The patient is laying faced down. The preoperative markings are shown. Reexamine the preoperative markings by performing pinch test both digital and using instruments. 

Use a knife to cut through the dermis of all markings. A monopolar electro dissector is used for dissection of excess skin starting medially going lateral in the scarpas fascia plane. A bipolar diathermy is used meanwhile to ensure hemostasis. 

Continue dissecting in the lateral direction in the scarpas plane. 

Continue the dissection to the vertical marking in the midaxillary line (line B) and remove the excessive skin corresponding to the vertical line.  

Use the same technique to remove excessive skin on the other site of the back. 

The first suture is placed centrally in order to suture the skin. Ensure hemostasis before closure of the skin.  

Place sutures in three layers using absorbable sutures; 0 size-sutures in Scarpa’s fascia, 2/3-0 inverted dermal sutures and 3-0 intracutaneous running sutures. 

Place the superficial sutures in the intracutaneous layer of the skin. 

The skin is sutured in three layers.  

Micropore tape is used to cover the incision lines and on top dressing is placed. 
When the procedure of the back is finished, the patient is turned to lay faced up.  

Make an incision through the skin according to the markings, starting from the xiphoid process. 

The umbilicus is incised and dissected from the abdominal tissue. Carefully cut through the skin while stretching the umbilicus. Pay special attention to the blood supply of the umbilicus. 

Starting from the xiphoid process gradually excise the abdominal skin flap using a monopolar electro dissector. Starting from the xiphoid process the desired level to reach is superficial to the rectus fascia. Stay just above Scarpa’s fascia the last 5-7 cm above the lower incision. Use a bipolar diathermy to ensure hemostasis. 

When the umbilicus is freed from the abdominal flap, two forceps can be used to hold the umbilicus in place. Continue to ensure hemostasis. 

Make an incision in the horizontal line approximately 7 cm above labia majora. 

Pull the abdominal skin flap in the caudal direction to estimate the amount of excess skin. This will create a triangle flap of excessive tissue on both sides of the abdomen. 

Mark the predicted line of incision (line A). Do this bilaterally. 

Place sutures in three layers. Place the deepest sutures trough Scarpa’s Fascia starting from the xiphoid process following the vertical scar. 

After placing the sutures in the deepest layer, examine the need of removing further skin before resecting the two skin flaps. Make an incision following the horizontal line A (See Figure 17). Excise the abdominal flaps bilaterally in the sub Scarpa’s fascia level.  

After removing the two skin flaps, place two drains bilaterally.

Place dermal and intracutaneous sutures.  

The umbilicus is sutured as well with dermal and intracutaneous sutures in the desired position.  

Cover the sutured incisions with micropore tape.