Vertical abdominoplasty: features and indications

Vertical abdominoplasty most often refers to a variant of abdominoplasty that adds vertical tissue excision along the midline of the abdomen to the traditional lower horizontal approach. The resulting scar resembles an inverted T, and the primary goal of this technique is to remove excess skin and subcutaneous fat not only downwards but also inward across the abdomen. [1]

This approach is particularly useful when excess tissue exists in two directions: vertically (sagging and "apron") and transversely (wide skin laxity, pronounced folds, and excess tissue in the epigastrium). In such patients, transverse resection alone often leaves "central fullness" and insufficient waist correction. [2]

In practice, the vertical component allows for the direct removal of excess tissue in the epigastric region and midline, improving the contour of the upper abdomen and waist shaping. This is why vertical abdominoplasty is often considered in patients after significant weight loss, when the skin loses elasticity and "biplane" excess tissue forms. [3]

The main compromise of this technique is the additional vertical scar along the entire height of the anterior abdominal wall and the increased vulnerability of the suture intersection at the T-junction, where tension and the risk of healing problems are higher. These factors are always discussed in advance, as the scar is often the deciding factor in the choice of technique. [4]

According to current data, among different types of abdominoplasty, the fleur-de-lis abdominoplasty with a vertical component demonstrates a higher complication rate in large samples than classic abdominoplasty, although absolute values remain relatively low. In an analysis of 55,596 patients, the overall complication rate was 2.1%, and for the fleur-de-lis abdominoplasty, it was 3.81%, confirming the need for more stringent selection and complication prevention. [5]

Table 1 helps to quickly understand when vertical abdominoplasty offers a clear advantage over the transverse technique.[6]

Table 1. Selecting the type of abdominoplasty based on the direction of excess tissue

Situation	What prevails	Usually preferable	Why
Excess tissue only below the navel	Local "apron" from below	Mini abdominoplasty	There is no need for a vertical component
Excess above and below the navel, but moderate in width	Vertical flabbiness	Classic abdominoplasty	Good correction without vertical scar
Marked stretching of the skin in width plus epigastric redundancy	Combined excess	Vertical abdominoplasty	Removes fabric both in height and width
After massive weight loss with "two-plane" flabbiness	Marked laxity in 2 directions	Vertical abdominoplasty or extended options	Often, the central redundancy remains

Indications: Who is vertical abdominoplasty best suited for?

The key indication is significant excess skin and soft tissue in the epigastric region and along the midline, which cannot be adequately removed by a lower transverse excision alone. In the classic formulation, the "ideal candidate" is a patient with noticeable laxity of the upper abdomen, for whom a transverse resection would leave an unsatisfactory result. [7]

A very common group of patients are those who have undergone significant weight loss, including bariatric surgery, when the skin is stretched both vertically and transversely, and persistent excess tissue forms in the epigastrium. For this population, the literature describes a wide range of complication rates (approximately 3%-35.5% in different series), emphasizing that selection and technique, not the surgical designation itself, are decisive. [8]

A special indication is centrally located scars following midline abdominal surgeries. In these cases, a vertical approach sometimes allows for the existing scar to be "integrated" into the future excision line while simultaneously taking into account the blood supply characteristics of the flaps, although planning requires extreme caution. [9]

Another argument in favor of the vertical technique is pronounced transverse skin hyperextension and weakness of the musculoaponeurotic layer, when significant fascial plication is expected (including in combination with diastasis or ventral hernias). The vertical component helps avoid persistent excess skin in the epigastric region, which can persist after transverse techniques. [10]

Candidates with significant risk factors for vertical abdominoplasty are not "allowed" to ignore safety. In a large analysis of complications, higher risk was associated with severe obesity, diabetes, and male gender, as well as certain time-of-year factors and population characteristics. This means, in practice, that more thorough evaluation and risk discussion are required before surgery. [11]

Table 2 summarizes the indications and situations where vertical abdominoplasty is usually not the first choice.[12]

Table 2. Indications and situations "rather not"

Category	Vertical abdominoplasty is more often a "yes"	Vertical abdominoplasty is often a no-no
Direction of excess skin	Excess in both height and width	Excess mainly below the navel
Epigastric region	Clear central redundancy	The epigastrium is relatively "clean"
After losing weight	Massive weight loss with "two-plane" flabbiness	Minor changes without pronounced transverse stretching
Scarring	The central midline scar can be included in the excision line	Complex scars that impair flap perfusion require an individualized solution.
Readiness for scarring	The patient is willing to accept a vertical scar for the sake of shape.	A vertical scar is unacceptable

Table 3 shows which risk factors should be adjusted preoperatively to reduce the incidence of complications and improve the predictability of outcome. [13]

Table 3. Risk factors and preoperative optimization

Factor	Why is it important?	What is usually done before surgery?
Diabetes mellitus	Higher risk of infection and healing problems	Glucose and associated factors control [14]
Severe obesity	Higher risk of complications and tension	Mass stabilization and discussion of stages [15]
Nutritional deficiencies after weight loss	Poorer healing and tissue quality	Assessment of protein, iron, vitamins and correction of deficiencies [16]
High risk of venous thromboembolism	Risk of severe events after surgery	Risk assessment and prevention plan [17]

Preoperative planning: what is assessed before the incision

Planning begins with assessing the direction of excess tissue: it's important to understand how much skin is "excess" vertically and transversely, as well as the location of the central excess that a transverse operation won't remove. With a vertical abdominoplasty, the goal is not simply to "lower the skin," but to create a narrower, more even contour by directly removing the central wedge. [18]

The markings are performed in a standing position and include the midline, the lower transverse incision line, and the approximate width of the vertical incision. The width of the vertical component essentially determines how much the abdomen will be "gathered" at the sides and the waist will be improved, but too aggressive markings increase the risk of tension in the T-junction. [19]

A separate planning section concerns the navel. In most full abdominoplasty procedures, the navel is preserved on a pedicle and brought out through a new opening after tightening the skin-fat flap. The aesthetics of the navel significantly influence the perceived outcome. Surgical literature emphasizes that an incorrect position or noticeable scars around the navel can spoil the appearance even with good contour correction. [20]

If necessary, a combination with liposuction is discussed, but it is important to avoid extremes: excessive tissue trauma and deterioration of the flap's blood supply increase the risk of ischemia, dehiscence, and scar problems. Therefore, modern combination logic is usually based on maintaining perfusion and reducing "dead space," rather than maximizing the volume of simultaneous correction. [21]

Preoperatively, the risk of venous thromboembolism is assessed and prophylaxis is planned. Professional community recommendations indicate that mechanical compression and early mobilization are appropriate for almost everyone, while drug prophylaxis is considered in patients with moderate to high risk and a low risk of bleeding, with the greatest absolute benefit expected at high Caprini scores, for example, above 8. [22]

In plastic surgery, the extent to which the Caprini scale predicts risk specifically for abdominoplasty patients is debated, and the literature presents differing positions. In practical terms, this means that decisions regarding drug prophylaxis should be based on the patient's overall risk and the extent of the surgery, not just a single number. [23]

Table 4 is a convenient checklist for planning vertical abdominoplasty. [24]

Table 4. Preoperative checklist for vertical technique

What needs to be clarified	For what
Is there excess tissue in the epigastrium and across the abdomen?	This is the main criterion for the usefulness of the vertical component.
Where will the vertical scar be and how acceptable is it?	A vertical scar is inevitable and should be a conscious choice.
Is diastasis plication necessary? Are there any hernias?	Affects the volume of intervention and pain profile [25]
Risk of venous thromboembolism and prevention plan	Reduces the risk of severe complications [26]
Nutritional deficiencies after weight loss	Affect healing and the risk of divergence [27]

Basic surgical principles of vertical abdominoplasty

The basic principle is to preserve the viability of the skin-fat flap. The greater the detachment and the higher the tension, the greater the risk of ischemia and dehiscence, so modern approaches often strive for a reasonably limited detachment, maintaining the blood supply, and reducing tissue displacement relative to the fascia. [28]

The vertical technique adds a key step: excision of a central wedge of tissue along the midline. This step allows for the removal of excess abdominal width and direct removal of epigastric excess, followed by convergence of the lateral flaps toward the midline, creating a more defined waist. [29]

Plication of the anterior abdominal wall fascia is performed based on indications, most often in cases of diastasis recti, and affects not only the appearance but also the flap tension and the sensation of a "tight abdomen" after surgery. More extensive plication can improve the contour, but also increases discomfort in the early period and requires careful management, including venous thromboembolism prevention and early ambulation. [30]

Treatment of the navel most often involves preserving it on its pedicle and creating a new opening after tensioning the flap. The details of the technique vary, but the general principle is the same: the natural shape and correct position of the navel are critical to aesthetics, so it should not be considered a secondary part of the surgery. [31]

Seroma prevention is considered one of the central principles of abdominoplasty. A 2024 meta-analysis found that progressive tension sutures are more effective than drains in reducing seroma and reoperations, and it is also discussed that a combination of liposuction and progressive tension sutures may be preferable to relying on drains alone. [32]

Another evidence-based approach to seroma reduction is preservation of Scarpa's fascia. A systematic review found that preservation of Scarpa's fascia was associated with reduced seroma rates, lower drainage volume, faster drain removal, and lower infection rates, making this technique an important part of modern protocols. [33]

Table 5 describes the logic of the stages of the operation without reference to the “only correct” school, but based on the principles of safety and complication control. [34]

Table 5. Stages of vertical abdominoplasty and their meaning

Stage	What is being done?	For what
Sections	Lower transverse plus vertical along the midline	Access for tissue removal in 2 directions [35]
Flap detachment	Limited and controlled if possible	Maintain blood supply, reduce the risk of necrosis [36]
Fascia plication according to indications	Diastasis suturing and anterior wall strengthening	Contour and shape support [37]
Working with the navel	Preservation on the leg and a new position	Aesthetics and natural look [38]
Closing the "dead space"	Progressive tension seams, sometimes drainage	Reduction of seroma and tension [39]
Closing the T transition	Layered seams, tension control	Reduced risk of scar dehiscence and problems [40]

Complications and prevention: what to focus on

Overall, abdominoplasty complications depend on the type of surgery and the patient profile. In an analysis of 55,596 patients, the overall complication rate was 2.1%, and for the fleur de lis variant, it was 3.81%, with a higher risk associated with severe obesity, diabetes, and male gender. This is a good guideline for preoperative risk discussion. [41]

The vertical technique is typically associated with "minor" wound problems: marginal dehiscence, delayed healing, and scar characteristics in the T-junction. Reviews of vertical abdominoplasty in patients undergoing massive weight loss emphasize that complications are more often of a superficial wound nature, and the incidence of complications varies greatly across series, which is usually attributed to differences in selection and technique. [42]

Seroma remains one of the most common complications of abdominoplasty overall, particularly in patients who have undergone massive weight loss, where tissue and lymphatic pathways are altered. Therefore, seroma prevention should be built into the technique rather than relegated to postoperative punctures as a default. [43]

In terms of seroma prevention, two approaches are considered the most effective: progressive tension sutures and preservation of Scarpa's fascia. Anecdotal evidence shows a reduction in seroma and faster removal of drains when preserving Scarpa's fascia, and meta-analyses confirm the benefit of progressive tension sutures compared to drains alone. [44]

Venous thromboembolism remains one of the most dangerous risks of abdominoplasty because the procedure is often lengthy, the patient's extension is limited in the early period, and fascial plication and bandaging can affect venous outflow. Professional society recommendations emphasize the role of mechanical compression and early mobilization for low-risk patients and the possibility of drug prophylaxis for moderate- and high-risk patients with a low risk of bleeding. [45]

Infections and hematomas in typical protocols are prevented by standard surgical discipline, including bleeding control and perioperative measures, and in clinical series in patients after bariatric surgery, both antibacterial prophylaxis and anticoagulant regimens are often used. These elements do not replace technique, but are part of modern safe management. [46]

Table 6 summarizes the “checkpoints” for complications specifically for vertical abdominoplasty. [47]

Table 6. Complications and what reduces the risk

Complication	What increases the risk	What reduces the risk
Healing problems in the T-junction zone	High tension, thick flap, unfavorable patient factors	Accurate marking, tension distribution, risk factor optimization [48]
Seroma	Large "dead space", lymphatic disorder	Progressive tension sutures, preservation of Scarpa's fascia [49]
Necrosis of the margins	Violation of the blood supply to the flap	Maintaining perfusion, limiting trauma [50]
Venous thromboembolism	High overall risk for the patient and the operation	Compression, early walking, drug prophylaxis as indicated [51]
Hematoma and bleeding	Insufficient hemostasis, drugs that increase the risk	Drug plan, precise hemostasis, observation [52]

Recovery, scarring, and long-term expectations

In the early postoperative period, limited trunk extension and gradual mobilization are usually required. Patient guidelines from major healthcare systems indicate a target for full recovery of approximately 6 weeks, with the timeframe for return to work and activity depending on the extent of the surgery and the nature of the work. [53]

Regarding daily activities, a practical framework is often given: 4-6 weeks without heavy loads and intense sports, while driving is usually postponed for several weeks until comfortable mobility is restored and in consultation with the surgeon and insurer. These recommendations are useful as "life planning" rather than as strict medical law. [54]

Compression bandages are used very frequently, although specific wearing patterns vary. The broader surgical literature has shown that abdominal bandages can reduce pain and improve early mobility after abdominal surgery, which indirectly supports their use as a comfort and mobilization aid with adequate tension control. [55]

Scar care is particularly important with vertical abdominoplasty because a prominent vertical scar line is added. A 2023 review of scar management emphasizes that topical silicone products, whether sheets or gels, remain a common and recommended option for the prevention and treatment of abnormal scarring, especially when initiated after suture removal and epithelialization has stabilized. [56]

Quality of life after contouring surgeries is also assessed using questionnaires such as the BODY Q, which show improvements in the domains of satisfaction with appearance and well-being in some patients after abdominoplasty and panniculectomy. Such data help formulate the goal of surgery as improving function and quality of life, rather than achieving "perfect anatomy." [57]

Long-term stability of results is best maintained with stable body weight. For patients undergoing bariatric surgery, clinical series often use weight stability for several months before reconstructive surgery and assess nutritional status, as this impacts healing and the risk of complications. [58]