4.

Postoperative assessment, anterior view.

DISCUSSION

Understanding the anterior abdominal wall blood supply is crucial in planning an abdominoplasty procedure and selecting the appropriate surgical technique. Three distinct vascular regions have been described as supplying this area.⁹ The central zone, located between the xiphoid process and the pubis, is vascularized by the superior and inferior epigastric arteries. These arteries follow a path behind and along the rectus abdominis and end at the skin through perforators. The inferior zone receives vascular supply from the superficial circumflex iliac, the superficial external pudendal, and the inferior epigastric arteries. Finally, the lateral abdominal blood supply comes from the lumbar, the intercostal and the subcostal segmental arteries.

Previous operations resulting in a horizontal or oblique subcostal scar could compromise the blood supply to the anterior abdominal wall from the top, potentially increasing the risk of abdominal wall necrosis if a conventional technique is used, as it sacrifices the vascular blood supply from the bottom.¹⁰ In such cases, a reverse abdominoplasty may be preferred to reduce the risk of vascular complications. This technique also has aesthetic advantages, as the scar is in the inframammary fold (IMF), which can be covered by a bra. Agha-Mohammadi et al report high patient satisfaction levels with the aesthetic results following this procedure.³

We find the use of reverse abdominoplasty to be a compelling method for accessing a subcostal hernia. By incorporating abdominoplasty techniques, we were able to address the aesthetic concerns by removing excess dermo-adipose tissue. Moreover, the placement of the scar, which was initially located at the center of the abdomen, was strategically positioned in the IMF. Although progressive tension sutures were not used in this particular case, the technique may be considered for improved anticipation of the final IMF scar.

CONCLUSIONS

The reverse abdominoplasty approach can be used in cases where there is a pre-existing subcostal scar. This technique offers many advantages and is a pragmatic option that can help prevent abdominal wall necrosis while producing excellent aesthetic and functional outcomes.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of her image.