Bowel preparation with enemas is carried out the day before surgery. Foley catheter is positioned preoperatively. Elastic stockings are applied to the legs to prevent venous stasis, and low-dose heparin is administered for deep venous thrombosis prophylaxis. Marking of the surgical incisions is made in the midline drawn from the xiphoid to the pubic symphysis with the patient in upright position. With the patient supine, a lower horizontal ellipsis plus an upper vertical medial triangle, which entails the supraumbilical scars, is marked. The upper components of the elliptical drawing run obliquely downward beneath the umbilicus, which is different from the conventional design. In this way, the final horizontal scars are placed as low as possible, in the natural suprapubic fold.

The width of the upper triangle is established by pinching, with the patient supine, so as to obtain the new abdominal silhouette. No excess tension must be exerted to avoid pubic hairline elevation.

Incisions are performed along the preoperative drawing, and an “en bloc” resection of skin and subcutaneous tissue is carried out. The umbilicus is resected in a triangular shape, with the base placed superiorly, isolating and preserving its stalk, which is left attached to the abdominal fascia.

The lateral flaps are elevated through sharp dissection in a prefascial plane in order to mobilize the flaps, sparing the lateral musculocutaneous perforators and being careful not to impair the vascular supply.

Plication of the rectus sheath is then performed; in most cases, it is vertical and sometimes vertical and horizontal depending on the myoaponeurotic laxity, and it is carried out with an inverted nonabsorbable suture such as Prolene 1-0.

In case of abdominal recurrent incisional or inguinal hernias, a Prolene mesh is placed in a preperitoneal position. The umbilicus, previously cut out in a triangular shape, with a superior base, is fixed to the aponeurosis and repositioned on the abdominal flap through a “Y”-shaped incision. Before advancing the abdominal flaps and starting the sutures, the operating table is flexed 30° to release tension on the sutures. Subcutaneous approximation is attained with absorbable polyglycolic acid sutures, followed by a running subcuticular nylon suture. Two suction drains are always placed, one in a supraumbilical position and the other in a lower position, beneath the umbilicus. The abdomen is padded with a cotton-wool bandage. An elastic pressure dressing is applied all over the area (Figs. 25.1 and 25.2).

For abdominal procedures, a multifactorial analysis of variance showed that the preoperative weight had a highly statistically significant effect on the incidence of complications, whereas previous bariatric surgery did not [13].

Patients with BMI over 35 have an increased risk to develop seromas, wound dehiscence, infection, and thrombosis [14].

Avoidance of pulmonary embolus is of utmost importance. Early mobilization and the use of low-molecular-weight heparin are commonly accepted even if with different schemes. The risk of seroma is high as well, and various techniques have been suggested to control its formation: mattress sutures, tissue sealants, and the use of doxycycline into the drains [15, 16].

Necrosis is less common and together with the recurrence of the upper abdominal excess or unsightly scars may depend on surgical planning and technique [17].

Preoperative marking according to Pitanguy’s inverted T superior pedicle mastopexy are obtained at the bed of the patient. A pinch test in the supine position is always performed to identify the presence of significant skin laxity in the upper abdominal wall. Under general anesthesia, disepithelization of the preoperative inverted-T pattern is performed. A flap is islanded on perforators from the anterior intercostal arteries and harvested to increase breast volume and correct abdominal skin laxity in a single step. The flap includes soft tissues above and below the inframammary fold, extending cranially 5–6 cm above the fold and inferiorly over the costal cage, according to skin laxity. The “auto-prosthesis” is stabilized to the pectoralis major fascia with absorbable sutures in order to prevent shearing forces on the perforators. Breast shape is then checked in sitting position, and abdominal subcutaneous tissue is undermined in order to allow primary closure of the abdominal donor site, as in a reverse abdominoplasty. The inframammary fold is redefined with nonabsorbable stitches to rib periosteum, in order to prevent its caudal dislocation.