370 Fig. 8 The patient is in the Fowler position and the superior ﬂap is pulled down to try to reach the inferior suprapubic outlined incision. This is a safety measure to prevent stretching and undesirable vascular complications Fig. 9 The inferior ﬂap is raised en bloc, preserving the umbilicus stack and an inferior border of 4–5 cm of scarpa fascia to protect the lymphatic vessels and the cutaneus muscle nerves Fig. 10 The excess abdominal wall fat is trimmed away, preserving the scarpa fascia and the neurovascular bundles 123 Aesth Plast Surg (2009) 33:366–376 Fat Trimming The excess fat from the upper ﬂap is trimmed, preserving the scarpa fascia and the superior lateral pedicle of the nerves, veins, and arteries—the branches that supply the entire abdomen ﬂap and which cannot be undermined. The scarpa fascia protects those branches laterally (Fig. 10). Rectus Muscle Aponeurotic Plication The rectus muscle diastasis is identiﬁed and two lines are drawn from the xiphoid appendix to the suprapubic area. A 3-0 nylon nonabsorbable suture (PDS) is used; sutures start from the epigastric area down to and including the umbilicus stack in a medium-to-ﬁrm ﬁxa- tion. We then have a tunnel approximately 6 cm wide