Standard Abdominoplasty versus Fleur de Lys excision.

One of the first described abdominoplasty procedures was a Fleur de Lys excision. Due to the fact that the procedure resulted in two scars - one horizontal and the other vertical in the middle of the abdomen plastic surgeons have moved away from this procedure. Nowadays, Fleur de Lys abdominoplasty is reserved for patients who have had massive weight loss and will not have a satisfactory skin resection with a regular abdominoplasty procedure.

When the abdomen increases in size, it does in 2 planes: vertical and horizontal. A vertical plane increase means the skin from the xiphoid of the chest and the pubic area increases in length. Shortening that vertical distance will result in a horizontal scar. In a horizontal plane increase, the skin distance from 1 hip bone to the other is increased, removing that extra skin with result in a vertical scar.

In a standard abdominoplasty, the skin of the upper part of the abdomen has not stretched as much as the skin in the mid-section. When the abdominoplasty incision is made, and the skin is pulled down, the skin of the upper abdomen moves to the middle of the abdomen, and the mid abdominal skin moves to the lower abdomen. If the skin of the upper abdomen has not stretched excessively, then it will look fine in the mid–abdomen. The mid abdominal skin will now be in the lowermost part of the abdomen hidden by underwear. Because of the mismatch in the length of the skin brought together for the closure (mid abdomen skin sewn to the lower abdominal minimally stretched skin) there will be a little wrinkling; however, it goes away within a couple of months. At times a small scar revision at the end of the excision may be needed to resolve whatever excess tissue did not correct itself in those first postoperative months.

About the scar of abdominoplasty.

When an experienced plastic surgeon looks at placing any scar, there are four thoughts that come to his mind:
-The location of the scar.
-The length of the scar.
-The closure of the scar.
-The direction of the scar.

The location of my scar is within the pubic hairline because I expect that with tight closure there will be a slight elevation of the upper margin of the pubic hairline and I want to keep the final scar located within bathing suit coverage. The day of surgery, the patient is marked wearing the bathing suit or underwear shape they prefer and I make my markings for the final scar to fall within the underwear boundaries.

The length of the scar is determined by the location and the amount of skin resected. The excision is more or less the shape of an eye and closes linearly like the eye.

The next issue has to do with direction of the scar. The limbs of the scar extend to the right and to the left. Here the situation is a little more delicate because of two principalfactors: one is whether the patient's spine is straight or there is a small element of scoliosis or whether one hip is higher than the other (not an infrequent finding).

The second factor is whether during pregnancy the abdominal wall and accompanying skin have been stretched homogeneously between the right and the left. Many times, there is a difference in the stretching between the right and the left. This may result in the scar on one side being slightly longer. The difference in this stretching between right and left may result in a slightly tighter closure on one side and this can result in the patient can end up with one limb of the scar slightly higher than the other.

Again, if noticeable a scar revision may be needed for correction.I close all my incisions with sutures buried inside the skin. They provide for longer wound support as they remain longer than removable sutures, and avoid an unpleasantsuture removal experience.