Multi-Level Abdominoplasty

Definition

Multi-Level Abdominoplasty is an approach to the abdominal wall in which internal support is built at each anatomical layer before the skin is tightened. The approach was developed and described by Or Friedman in Multi-Level Abdominoplasty: Principles, Practice and Proven Outcomes, and applies to the abdomen the same layered framework described earlier in breast surgery.

Anatomical rationale

A lax abdomen is usually described as excess skin and fat, but it is generally the result of three separate problems acting together: excess skin, separation of the rectus muscles, and tissue displaced laterally rather than only downward. The central distinction follows from this. Most techniques address the central vector of laxity, meaning what has descended, and leave the lateral vector unaddressed. The result is an abdomen flattened in the midline in which the lateral fullness remains and the width of the waist is unchanged. Where tension is concentrated at the skin closure, that closure also carries the entire load of the result, which is the mechanism behind scar widening and healing problems along the incision.

Operative principles

The foundation is built from the inside outward, and the skin is closed last, over an abdomen that already holds its shape. The early step is the placement of lateral tension sutures between the lateral tissue and the fascia of the external oblique. These sutures draw the laterally displaced tissue back inward, and as they are tightened the waist narrows. They are not tied immediately. Their effect on the outer contour is assessed first and the degree of tension adjusted intraoperatively, exactly as the foundation sutures are handled in the breast operation.

Once lateral support is in place, rectus diastasis is addressed where present, with the muscles approximated from the sternum to the pubis. Mild separation does not require repair, and the decision follows from examination rather than from routine. The umbilicus does not travel with the skin; it remains attached at its base and is delivered through a new opening whose position is determined with the patient semi-upright, according to her pelvic proportions rather than a formula. Quilting sutures distribute tension between the layers and reduce dead space, and only then is the excess skin excised and the low transverse closure completed, planned in the standing position with the patient before surgery.

How it differs from conventional technique

The structural difference is the distribution of tension. In a conventional operation tension is concentrated at the skin closure, whereas here it is divided among several layers, each carrying part of the load. Two practical consequences follow. The first is treatment of the lateral vector, which cannot be achieved by addressing the midline alone. The second is the avoidance of routine drains in aesthetic cases, because the layered closure and the quilting sutures reduce the dead space for which drains are otherwise required. In place of a drain, external support based on the same principle of distributed tension is applied at the end of the operation and remains for approximately three weeks.

Indications

The approach suits an abdomen with a significant lateral component rather than central descent alone, and cases in which rectus diastasis requires repair alongside treatment of the skin excess. It is particularly relevant after pregnancy and after massive weight loss, including weight loss induced by GLP-1 receptor agonists, where tissue characteristics differ from those seen after bariatric surgery.

It is not the right operation for every patient. Where the problem is localised fat without skin excess or muscle separation, liposuction alone is preferable. Mild diastasis requires no repair. The choice of technique follows from the surgical problem, and part of the consultation is establishing which problem is actually being solved.

Limitations

The approach does not eliminate the scar and does not shorten it. The opposite is true. Where there is substantial lateral excess the scar extends further towards the flanks, and that is the condition for treating the lateral fullness at all. The tradeoff is presented to the patient before surgery rather than after it. The avoidance of drains is not absolute; in patients after massive weight loss, whose tissue characteristics differ, a drain may still be required. The published evidence is retrospective and drawn from case series, establishing safety and reproducibility rather than superiority over every alternative. The approach is also no substitute for weight stability before surgery.

Sources

Friedman O. Multi-Level Abdominoplasty: Principles, Practice and Proven Outcomes. Book details
Friedman O, Tal D. Abdominoplasty Outcomes after GLP-1 Agonist-Induced versus Postbariatric Massive Weight Loss: A Retrospective Comparative Case Series. Plast Reconstr Surg. 2026;157(6):860e-868e. doi:10.1097/PRS.0000000000012523
Borenstein A, Friedman O. Multi-Level Mammaplasty: Anatomical Support and Re-Shaping of the Breast. Singapore: World Scientific; 2020. ISBN 978-981-121-912-2.
Borenstein A, Azaria R, Inbar R, Friedman O. The Paper Mache Bra: A Postsurgical Breast Taping Technique. Plast Reconstr Surg Glob Open. 2019;7(9):e2407. doi:10.1097/GOX.0000000000002407

The corresponding approach in breast surgery is described on the Multi-Level Mammaplasty page. The operation itself is described on the Abdominoplasty page. The complete publication record is available at ORCID. Written and reviewed by Or Friedman, MD. Last reviewed: August 2026.