Aesth Plast Surg

DOI 10.1007/s00266-017-0909-9

I N N OV A T I V E T E C H N I QU E S BODY CONTOURING

Rectus Abdominis Fat Transfer (RAFT) in Lipoabdominoplasty:

A New Technique to Achieve Fitness Body Contour in Patients
that Require Tummy Tuck
Stefan Danilla1

Received: 20 April 2017 / Accepted: 21 May 2017

! Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2017

Abstract Keywords Fit ! Fat transfer ! Lipoabdominoplasty ! High

Objective To describe a new technique to achieve a fit- definition ! Tummy tuck ! Six-pack ! Rectus abdominis !
look in lipoabdominoplasty patients through liposculpture Fitness ! Liposuction ! Liposculpture
and rectus abdominis fat transfer (RAFT).
Methods Patients with a body mass index under 26 and of
both genders scheduled for abdominoplasty or body lift Introduction
were selected for this procedure. Fat was transferred
directly to the rectus abdominis muscle after flap elevation Body contouring surgery is among the most required pro-
during lipoabdominoplasty. cedures in cosmetic surgery [1, 2]. Since the beginnings of
Results A total of 26 patients were operated on with this body contouring surgery, significant advances in the tech-
technique. No complications attributable to the fat grafting nique have been described by several authors globally.
were noticed. All patients had a high satisfaction level with Classical abdominoplasty elevates the flap in a supra-
the procedure. Demonstrative cases are shown. aponeurotic plane from the pubis to the costal border, and
Discussion The RAFT technique is a useful and effective concomitant liposuction was prohibited. That maneuver
technique to improve results in standard lipoabdomino- creates a tubular flat abdomen without the natural con-
plasty. Its main limitation is the adequate selection of the cavities and convexities of an aesthetically pleasant
patient. The RAFT technique can be incorporated easily to woman’s abdomen and usually carries a high rate of ser-
common day practice. oma formation and distal flap ischemic problems.
Level of Evidence IV This journal requires that authors Ted Lockwood [3] defined paradigms and advocates three
assign a level of evidence to each article. For a full important concepts: the high lateral tension abdominoplasty,
description of these Evidence-Based Medicine ratings, liposuction of the body contour and selective undermining.
please refer to the Table of Contents or the online Ricardo Baroudi [4] and Pollock [5] advocate the routine use
Instructions to Authors www.springer.com/00266. of quilting sutures with the aim of reducing seroma formation
and advancing the flap to the pubis. Osvaldo Saldanha [6]
popularized unrestricted liposuction of the abdomen in
abdominoplasty, with limited supraumbilical undermining
and preservation of Scarpa’s fascia; later, Dirk Richter
Electronic supplementary material The online version of this applied the concept to post-bariatric surgery [7–9] drastically
article (doi:10.1007/s00266-017-0909-9) contains supplementary
material, which is available to authorized users.
diminishing seroma formation.
In the field of liposculpture, advances have come in the
& Stefan Danilla technical field and the devices.
[email protected] In liposuction techniques, Henry Mentz [10, 11] and
1 Alfredo Hoyos [12–15] described selective fat removal to
Unidad de Cirugı́a Plástica, Departamento de Cirugı́a,
Hospital Clı́nico Universidad de Chile, Santos Dumont 999, recreate the appearance of a muscular look and called their
Independencia, Santiago, Chile techniques, muscle etching and high-definition liposculpture,

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 Aesth Plast Surg

Fig. 1 Left and central panel. Blue areas represent usual debulking fat grafting or implants. In the right superior and inferior panel, an
zones for deep liposuction, green zones represent zones for additional actual marking of a post-bariatric patient is shown
superficial liposuction and red zones correspond to addition zones via

Fig. 2 In panels A, B and C intra-operative photographs of patient in alba and linea semilunaris superficial and deep liposuction is
whom liposuction is finished and the flap is already cut. Over the performed leaving a flap of 3 mm or less. Panel D shows the
rectus abdominis, a flap of 8–10 mm is the liposuction endpoint, over immediate postoperative result
the oblique muscles a 3–5 mm must be achieved and over the linea

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Aesth Plast Surg

respectively. Constantino Mendieta [16–18] systematized the Table 1 Patient characteristics

buttocks fat grafting technique, and other authors such as Age (Mean ± SD, Range) 38.7 ± 7.6, 28–56
Roger Khouri and Daniel Del Vechio [19] popularized breast Women/men 23 (88.5%)/3 (11.5%)
fat grafting and mega-volume fat grafting.
Surgeries Lipoabdominoplasty 16 (61.5%)
One of the problems of high-definition liposculpture is
Lower body lift 5 (19.2%)
that for optimal results, adequate skin retraction is
Mini-abdominoplasty 4 (15.4%)
mandatory and suitable patients for this procedure are
Vertical abdominoplasty 1 (3.9%)*
young men or women without abdominal skin flaccidity,
Post-bariatric 5 (19.2%)
usually nulliparous women. Although VASER may be used
Women 3 (13.0%)
to improve skin retraction [20], for most multiparous
Men 2 (66.7%)
women and also for post-bariatric patients, it cannot pro-
Combination surgery 11 (42.3%)
vide adequate skin retraction and also can produce other
Augmentation mastopexy 8 (72.7%)
mild to severe problems such contour irregularities, high
Breast augmentation 2 (18.2%)
seroma formation rate, skin burns and necrosis. Further-
Gluteal implants 1 (9.0%)
more, in patients in whom skin retraction is planned,
transverse abdominal inscriptions cannot be accurately * Vertical skin pattern abdominoplasty was performed in a patient
positioned, leaving unnatural results if they are performed with previous median supraumbilical laparotomy scar
concomitant with abdominoplasty.
Looking for an adequate solution for these patients, we
developed a new technique, using selective fat grafting in flaccidity that requires skin resection with or without rectus
addition to selective liposuction to provide and optimal abdominis plication. The maximum body mass index (BMI)
body contouring. is 26 kg/m2 for woman and 28 kg/m2 for men. Patients with
The objective of this paper is to describe a new surgical higher BMIs are counseled to lose weight. Smoking cessa-
technique consisting of rectus abdominis fat transfer (RAFT) tion is mandatory at least 4 weeks prior to surgery and
and to present the results and surgical complications. 3 months after. All patients were operated on by the author.

Surgical Planning, Marking and RAFT Technique

Methods
Liposuction
Patient Selection
For more accurate operation planning, different colors are
Suitable patients for this technique are healthy men or used in the patient markings, blue corresponds to areas of
women with type II or more Matarasso abdominal skin debulk (deep) liposuction, green corresponds to superficial

Fig. 3 Diagram showing the

amount of fat grafted on each
rectus abdominis belly. Men
usually have larger muscles than
women, so more fat is needed,
on average 380 mL of decanted
fat are needed in men and
240 mL in women

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Fig. 4 Preoperative, markings and 3-month follow-up result of a adequately photograph the result, natural side lightning was obtained
38-year-old woman with lipoabdominoplasty and RAFT. At this standing the patient lateral to the window. After that index case, a
stage, no standardization of photographs was available other than photographic studio was set up to have constant lighting
usual photography with a camera-mounted frontal flash. To

liposuction, red to addition (lipofilling) areas and black lines midline at the intergluteal crease is preferred to avoid
to incisions (Fig. 1). It is absolutely mandatory to strictly visible scars.
follow patient anatomy to achieve a natural look. To accu- Addition areas Supratrochanteric area and the body of
rately demarcate areas, the surgeon must ask the patient to gluteus maximus muscle are marked if needed according to
contract and relax muscle during markings and perform the technique described by Mendieta [18].
maneuvers such as forced arm contraction, back hyperex-
tension, abdominal crunches and forced knee contraction.
Anterior Abdomen

Back and Buttocks Debulking areas Depending on patient anatomy, all of the
abdomen can be aspirated. Usually the flanks and lower
Debulking areas All the back lateral to the lateral border of ventral area are treated.
the erector spinae muscle is marked. The area medial to Definition lines Inguinal ligament, linea alba and linea
this muscle is left untouched and therefore not marked. semilunaris.
Inferiorly, the flanks are marked up to the iliac crest, where Incisions Inframammary crease bilaterally, umbilicus
the gluteus maximus muscle starts. and pubic stab incisions are made. The surgeon can place
Definition lines Midline is approximately from T10 to as many liposuction ports as desired along the skin to be
L5, posterior superior iliac spine (PSIS) and latissimus resected in the lower abdomen.
dorsi muscle lateral border superior to PSIS. Liposuction endpoints Over the rectus abdominis usu-
Incisions In women, usually in the midline at the bras- ally a flap of 8–10 mm pinch is preferred. In flanks
siere belt, intergluteal and in some patients in the most 5–7 mm flap is left. In semilunaris lines, 2–3 mm flap is
concave aspect of the lumbar zone also. In men, only the needed to achieve adequate definition (Fig. 2).

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Fig. 5 Preoperative and 1-year follow-up result of a 55-year-old patient with lipoabdominoplasty with RAFT technique and periareolar
augmentation mastopexy

Tummy Tuck Flap Elevation

If skin laxity exists over the abdomen, skin resection is The flap is undermined preserving Scarpa’s fascia and
mandatory. In patients with minimal skin flaccidity, a mini- inguinal lymph nodes approximately 5 cms above the
abdominoplasty without umbilical transposition is planned. incision. After the rectus fascia is reached and suprafascial
In patients with moderate or severe skin resection, a stan- plane is worked, central tunneling for rectus abdominal
dard abdominoplasty is planned. In post-bariatric patients, plication is worked until the xiphoid process, preserving
an extended abdominoplasty or lower body lift is perforators vessels as described by Saldanha [6].
performed.
For most abdominoplasty cases, a wide (608) angle is Rectus Abdominis Fat Transfer (RAFT)
designed at the lateral border of the skin resection pattern
as described by Lockwood to obtain high lateral tension to Fat is harvested by standard liposuction cannulas, and no
recreate the waistline. special cannulas were used. After suction, fat is decanted in

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Fig. 6 A 34-year-old patient, 7-month follow-up. Lipoabdominoplasty with RAFT technique and breast augmentation

a closed sterile canister, no exceptional preparation of the the plication increases intraabdominal pressure causing
fat is made, and it is taken out from the canister just before extrusion of the fat if it is done after the plication.
the fat grafting procedure.
Before plication, stab incisions with an 11 blade are
made over the rectus fascia over the muscle bellies, a 3-0 Finishing of the Surgery
Vicryl stich is passed before the fat grafting to close the
fascia after injection (It is easier before the injection Plicature is performed with two layers of 1-0 V-Lock
because fat drops can make the process difficult after). suture after the fat grafting. The flap is advanced and
With a 3-mm blunt fat grafting cannula, the fat is grafted Taylor tuck with moderate to high tension. Quilting con-
intramuscularly in retrograde fashion in small amounts in a tinuous sutures with 1-0 CTX Vicryl are stiched in the
multi-planar noodle technique. Usually 20 mL of fat is midline. A closed drain is usually used, and the surgery is
enough for the three superior bellies and 60 mL for the finished as a standard abdominoplasty. The incision is
inferior belly. So 240 mL of pure fat is needed to perform closed in three layers with 3-0 Vicryl for subcutaneous fat,
both rectus abdominis muscle fat grafting (Video 1, 4-0 Vicryl for deep dermis and subcuticular 4.0 monocryl
Fig. 3). RAFT is performed before the plicature, because for skin. If the surgeon does not want to use drains,

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Fig. 7 A 38-year-old patient, 13-month follow-up. Lipoabdominoplasty with RAFT technique and tuberous breast correction with Puckett’s
technique and implants. The patient developed bilateral periareolar wound dehiscence attributable to poliglecaprone suture allergy

Fig. 8 A 34-year-old patient, 7-month follow-up. Lipoabdominoplasty with RAFT technique

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Fig. 9 A 32-year-old patient, 15-month follow-up. Lipoabdominoplasty with RAFT technique and breast augmentation

additional quilting sutures can be used, but the author does Results
not use them because they prolong the surgical time [21].
From November 2015, 26 patients met the criteria for the
Postoperative Care surgery and the RAFT technique was performed. Usual
patients were middle-aged women after pregnancy or
Postoperative garments are used for 3 weeks, day and post-bariatric massive weight loss men. The skin resection
night, and for 3 weeks by day according to the patient pattern was tailored to patient needs and mini-ab-
preference. Manual lymphatic drainage and ultrasound is dominoplasty, full abdominoplasty and body lift were
applied by a physiotherapist three times per week for performed. Detailed patient characteristics are shown in
2 weeks and twice a week for 2 weeks, ten sessions in Table 1.
total. Drains are retired when daily output is less than The usual duration of the RAFT procedure was
30 mL, usually 1 week after the surgery. Silicone sheeting 5–10 min in addition to the surgery.
is prescribed at the 6th week. No complications attributable to the fat grafting proce-
All these patients are considered high risk for throm- dure were observed. The main patient concerns were lack
boembolism; in consequence, low molecular weight hep- of definition and visible or palpable irregularities in the
arin is prescribed for 10 days after the surgery. areas of superficial liposuction. These areas usually resolve

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Fig. 10 A 31-year-old patient with massive weight loss (food and habit modification) and breast augmentation and liposuction performed
elsewhere. A lower body lift with RAFT technique was done, 6-month follow-up

spontaneously in 3–4 months, but can take up to 8 months to 10 min, with no additional costs rather than 20-mL
to fully disappear. syringes, a sterile canister and a fat grafting cannula to
In Fig. 4, one of the index cases of the present series is implement the technique.
shown, a 38-year-old woman with lipoabdominoplasty and Although this procedure theoretically could be done
RAFT. blindly on liposuction patients, the author has not tried it
In Figs. 5, 6, 7, 8, 9, 10 and 11, demonstrative cases are because of the risk of intraabdominal injury with catas-
shown. trophic consequences. Moreover, high definition
liposculpture provides excellent results for patients that do
not require skin resection.
Discussion The potential disadvantages of the technique are the
selection of patients, the potential risk for injection site
Body contouring procedures are among the most requested infection and fat embolism. Nevertheless, the author has
in plastic surgery. Modern techniques such as high defini- not observed those complications in the present series, not
tion liposuction or dynamic definition mini-lipoab- in other lipofilling procedures like buttock, breast, deltoid,
dominoplasty can give excellent results in selected cases, pectoral or biceps fat grafting.
but they are not adequate for patients with moderate to The rectus abdominis muscle is a type III Mathes–Nahai
severe abdominal skin redundancy. In those patients, the irrigation-type muscle, receiving blood supply from the
RAFT technique can improve surgical results giving the inferior epigastric artery (dominant pedicle) and the supe-
currently desired ‘‘fit-look.’’ As shown in cases, adequate rior epigastric artery, ensuring the blood supply in case of
results can be obtained from mini-tummy tuck patients to theoretical fat embolism.
lower body lift after massive weight loss patients. Standardized photographs were not implemented until
The technique is straightforward, and the only devices recently, so most cases do not have even lightning in the
necessary are a small fat grafting cannula and 240–300 mL before and after pictures; nevertheless, the author thinks the
of decanted fat. The added time for this procedure is from 5 results obtained cannot be achieved without the RAFT

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Fig. 11 A 28-year-old patient with massive weight loss (food and habit modification). A lower body lift with RAFT technique was done,
7-month follow-up

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