Case 1: Fleur-de-lis abdominoplasty
Authors: Dominika Miklisova, med. student, Ema Sutakova, med. student, Miroslava Verbat, med. student, Zuzana Jelinkova, MD, Julia Bartkova, MD, MBA
A 53-year old woman presenting with venter pendulus and diastasis of the rectus abdominis muscles was admitted to the Department of Burns and Plastic surgery for fleur-de-lis abdominoplasty. The patient underwent bariatric surgery in June 2021, resulting in significant weight loss causing extensive laxity of the abdominal skin. She decided to have the consultation at our clinic to assess the problematic excessive tissue and seek surgical resolution for the unsatisfactory appearance, which has caused her mental and physical distress. In terms of further anamnesis, the patient is being treated for hypertension, depressive disorder and osteoporosis. She is also diagnosed with nephrolithiasis, hypothyreosis sleep apnoea, polytopic vertebrogenic algic syndrome and has an anterolisthesis of lumbosacral spine. Apart from bariatric surgery she underwent an urethral stent placement and the total endoprosthesis of the right knee joint. In terms of gynecological history, the patient has three children, one delivered vaginally and two by cesarean section. Concerning family history, her mother has an ischemic disease of the lower limbs and her father died of myocardial infarction. The patient is on disability pension, formerly a saleswoman. No allergies reported.
Before and after
During the initial physical examination, a massive portion of excessive skin was identified, causing a large horizontal and vertical laxity. Abdominal rectus diastasis was also present. Due to the patient’s dual laxity, fleur-de-lis pattern was chosen for the abdominoplasty procedure. The patient underwent an internal preoperative examination and an anesthesiological assessment. She was recommended to purchase an abdominal compression garment and a compressive stockings for a post-operative regime.
After a previously mentioned bariatric surgery it is recommended to wait at least 1 year or until the weight loss has stabilized before performing body contour abdominoplasty. This timeline was respected for our patient who was admitted for surgery in 2023. In contrast to the traditional abdominoplasty, in the fleur-de-lis abdominoplasty both horizontal and vertical resections are required. Marking was performed preoperatively with the patient standing. First the planned horizontal incision was marked from the superior border of the umbilicus to the lowest abdominal crease in order to fix the circumferential component. The vertical component of the abdominoplasty was marked as an inverted “V” or triangle, the widest portion at the base of the triangle was determined by using a “pinch test”. The patient is marked standing, they are used as a reference point for the excision and adjustments are made during the procedure. Smoking and morbid obesity are relative contraindications due to the high risk of skin necrosis and infection. The patient should clearly understand the advantages, limitations and potential complications of the procedure as well as the range of scars1. Insertion of a Foley catheter and prophylactic antibiotics are recommended before the surgery.
Step 1: Preoperative markings
Preoperative markings on the abdomen.
Step 2: Horizontal resection
The horizontal resection was performed firstly as with a standard transverse abdominoplasty.
Step 3: Dissection and umbilical stalk preservation
Sharp dissection was performed to the level of umbilicus. The umbilicus was then preserved on a stalk and transected as the vertical incision continued supraumbilical to the level of xiphoid process.
Step 4: V shape and vertical incisions, en bloc resection
The dissection continued in an inverted V shape. To avoid over resection, sharp towel clips were used to secure the excised tissue edges and the limits of vertical resection were then reassessed. A sharp towel clamp was placed subcutaneously, the mons pubis was pulled upward and the mobilized flaps were pulled inferomedially. The operating table was slightly flexed to decrease the tension of the abdomen. En bloc resection was carried out and hemostasis was achieved by electrocautery. The inferomedial edges of the skin flaps were fixed to the suprapubic skin at the midline with a strong suture. A vertical incision was performed afterwards, with supraumbilical incision extended to a level just caudal to the xiphoid process. Minimal undermining was necessary in this area with an emphasis on the perforator preservation. In the apex of the incision, subcutaneous tissue was debulked to avoid a dog-ear.
Step 5: Diastasis recti repair
In conjunction with abdominoplasty, the rectus abdominis muscles were sutured to repair the aforementioned diastasis of the patient. This serves to restore the firmness of the abdominal wall and also contributes to achieving favorable cosmetic results.
Step 6: Translocation of the umbilicus, drainage, suturing
The umbilicus was then set directly into the vertical incision. A total of 2050 mg of the skin was removed. Redon drains were placed under the skin flaps. The dermis was sutured by running subcutaneous suture and the skin was sutured by intradermal suture2.
Post operatively, the patient was kept in bed in the modified Fowler’s position. An abdominal pressure garment and antithrombotic pneumatic compression stockings were placed in the operation theatre. The stockings are kept until the patient is discharged and the abdominal binder is instructed to be worn for a period of 3 to 6 weeks. The drains are routinely removed when less than 20 mL drainage is observed in a 24h period. The Foley catheter is removed the next day after surgery. The patient came for follow ups regularly for wound assessment, 15 days and 3 weeks and 5 weeks post operatively. At the first visit, a hematoma was visible near the umbilicus, a 20 mL puncture was therefore performed. The stitches were consequently removed around the umbilicus and a betadine cream was prescribed to prevent infections. The patient came back for a 3 weeks follow up, the scar was without other complications, a small persistent hematoma was seen on the left side of the umbilicus but signs of resorption were present. An additional 5 mL puncture was done. During the last follow up (5 weeks after the surgery), the haematoma was fully resorbed and the scars healed by primary intention without secretion or dehiscence of the wound. The relocated umbilicus appeared to be vital. The patient is highly satisfied with the aesthetic results and reports experiencing mental and physical relief.
- Fleur-de-lis describes an inverted-T incision where horizontal and vertical incisions resemble the stylized flower of the lily3.
- This type of abdominoplasty is an ideal choice for massive weight loss patients with upper abdominal skin laxity. Transverse-only abdominoplasty may not achieve satisfactory aesthetic results due to lack of correction of the vertical laxity and epigastric redundancy4.
- Apart from massive weight loss, other indications for this type of surgery can be abdominal panniculus associated with general obesity, supra-umbilical dermatochalasis with or without multiple abdominal scars5.
- A 2003 study from British Journal of Plastic Surgery suggested that this technique could also be used in patients with midline tissue excess regardless of their body mass index (BMI)6.
- This procedure is becoming more popular due to the increase of patients undergoing bariatric surgery who favor the body contouring outcome over the scarring outcome3. The degree of tissue undermining is limited, thereby minimizing or eliminating the occurrence of skin necrosis7.
- According to previous studies, transverse-only and fleur-de-lis abdominoplasty had similar rates of complications with slightly higher rate of wound infection in the fleur-de-lis group. There is a higher risk of postoperative complications in massive weight loss patients compared to those who were not previously morbidly obese. Male sex is another risk factor to be considered. Hypertension and diabetes have been found to correlate with higher complication rates.
- Most common complications that have been reported are hematoma, infection, wound dehiscence, tissue necrosis and seroma.
- There is an increased rate of wound infection with fleur-de-lis abdominoplasty present in multiple studies. The possible cause is a consequence of decreased perfusion at the skin edges.
- Wound healing problems have been mostly reported at the confluence of the horizontal and vertical incisions, with an incidence ranging from 3 to 35.5%. Wound dehiscence is often a minor complication treated with local wound care. In major wound dehiscence, vacuum-assisted closure placement might be necessary. A major skin necrosis can be prevented by preservation of perforating vessels and minimal undermining of the upper abdominal flaps.
- Persistent seroma formation after drain removal occurred in 8.4 percent, the majority of them were treated successfully by serial percutaneous drainage.
- There were no statistically significant differences in major postoperative complications such as pulmonary thromboembolism between transverse-only abdominoplasty and fleur-de-lis abdominoplasty1.
- Wallach SG. Abdominal contour surgery for the massive weight loss patient: the fleur-de-lis approach. Aesthet Surg J. 2005;25(5):454-465. doi:10.1016/j.asj.2005.06.001
- Eisenhardt SU, Goerke SM, Bannasch H, Stark GB, Torio-Padron N. Technical facilitation of the fleur-de-lis abdominoplasty for symmetrical resection patterns in massive weight loss patients. Plast Reconstr Surg. 2012;129(3):590e-593e. doi:10.1097/PRS.0b013e3182419c96
- Lahiri, Anindya & McKenzie, Gordon. (2014). The History of The Fleur-de-lis Technique: A Review of The Literature and Case Report. Plastic Surgery Journal for Trainees.
- Friedman T, O’Brien Coon D, Michaels V J, et al. Fleur-de-Lis abdominoplasty: a safe alternative to traditional abdominoplasty for the massive weight loss patient. Plast Reconstr Surg. 2010;125(5):1525-1535. doi:10.1097/PRS.0b013e3181d6e7e0
- Dellon A. L. (1985). Fleur-de-lis abdominoplasty. Aesthetic plastic surgery, 9(1), 27–32. https://doi.org/10.1007/BF01570680
- Duff, C. G., Aslam, S., & Griffiths, R. W. (2003). Fleur-de-Lys abdominoplasty–a consecutive case series. British journal of plastic surgery, 56(6), 557–566. https://doi.org/10.1016/s0007-1226(03)00174-7
- O’Brien, J. A., Broderick, G. B., Hurwitz, Z. M., Montilla, R., Castle, J., Dunn, R. M., Akyurek, M., & Lalikos, J. F. (2012). Fleur-de-lis panniculectomy after bariatric surgery: our experience. Annals of plastic surgery, 68(1), 74–78. https://doi.org/10.1097/SAP.0b013e31820eb92d