Direct Excision Research Articles

Management of scalp arterio-venous malformation: case series and review of literature

Objective. Evaluation of management strategies for scalp arterio-venous malformation (AVM). Materials and methods. A retrospective analysis of data of 31 patients with scalp AVM was carried out at all India Institute of medical sciences New Delhi between 1997 and 2010. All the patients except one underwent digital substraction angiography. Depending upon the size of AVM, we classified them in to three groups. Group 1 (small) size up to 4.9 cm, group 2 (medium) size 5–9.9 cm and group 3 (large) size more than 10 cm. Patients in group 1 and 2 underwent direct excision. Patients in group 3 underwent pre-operative embolization followed by surgical excision. Five patients refused any treatment. Patients were analysed to look into results, complications and recurrence in follow up. Results. There were 11 patients in group 1, 12 in group 2 and 8 in group 3. There were 18 males and 13 females with mean age of 25 years ranging from 13 to 55 years. The mean duration of symptom was 7.2 years. Angiography was performed in 30 patients. Superficial temporal artery (80.6%) was the most commonly involved. 18 patients underwent direct excision, 6 underwent embolization followed by excision and 2 underwent embolization. One patient in surgery group and two patients in embolization group had recurrence. One patient expired due to complications of hypotensive shock secondary to exsanguinating haemorrhage from AVM. Conclusion. Surgical excision has excellent outcome in treatment of scalp AVM. Pre-operative embolization reduces vascularity and helps in easy identification of AVM during surgery thus achieving complete excision. The size of AVM has no correlation with the number of feeding vessels. There are high chances of recurrence in large AVM after embolization.

The Lateral Chest Wall

The lateral chest wall is an aesthetic unit often overlooked in breast surgery. Abnormalities are often seen in candidates for aesthetic and reconstructive breast surgery and in the massive weight loss population. Preoperative evaluation of the lateral chest wall is necessary to address this area properly. These deformities are intimately associated with the final outcome of any breast operation. To better define deformities of the lateral chest wall, a series of 522 patients who had aesthetic or reconstructive breast surgery was reviewed retrospectively. The preoperative and postoperative photographs were evaluated by two surgeons independently. Any surgical approaches used to correct lateral chest wall deformities were documented. In evaluating the lateral chest wall, the authors identified three subunit areas that need to be addressed to maximize aesthetic result: the axilla, the lateral breast, and the chest wall. Deficiency and excess of skin and fat contribute to any deformities in this region; deficiency or excess was found in 39 percent of patients. These deformities, when identified, were surgically addressed in 40 percent of patients, as management strategies included transfer of autologous tissue, fat injection, liposuction, or direct excision. Lateral chest wall deformities are often found among breast surgery candidates and can affect the final outcome. This area should be treated as a separate aesthetic unit from the breast. Patients with deficiency or excess should be counseled appropriately, as proper treatment may require procedures in addition to the primary breast procedure. The classification system presented can serve as a guideline for management of deformities in this region.

Results of combined preoperative direct percutaneous embolization and surgical excision in treatment of carotid body tumors

Carotid body tumors are infrequent neoplasms in daily practice. Diagnostic difficulties exist because of their slow growth and asymptomatic progress. The surgical treatment is complicated and difficult due to their proximity to vascular and neural structures. In this study we present the results of 12 patients operated for carotid body tumor that underwent preoperative percutaneous direct embolization. The data of 12 patients, diagnosed with carotid body tumor and surgically treated at our department between 2000 and 2010, was retrospectively analyzed. Duplex ultrasound, computerized tomography and selective carotid angiography were the applied diagnostic tools. Two days before the planned surgery all patients underwent percutaneous direct embolization to achieve devascularization of the tumor. Afterwards, surgical excision of the mass under general anesthesia was performed in all cases. Five tumors were classified as Shamblin type I (41.7%), and the others were type II (58.3%). All masses were removed sub-adventitially and no vascular reconstruction was necessary. There was no mortality and no permanent neural damage. Malfunction of the tongue was observed in only one case, which recovered completely in one month. There was one recurrence detected by Duplex ultrasound and angiography during the follow up period. Surgical excision is mandatory to be performed as soon as diagnosed in carotid body tumors. Preoperative direct percutaneous embolization of the mass helps to devascurize the tumor, enabling an optimal surgical procedure. The outcomes of such a combined intervention are excellent and neurovascular structure preservation decreases complication and morbidity rates.

The potential role of ductoscopy in modern breast diagnostics and therapy

Mammary ductoscopy is a modern, minimally invasive procedure that enables direct, in vivo observation of the mammary ductal system, primarily by nipple discharge. The rapidly developing device is suitable for aimed biopsy for further cytological or molecular examinations. High-tech equipments facilitate polypectomy or laser vaporization of certain intraluminal lesions, and play an important role in the direct surgical excision of the duct or the so-called terminal duct-lobular unit. The above listed facilitate the early diagnosis of malignancies even before imaging could detect them, and the control of high risk patients. Ductoscopy can foster surgical removal of ductal in situ tumors as anatomical units, thus enabling the optimization of radicality of breast conserving surgeries. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language. Orv. Hetil., 2011, 152, 1284–1293.

A Novel Lid Crease Approach to Supraorbital Mucoceles

Objective: 1) Review various approaches to lateral frontal supraorbital mucoceles (endoscopic, open: bicoronal, hemicoronal with osteoplastic flap, subfrontal, and supraciliary approach). 2) Describe a hybrid lid crease approach that allows the direct excision of the mucocele lining and harvest of a pericranial flap through a minimally invasive well-hidden blepharoplasty incision. Method: 1) Literature review of current endoscopic and open approaches for the removal of frontal/supraorbital mucoceles. 2) Description of surgical technique of the lid crease approach, harvest of pericranial flap, and a representative case with radiology, pathology, preoperative photos, intraoperative photos, postoperative photos, and follow-up. Results: Open approaches to the frontal sinus are successful in the removal of lateral frontal/supraorbital mucoceles. However, disadvantages include large scars and increased operative and recovery time. Endoscopic approaches are also successful but can be limited in lateral frontal lesions. We describe a novel approach via a lid crease incision. This approach provides direct access to the frontal sinus with complete removal of the mucocele lining. In addition, a pericranial flap can be harvested to obliterate the frontal sinus. In our case, one month postoperative photos show a well-hidden scar and 9-month follow-up does not show recurrence of disease. Conclusion: The hybrid lid crease approach combines the advantages of direct removal of the mucocele lining in a well-hidden blepharoplasty incision. Although long-term follow-up is required to validate this technique, our preliminary data suggests this technique combines the advantages of both open and endoscopic approaches.

The Circumferential Thigh Lift and Vertical Extension Circumferential Thigh Lift

Excess skin and soft tissue of the thighs after massive weight loss (MWL) can present with varying degrees of severity. The classic medial thigh lift has considerable limitations in the postbariatric population, inspiring the quest for safer and more effective technical solutions. In this study, the circumferential thigh lift (CTL), and CTL with vertical extension, predicated on a theoretical and technical approach that improves safety and aesthetics in thighplasty after MWL, is described and evaluated. Nine patients were treated; all patients experienced MWL and all had previously undergone first-stage contouring with circumferential abdominal dermolipectomy. Patients were treated with a prone-to-supine approach with concomitant suction-assisted lipectomy (SAL). Lumbar and lateral thigh and infragluteal skin and fat were excised to the midaxillary lines and medial thigh meridians. Direct excision of anterolateral thigh skin was carried in a superficial plane into the medial thigh to confluence with the posterior excision. No direct undermining of any skin margin was performed. When soft-tissue excess is limited to the proximal third of the thigh, a horizontal excision pattern is used; with middle and lower one-third thigh excess, a vertical extension is employed. The medial superficial fascial system is anchored to the superficial perineal fascia. Data were reviewed retrospectively. In the 9 procedures performed, 3 achieved MWL by nonsurgical means, and 6 underwent bariatric surgery (bypass or band). Three patients were treated with CTL, and 6 with CTL with vertical extension. There were 3 seromas (33%) treated with percutaneous aspiration. There was 1 case of cellulitis (11%) treated successfully with in-office incision and drainage, and oral antibiotics. There were no hematomas, skin loss, wound dehiscences, lymphedema, or vulvar distortions. The circumferential excision of thigh excess without direct undermining allows for the maintenance of a rich blood supply to skin margins, and concomitant SAL improves thigh contour while providing discontinuous thigh undermining. Anchoring of the superficial fascial system to superficial perineal fascia reinforces the medial lift and prevents scar migration. CTL with or without vertical extension can be combined with SAL to maximize safety and aesthetic results after MWL.

Overview of Gynecomastia in the Modern Era and the Leeds Gynaecomastia Investigation Algorithm

Gynecomastia is a benign enlargement of male breast glandular tissue. At least a third of males are affected at some time during their lifetime. Idiopathic causes exceed other etiologies and relate to an imbalance in the ratio of estrogen to androgen tissue levels or end-organ responsiveness to these hormones. Assessment must include a thorough history and clinical examination, specific blood investigations and usually tissue sampling and/or breast imaging. Management consists of a combination of measures that may include simple reassurance, pharmacological manipulation, medical treatment or surgery. Hormone therapy may help to abort the acute proliferative phase of gynecomastia with a 30% response rate but should not be considered in chronic established cases. Surgical treatment may comprise simple liposuction for a predominant fatty component or direct excision when glandular tissue is predominant. The main aim is to control the patient's symptoms and to exclude other etiological factors.

Reply: Surgical Procedure for Direct Excision of Glabellar Furrows May Be Problematic

Reply: Surgical Procedure for Direct Excision of Glabellar Furrows May Be Problematic

Surgical Procedure for Direct Excision of Glabellar Furrows May Be Problematic

Surgical Procedure for Direct Excision of Glabellar Furrows May Be Problematic

Zur Therapie des Festoons (Hängefalten)

In German there is no word for the term "festoon" but it can be used to describe folds due to gravity of the upper and the lower lid, sometimes accompanied by an oedema. The manuals of eyelid surgery (Neubauer or Heilman and Paton) recommend a direct excision, perhaps in combination with a shortening of the lid. But the postoperative result may show a poor scar and a persisting oedema. In cases of low grade festoon a temporary therapy using hyaluronic acid is possible. A combination of different surgical steps, such a subciliary incision, arcus marginalis release, a lift of the malar region, thinning out the subcutaneous oedematous skin region, skin excision and optionally a resurfacing may lead to a better cosmetic outcome.

Commentary on: Lower Blepharoplasty With Direct Excision of Skin Excess: A Five-Year Experience

Every plastic surgeon has “backup” procedures that he or she utilizes to address a problem that cannot be handled with a conventional or straightforward operative approach. Certainly, excision of excess skin around the eyes—and around the facial area in general—falls into this category very well. I was pleased to see this article and review the substantial number of cases that have been performed by the author, given the strong results. I have been employing direct skin excision in the facial area for more than 25 years, including the lower lids, the upper lateral brow area, the perioral area, and sometimes the submental area. These procedures for direct excision have been well received by patients and, for the most part, have been trouble-free. Furthermore, …

Removal of the Permanent Filler Polyacrylamide Hydrogel (Aquamid) Is Possible and Easy Even after Several Years

Sir: In fillers for soft-tissue augmentation, not only safety and efficacy but also possible removal is of concern. The necessity for extensive surgery to remove some fillers deters many surgeons from their use.1 We report on the easy removal of polyacrylamide hydrogel, marketed as Aquamid. Several long-term studies proving its safety and efficacy have been published.2 Few reports are found about complications, yet some cases required removal.3 Experience with removal of the gel has not yet been described. Aquamid is considered to be inert, but gel accumulations, especially on the lip, occur sporadically. This complication can be seen shortly after injection, but also after several years. The following two cases represent examples of the surgical removal of Aquamid. Patient 1 was a 42-year-old woman who presented with asymmetry on the upper lip following previous trauma and scarring. She underwent treatment with 2 ml of Aquamid. After 3 months, she presented with overcorrection and several small lumps in the upper lip. Because of the scarred tissue, the application had been too superficial and manual modulation after application was insufficient. Removal of the excess gel was possible by direct excision using local anesthesia. Patient 2 is a 34-year-old woman who sought consultation for lack of projection of the upper lip. She received 4 ml of Aquamid to the upper and lower lips and was satisfied with the result. After 6 years, she developed asymmetry and bulging in the upper lip. This was possibly related to a rhinoplasty procedure performed several months before. In this patient, easy and complete removal of the lump could be achieved by needle aspiration (Fig. 1) and manual expression through a small stab incision using local anesthesia (Fig. 2).Fig. 1.: Patient 2, undergoing needle aspiration to remove excess gel.Fig. 2.: Patient 2, undergoing manual expression through a stab incision.In conclusion, we find that removal of Aquamid is possible but should be performed under surgical precautions. In case of erroneously superficial application, the material can be excised directly; otherwise, manual expression and/or needle aspiration is possible. Visible scars can almost always be avoided. Most undesired results with fillers can be attributed to incorrect application4; nevertheless, even if all precautions are taken, removal may be desired. An altered body image or changes in facial architecture with aging or caused by additional surgery or subcutaneous tissue dystrophy associated with weight changes can necessitate filler removal even after several years. Easy removal is safest when there is no tissue ingrowth and no significant capsule formation that needs to be removed surgically. Permanent fillers are either hydrophilic, hydrophobic, or combination products. Hydrophilic fillers, such as Aquamid, seem to induce the least capsule formation and tissue ingrowth, probably because the water exchange allows reduction of a biofilm.5 Because necessity of removal cannot be ruled out for any permanent filler, polyacrylamide hydrogel seems to be a good option, as it has been in successful clinical use for more than 16 years and allows for correction even after a long time. Timm P. Wolter, M.D. Norbert Pallua, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Hand Surgery, Burn Center University Hospital of the RWTH Aachen, Germany DISCLOSURE The authors have no financial interest in any of the products mentioned in this article.

Early Results Using Ultrasound-Assisted Liposuction as a Treatment for Fat Necrosis in Breast Reconstruction

Fat necrosis is a common complication from autologous breast reconstruction that can compromise the aesthetic outcome and can be confused with recurrent breast cancer. Removal of fat necrosis through direct excision can be difficult with lesions in the periphery and may result in contour deformities. The article describes a case series of patients with fat necrosis treated with ultrasound-assisted liposuction. A retrospective database was created consisting of consecutive patients treated with ultrasound-assisted liposuction at a single academic institution. Patient demographics and complications were identified, including initial size of fat necrosis, number of ultrasound-assisted liposuction treatments, and final size of fat necrosis. Surgical technique was standardized over the entire series. There were 54 breast reconstructions with fat necrosis treated with ultrasound-assisted liposuction. The average initial size of fat necrosis was 2.72 cm. Twenty-seven lesions (50.0 percent) were treated once, 20 (37.0 percent) were treated twice, and seven (13.0 percent) were treated three times. The final size of fat necrosis was 0.44 cm (p < 0.0001), with an average time to follow-up of 17.8 months. Complete resolution (<0.5 cm) was seen in 44 lesions (81.5 percent). Only one complication, a thermal burn, was seen from ultrasound-assisted liposuction, and this resolved with conservative management. This case series describes the successful use of ultrasound-assisted liposuction for treatment of fat necrosis after autologous breast reconstruction. The authors find this technique to be safe, effective, and reproducible, as the majority of fat necrosis areas resolved with one or two treatments.

Lower Blepharoplasty With Direct Excision of Skin Excess: A Five-Year Experience

Many patients present for aesthetic treatment of their lower eyelid region. Although traditional lower blepharopasty can successfully correct prominent lower eyelid bags, tissue excesses in the lower periorbital region (such as crepe-like skin and festoons) can cause distress for patients both aesthetically and physically, as they may cause discomfort. The skin that can be removed from this area (below the eyelashes) with a traditional incision is limited since tension on the lower eyelid must be avoided. The authors report the results of their five-year experience performing lower blepharoplasty with a direct skin excision in the lower periorbital region. Fifty-five patients were treated with the authors' method of blepharoplasty between Ferbruary 2004 and February 2009. After precise preoperative marking, each patient was placed under local anesthesia and the excess of tissue in the lower periorbital region was removed. When necessary, removal of fat bags was performed. When the tissue in excess was significant, this kind of direct incision allowed the removal of more skin than the traditional method, without tension on the lower eyelid. No major complications-or even temporary scleral show-was observed in any of the patients in this series. In addition, no patients complained of any exaggerated visibility of postoperative scarring. The high rate of patient satisfaction with this procedure has led the authors to apply this type of incision with increasing frequency in their blepharoplasty patients. The authors' direct incision technique for lower blepharoplasty, when selected with the appropriate indications, can provide a successful and safe alternative to traditional methods. Options for treatment of the lower lid are few since the area is a very challenging one to treat and the authors believe that this additional alternative will be helpful to both surgeons and patients alike.

Mons Rejuvenation in the Massive Weight Loss Patient Using Superficial Fascial System Suspension

Sir: Significant ptosis and fullness of the mons region often creates an additional skin roll in massive weight loss patients. Traditional abdominoplasty techniques may leave these patients with a ptotic mons and an unsatisfactory aesthetic result. Treating the mons region as a distinct aesthetic unit and incorporating correction into abdominal contouring procedures will lead to greater satisfaction. There are few references that address the mons region. Liposuction and wedge dermolipectomy have been advocated by some authors.1,2 We describe a technique of mons rejuvenation that involves direct excision of sub-Scarpa fat and suspension of the mons using the superficial fascial system. Over 400 massive weight loss patients have undergone mons rejuvenation at our center between 2002 and 2009. The severity of the mons deformity was either grade 2 or 3, as based on the Pittsburgh Rating Scale.3 Two considerations are necessary to adequately rejuvenate the mons region: does the mons need to be resuspended to the abdominal fascia? Does the mons thickness need to be reduced? After fascial plication and resection, the thickness of the remaining upper abdominal flap is compared with the mons region. If the thickness is comparable, defatting of the mons is not necessary. In patients with a thicker mons region, we directly excise a wedge resection of the deep, sub-Scarpa adipose tissue down to the level of the anterior abdominal wall overlying the pubic symphysis. Care is taken to uniformly thin the mons and to avoid entering the vaginal vault. To elevate the mons to a rejuvenated position and minimize recurrent ptosis, the deep surface of the mons superficial fascial system is suspended to the abdominal wall fascia with three to five 0 braided nylon sutures. Layered closure of the abdominal incision is then performed. Over 400 patients have undergone mons rejuvenation using this technique. Average follow-up is 6 months. There was significant improvement in the mons contour, with a smooth transition to the upper abdominal flap. The mons was suspended to a more youthful position (Fig. 1). Complications included self-limited edema and mons fullness secondary to conservative defatting. We had one case of suture granuloma from the permanent suture requiring excision. Temporary change in the angle of urinary stream may be encountered. There were no incidences of dyspareunia. Patient satisfaction with the rejuvenated mons contour was very high.Fig. 1.: (Above) Preoperative anteroposterior view of a 48-year-old woman after 137-lb weight loss. (Below) Postoperative view 1 year after fleur-de-lis abdominoplasty.Massive weight loss patients often present with severe ptosis and fullness of the mons region. Traditional cosmetic abdominoplasty techniques do not specifically address the mons regions. Failure to address the pubic region in the massive weight loss patient will result in fullness of the pubic area, ptosis, and an appreciable step-off between the mons and the upper abdominal flap. Suspension of the superficial fascial system in the mons region to the abdominal wall fascia minimizes recurrent ptosis, providing a durable result. Mons rejuvenation may be a source of patient embarrassment, but correction leads to high patient satisfaction and is necessary to obtain an acceptable aesthetic result. This technique can easily be incorporated during abdominal recontouring in the massive weight loss patient. DISCLOSURE The authors have no commercial interests or financial disclosures that might pose or create a conflict of interest with the information presented in this article. Joseph Michaels V, M.D. Tali Friedman, M.D. Devin Coon, B.A. J. Peter Rubin, M.D. Division of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, Pa.

Endoscopic Removal of Nasoglabellar Dermoid Cysts

Dermoid cysts are common tumors resulting from entrapped ectodermal elements at fetal suture lines. Management is conceptually straightforward, with surgical excision of the mass in its entirety without rupture. The conspicuous location and potential scarring from direct excision can be objectionable, particularly in children. The authors describe 2 cases using a hidden hairline incision and an endoscopic approach to remove dermoid cysts in the nasoglabellar region.

Laser-Assisted Liposculpture Improves Male Gynecomastia Outcomes with Minimal Scarring

Background: Currently, 36% to 40% of men have gynecomastia. Most cases involve excessive subareolar glandular development, an enlarged subareolar region, and adipose cells. When obesity is present, gynecomastia is complicated by the intertwining of glandular breast tissue with enlarged adipose cells. Although direct excision has been the standard technique for fat removal, it is often accompanied by periareolar scars, skin laxity, and other adverse events. Laser-assisted liposculpture removes adipose and glandular tissue in gynecomastia with postsurgical contraction of the skin. The purpose of this article is to evaluate the use of laser-assisted liposculpture for removing glandular and adipose tissue in gynecomastia. Materials/Participants/Methods: Forty men (aged 30 to 35 years) with gynecomastia underwent treatment in both breasts with laser-assisted liposculpture. Most participants were overweight but in good overall health. Using Klein's double-strength solution as a local anesthetic, breast tissue was treated using a 4-mm Blugerman disruptor for 3–5 minutes on each side until the tissue became morsalized. Laser-assisted lipolysis was then used on the subareolar bud and remaining fatty and fibrous breast tissue to create tissue coagulation and skin contraction. Energy levels of 1000 J per pass were used, and total energy applied to each breast ranged from 3000 to 5000 J. After treatment, components of the destroyed adipocytes were removed by negative pressure (350–450 mm Hg) through a 3-mm cannula. The small incisions did not require sutures. Patients were examined for symmetry between the treated breasts. Diluted triamcinolone (0.1 mL Kenalog 40 mg/0.9 mL sterile water) was injected beneath the areolar complex to reduce swelling. Patient satisfaction with skin tightening, chest contour, skin smoothness, and reduction of areolar size was graded on a scale of 0 to 10. Results: Postsurgical photographs showed reductions in breast tissue volume and more masculine-appearing chests. Patient expectations for outcome were met; satisfaction was generally 8 or higher. Discussion: Two earlier studies and the present study show that use of laser-guided lipolysis results in cellular lysis and collagen neoformation. Laser-assisted lipolysis and traditional liposculpture have similar risks and complications: increased asymmetry, waviness, pitting, and cobble-stoning or sagging in breasts. Patients may also develop hematomas, seromas, nerve damage, hypertrophic scars, infection/sepsis, bleeding, persistent edema, and allergic reaction. Conclusion: The SmartLipo and SlimLipo laser-assisted liposculpture systems can be used on most anatomic regions. Both offer reduced treatment time, smoother skin and less contour deformities, improved healing, less bruising, and reduced pain compared with traditional lipolysis.

Surgical treatment of nevus-like benign melanocytic tumors in the head and face.

Objective To observe the treatment outcome of different surgical strategies in nevus-like benign melanocytic tumors with various size and shape in the head and face. Methods A total of 180 cases with nevus-like benign melanocytic tumors received surgical treatment from February 2005 to February 2008. The following surgical strategies were selected, including direct excision, partial excision, skin grafting, skin soft tissue expanding and application of local flaps (inter-flap, diamond-shaped flap, A-T flap, kite flap, etc), to treat skin lesions in the head, nose, cheek and eyelid. All patients were followed up for 3 to 6 months. Results The incisions for direct and partial excision were well healed without infection or recurrence. Of those cases treated with local flaps or expander, 3 (1 on the face and 2 on the head) experienced recurrence, 2 on the head suffered from post-operational infection. Conclusion To select different surgical strategies according to lesion size, sites and shape may lead to a favorable cosmetic result in the treatment of nevus-like benign melanocytic tumors in the head and face. Key words: Nevus; pigmented; Surgery; plastic

Surgical Correction of Gynecomastia

Gynecomastia, or persistent enlargement of the male breast, is a common occurrence during early sexual development. Typically, two types of tissue can be identified during this period of growth. Initially, a dense fibrous growth of supporting stroma and breast tissue forms directly under the areola, creating a prominent mass effect. A supporting fibrofatty stroma variably develops around the periphery of the breast, particularly as the body mass index of the patient increases. Treatment is directed at both of these tissue types and includes liposuction contouring along with direct excision of the fibrous subareolar tissue. Resection of redundant skin is performed as needed either immediately or in a delayed fashion. These various modalities can be used either alone or in combination to restore a normal chest wall contour to affected individuals, thus easing the emotional burden that is associated with the condition.

Abdominoplasty with Direct Resection of Deep Fat

Suction-assisted lipectomy is an integral component of abdominoplasty for many surgeons. Its potential to affect the vascularity of the abdominal flap is usually offset by limiting the extent of undermining and not suctioning the central flap. The authors address whether these guidelines apply to direct excision of subscarpal fat and whether direct excision provides aesthetically superior abdominoplasty results with fewer complications. A 10-year review of consecutive abdominoplasty patients (n = 181) was conducted. Undermining was done to the xyphoid and just beyond the lower rib margins superiorly and at least as far as the anterior axillary line laterally. Fat deep to Scarpa's fascia was removed by tangential excision in all zones of the abdominal flap, including those considered at high risk for vascular compromise if subjected to liposuction after similar undermining. Concurrent liposuction of the abdominal flap was not done. Thirty patients had concurrent flank liposuction. No patients experienced major full-thickness tissue loss. The incidence of limited necrosis at the incision line requiring subsequent scar revision was 0.7 percent in the 151 patients having abdominoplasty and 6.7 percent in the 30 patients having abdominoplasty combined with flank liposuction. Erythema and/or epidermolysis was seen in 4.8 percent of the abdominoplasty patients and 10 percent of the abdominoplasty/ flank liposuction group. The rate of seroma formation in both groups was approximately 16.5 percent. Direct excision of subscarpal fat does not subject any zone of the abdominoplasty flap to increased risks of vascular compromise. It is a safe technique that provides excellent abdominoplasty results.