Safely Performing the Inferio-Medial Vector Fleur-De-Lis Panniculectomy

Background:

The Fleur-De-Lis Abdominoplasty (FDLA)  is a unique procedure that addresses both horizontal and vertical skin excess in one operation.   Unfortunately, the FDLA is often avoided due to a perceived increased risk of flap necrosis.

Technique:

There are several published techniques for performing the FDLA.  The simplest begins with a standard abdominoplasty resection, to which an upper midline resection is added.  This technique is mentioned only to be condemned.  The point of rotation for the two flaps is the costal margin.  After resection, closing the midline draws the flaps tips medially and upwards, increasing tension on the central transverse closure.  Pulling the combined flap downward for closure of the horizontal incision, causes the flap tips to rotate laterally, increasing tension to the lower midline incision. 

Our technique begins with a transverse incision inferiorly.  Flaps are elevated to the level of the umbilicus transversely, preserving perforators superior to this.  The skin is split in the midline to the level of the xyphoid process.  Each flap is then drawn inferiorly and medially and a new midline marked.  The horizontal excess is removed and the midline closed.   The vertical excess is then marked using Lockwood demarcating clamps, excised, and closed.   By drawing the flaps inferiorly and medially, the maximal midline resection can be performed without increasing tension on the lower midline closure.  By delaying the transverse resection until the midline is closed, increased tension on the central portion of the transverse incision is avoided.

Results:

We reviewed our experience from 2001 to 2013 and identified 45 FDLA patients.  Using the this technique our overall complication rate was 26.7%.  Only two cases required re-operation.  (4.4% - one hematoma, one fatty necrosis)  There were no cases of skin flap necrosis.   FDLA complication rates reported in the literature range from 6.7 to 44.7%, with a major complication rate averaging 8.3%

Conclusions: 

Complication rates for FDLA slightly higher than to those of traditional abdominoplasty.  With proper technique, these complications are minor and are likely related to the ~50% longer incision length.  The incidence of major skin flap necrosis appears to be strongly technique dependent.  Using the technique presented, we have had zero incidence of skin flap necrosis.  We have found the FDL to be safe and effective, with high patient satisfaction.