Reconstruction of the abdominal wall is one the most gratifying interventions in aesthetic surgery.

After giving birth or with major changes in weight, women may find that their abdominal wall appears stretched and flaccid.

This stretching causes a globular appearance of the abdomen and is sometimes accompanied by folds of fat, causing discomfort that is not resolved by dieting.

Diastasis of the rectus muscles of the abdominal wall may also leave the lumbar spine unprotected due to the weakness of the pelvis, and causes pain in the back and spine.

Our advanced technique, described in the journal Plastic and Reconstructive Surgery, involves the creation of customized muscle plications. When monitoring our patients treated with Pitanguy’s classic muscle plication technique, we found that they tended to be satisfied with the result when standing; however, many patients reported an abdominal bulge when seated. To address this problem, we developed our customized plication technique. First we correct the diastasis of the rectus muscles with the classic technique, and then seat the patient at an angle of 90º. If bulging appears, we draw a horizontal line at the center of the curvature. We place the patient in a horizontal position and perform the horizontal plication perpendicular to the suture made to correct the diastasis. We then seat the patient again; if bulging appears either above or below, we mark the center of the bulge and perform the plications again until the muscular wall is completely flat with the patient seated.

The correct treatment requires an anatomical assessment of the structures involved at four levels:

  • · First, we assess the state of the skin; whether there is excess skin,  striations, and whether it is stretched; the presence of scars, their location, and whether they can be excised without compromising the vascularization.
  • · Second, we assess the fat tissue, deciding whether there is an excessive amount, whether it is asymmetrically distributed in upper abdomen, flanks, waist, the back, and so on.
  • · Third, we assess the muscle wall, that is, whether the muscles are joined together, whether the muscle tone is good and the abdomen has the  hourglass shape, and whether muscles are stretched and separated, resulting in in diastasis.

There are two major considerations regarding the surgery. First, we have to design the incisions that allow us to remove the excess skin. Second, we have to ensure that the scar is hidden below the underwear or the swimsuit. To do this, we make a “U” shape incision in the groin, avoiding lateral prolongation.

In older women, we have to assess whether the mons veneris is horizontal. If so, the surgery will tighten this area, verticalizing and rejuvenating it. If it is very prominent, liposuction can be performed as well.

The reconstruction of three planes is performed during the surgery: the skin, fat remodeling with liposuction, and plication of the rectus abdominis muscle and muscular reconstruction.

The incision is then closed using a subcuticular running suture to avoid zip-shaped marks along the scar. We advise the patient to rest (though not completely) for two weeks before beginning more active physical exercises to permit better muscular wall remodeling and healing.

Applying these measures, the aesthetic outcomes obtained are highly satisfactory.