Abdominoplasty: Both vertical and horizontal plication required or is vertical plication enough for an extremely active person?

Question

Photos not supplied. Advice only. 44 years old female/Weight 60kg/height 172 cm/normal weight. Extremely active – involved in surfing & SUP surfing (challenging core) and lift heavy weights. Have Been recommended 2 types of procedure: 1) Abdominoplasty - vertical plication only 2) Abdominoplasty - horizontal and vertical plication. Which is the preference? Will vertical plication only suffice for my heavy sport involvement? Or should I go for vertical and horizontal due to my extreme sports

J. Timothy Katzen, MD, FACS · Answer

Thank you for your question regarding if vertical and horizontal plication is necessary during your abdominoplasty. I usually perform vertical plication and my patients that snatches their waistline by 2-6 inches alone. Especially if you are healthy and heavily involved in sports, I think a vertical plication will suffice.

Thank you for your question regarding if an abdominoplasty with vertical plication is enough for an extremely active person/

Thank you for your question regarding if an abdominoplasty with vertical plication is enough for an extremely active person/

Amir Sadr, MD, MSc (Plast), FEBOPRAS · Answer

Dear Weddingplanner1234
Thanks for sharing your question. Usually for majority of women who only had changes associated with pregnancy , usually the vertical midline placating is enough. Some women who have lost some of their muscle tightness, they can have -location in other directions usually oblique or L shaped which can further tighten the muscles or make the waist line more defined.I usually ask about patients preferences but final decision would be made during operation when I tighten the midline and assess the laxity of abdominal wall. You will need a clinical examination to determine the level of muscle laxity.I hope you find this answer useful.

Lisa Sacks, MBBCh, FRCS · Answer

Dear Weddingplanner1234,From the description of your body, I would not recommend anything other than a vertical muscle plication. You don't say whether you have had multiple pregnancies, nor massive weight loss.The vertical plication repairs the split in the muscles caused by pregnancy or excessive intra abdominal fat (that has been lost). It is simply repairing or reconstructing the muscle to correct the defect. There is no defect in the horizontal plane that needs correcting. In my 27 years of experience I have not found the need to do a horizontal plication in a patient requiring an abdominoplasty, including any of my patients, some of who are super fit athletes.I hope this information is helpful.

Ahmad H. Ahmadi, MD · Answer

The use of vertical plication or vertical and horizontal plication really depends on the degree of laxity of the abdominal wall, not as a preventive measure for expected intense activity.  Some may advocate the use of mesh, which most board-certified plastic surgeons would consider excessive even if absorbable mesh is used.

Jeremy S. Hurren, BSc, MBBS, FRCS (Plast) · Answer

Firstly it is not possible to give you specific advice without examining you. I advise you to have a consultation with a suitably qualified and experienced plastic surgeon. If a surgeon has advised vertical and horizontal plication there may be a good reasons for this. I assume you are referring to plication of the rectus sheath for diastasis or divarication. Divarication usually only requires a vertical plication which is what I would consider to the the standard or routine practice. Some people with a good muscle core do not need any plication of the rectus sheath and there are certainly patients on whom I would not plicate the recuts sheath. If you are already practicing 'heavy sports' it possible that you do not need a plication! or at least it would make very little difference. Sorry to give you a third option to consider!Best wishes.

Connie Hiers, MD, FACS · Answer

An examination and photos can determine which would be best. Without an exam and photos, I would overall recommend the vertical repair only because of your type of exercising.

Mats Hagstrom, MD (license on probation) · Answer

If you want to strengthen the abdominal muscle play Quetion, then you shouldn’t do that by adding muscle tightening in a perpendicular direction. If you want the most secure, abdominal wall reconstruction that would include using mesh.
That seems excessive in my opinion and I would skip trying to understand details or technical aspects of surgery and instead focus on the two variables that matter. Those are your candidacy for the procedure and the skill and experience of the provider.
Understanding your own candidacy, for the procedure is the first step in the process. There are four variables to determine with someone’s abdomen looks like. These are abdominal skin laxity, excess, subcutaneous fat, muscle, separation, and excess visceral or intra-abdominal fat. If somebody doesn’t like the way, their abdomen looks it is always because of one or more of those four variables. Without including pictures, we can’t begin to make an assessment.
A tummy tuck, primarily treats, abdominal skin, laxity, and muscle separation. I’ve never heard of somebody requiring more than a well-done tummy tuck to maintain results because of athletic activity.
Defined the best provider I suggest having multiple in person consultations. There’s no correct number of consultations needed but the more consultations you have the more likely you are to find the best provider. I suggest patient start by having at least five in person, consultations and consider scheduling more unless they have any Concerns about having found the best provider. During each consultation, your job is to get an assessment or confirm your assessment regarding your candidacy for the procedure and vet the provider. 
I recommend patients bring pictures of their own body, taken the same way plastic surgeons take before and after pictures preferably in printed format. Use pictures of your own body for reference when reviewing before and after pictures. There’s no point in seeing results of patients who have different body characteristics than your own. Candidacy after all, is half of what determines quality results. The other half is the scale of the provider.
During each consultation, ask providers to open up their portfolio and show you their entire collection of before, and after pictures of patients who had similar body characteristics to your own. Ask providers to specifically show you examples of excellent outcomes, average outcomes, and outcomes that did not turn out, as well as they had hoped for. Being shown a handful of preselected images, representing the best results of a providers career is completely insufficient to get a clear understanding of what average results look like or how many of these procedures anyone surgeon has actually performed. Learn what quality tummy tuck results look like. Look very carefully at the belly buttons about the results to make sure they consistently look natural. The incision should be set low following anatomical, contours naturally and evenly on both sides, leaving the torso looking balanced, attractive, and proportionate from all angles, including from behind. For a reference and experience provider should have no difficulty showing you at least 50 set a before, and after pictures of commonly performed procedures, like a full tummy tuck. Highly experienced surgeons fallen back up hundreds or potentially thousands of before, and after pictures of this common procedure.
While providers will prefer to show you examples of their best work, this is not in your best interest. What your goal is to find out what the average results look like especially on previous patients who had similar body characteristics to your own.
Different doctors have different techniques when it comes to muscle tightening. Some people do it quick and dirty, while others are meticulous and do it in a more formal approach. I’ve seen everything from a single, running absorbable suture to interrupted figure of eight sutures, followed by a reinforcing, running suture on top of that. Some providers will even add mesh to reinforce the strength of the abdominal wall. I don’t see how adding a horizontal muscle tightening layer is going to strengthen the vertical repair but perhaps your doctor knows something I don’t. I’ve never seen anybody else add horizontal muscle tightening so that’s a new one for me. I have seen providers do muscle tightening on the oblique muscles but I question if this adds any benefit. The best surgeons I know do a standard tummy tuck. They are meticulous about their work and spend enough time to do it right. They have the skill and experience to know how to make a proper assessment, and I have to technically do the procedure correctly. The hallmarks are always natural looking belly buttons with a very low set scar that follows anatomic contours, preferably right in the groin crease With a slightly convex curvature over the mons pubis 
If, in doubt continue having in person, consultations, until you feel very confident, you found the best provider. It is unlikely your physical activity is going to compromise your outcome. Being an athlete does not require altering your procedure.
Best,
Mats Hagstrom, MD

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