Sir:FigureThe vertical skin excision in fleur-de-lis abdominoplasty1 can complicate the preoperative planning and the procedure itself compared with traditional abdominoplasty techniques. Irregularities caused by asymmetrical skin resections can lead to unfavorable results and have to be avoided. In this communication, we describe a novel technical method of facilitating symmetrical resection patterns in fleur-de-lis abdominoplasty. Unlike in other previously described techniques,2–5 the vertical and horizontal resection patterns are defined not preoperatively but during the operation after mobilization of the tissue with the help of a “plumb-line” suture stretching from the xiphoid to the mons pubis. Marking is performed preoperatively with the patient standing and begins by drawing a line between the xiphoid appendix and the pubic symphysis (median line), which marks the vertical incision line. Then, the lower abdominal skin is stretched cranially and the horizontal incision line is marked. The horizontal incision is carried out first. Sharp dissection is performed up to the level of the umbilicus. The lower flap is split in the midline and the umbilicus transected and preserved on a stalk. Supraumbilically, the vertical incision is now continued approximately up to the level of the xiphoid process. Epifascial dissection is continued in an inverted V shape (Fig. 1). The skin flaps are left attached to the underlying fascia, except in the areas that are contained within the fleur-de-lis excision. If necessary, a wide abdominal rectus plication is performed. The operating table is flexed at the patient's waist to reduce tension.Fig. 1: Tissue mobilization and definition of the new flap tip A′.At this stage, the point of confluence of the horizontal and vertical incisions is defined. This new flap tip is marked as A′ in Figures 1 and 2 [the blue cross (A) marks the flap tip before excision]. Using a sharp towel clamp placed subcutaneously caudally in the middle of the horizontal incision (red cross), the remaining mons pubis is moderately pulled upward (Fig. 1, left) and the mobilized flaps are pulled inferomedially (to obtain an oblique vector, indicated by the upper arrow in Fig. 1) over the towel clamp, which can be palpated through the flaps, and the point is marked as new flap tip A′.Fig. 2: Use of the plumb-line suture for intraoperative marking of the resection margins. Note the symmetrical markings. The preoperatively marked supraumbilical horizontal lines are matching each other and facilitate symmetrical closure.A suture is placed at the level of the xiphoid process in the midline and is pulled toward the marking of the midline caudally of the horizontal incision (Fig. 2). This suture is used as a plumb-line. Now, both flaps are pulled inferomedially under the suture so that the newly defined point of confluence A′ is met by the suture that is marking the midline, and tissue exceeding the midline indicated by the plumb-line suture is marked for resection on both sides (Fig. 2). To define the horizontal resection line, three sharp towel clamps are placed along the caudal incision on either side of the midline subcutaneously and pulled cranially, and the mobilized flaps are pulled inferomedially again, and the points on which the clamps can be palpated are marked. En bloc resection is carried out and hemostasis is achieved by electrocautery. Now, the inferomedial edges of the skin flaps are fixed to the suprapubic skin at the midline with a strong suture. Two Redon drains are placed under the skin flaps and the incisions are closed by a single running subcuticular layer using 2-0 polypropylene suture. The umbilicus is inset into the vertical incision. This novel approach simplifies the fleur-de-lis technique and allows for the intraoperative determination of the resection margins with symmetrical resection patterns. Steffen U. Eisenhardt, M.D. Sebastian M. Goerke Holger Bannasch G. Björn Stark Nestor Torio-Padron Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Freiburg, Germany