Fleur-de-lis abdominoplasty after major weight loss

When fleur-de-lis is the right operation

Standard abdominoplasty addresses excess lower abdominal skin through a single horizontal incision running hip-to-hip. The procedure works well for most aesthetic and post-pregnancy cases, where skin redundancy is primarily horizontal — gathered in the lower abdomen below the umbilicus.

After major weight loss, the pattern of skin redundancy is different. Significant skin redundancy often extends both horizontally (around the entire trunk) and vertically (along the midline of the abdomen). Removing only the horizontal component leaves the midline redundancy unaddressed — the result is a visibly "vertical fold" in the abdomen even after a successful standard abdominoplasty.

Fleur-de-lis abdominoplasty adds a vertical incision running up the midline of the abdomen, from the lower transverse scar to the level of the xiphoid (the lower end of the sternum). This allows excision of both horizontal and vertical skin redundancy in a single procedure.

The trade-off is the most conspicuous scar in body contouring: a permanent vertical line on the front of the abdomen that is visible when wearing a bikini top, a low-cut swimsuit, or any garment exposing the upper abdomen. The horizontal component still hides within underwear; the vertical component does not.

Who should consider fleur-de-lis

Patients for whom the vertical component is appropriate typically have:

• Lost 40+ kg (often 60+ kg) — usually after bariatric surgery
• Visible vertical midline skin redundancy that "pleats" or "folds" when standing
• Significant horizontal redundancy as well — both axes are involved
• Realistic understanding that the scar trade-off is real and permanent

For these patients, fleur-de-lis produces a substantially better result than standard abdominoplasty would. The longer scar is the cost of addressing the actual pattern of laxity.

Who should NOT have fleur-de-lis

The wrong patient for fleur-de-lis is one whose anatomy doesn't need it. Performing fleur-de-lis on a patient with primarily horizontal redundancy adds a vertical scar without aesthetic benefit. This is a real risk in practices that adopt fleur-de-lis as a default for "post-bariatric" cases without honest case-by-case assessment.

Patients who could be adequately treated by extended (but not fleur-de-lis) abdominoplasty, with its hip-to-hip horizontal scar, generally should be — the visible scar burden is lower.

Wound healing considerations

The intersection point of the horizontal and vertical scars — the central T-junction — is the highest-tension area in fleur-de-lis abdominoplasty and is the location most prone to wound healing complications. Particular care is taken at this junction; smoking is an absolute contraindication.

Other risks are similar to standard abdominoplasty but at slightly higher rates given the larger area of dissection: seroma, scar widening (particularly along the vertical component), and DVT.