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

Introduction

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.

Patient examination

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.

Preoperative considerations

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.

Procedure

Postoperative plan

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.