The Gil Classification: A Novel Anatomical and Surgical Staging System for Reverse Abdominoplasty.

Reverse abdominoplasty is a body-contouring and reconstructive technique in which redundant upper abdominal skin and soft tissue are resected through an inframammary incision and the resulting flap is advanced cephalad rather than caudally, as in conventional abdominoplasty. Although first described more than five decades ago, the procedure remains comparatively underused, and its literature is limited to small retrospective case series without a shared framework for grading the severity of upper abdominal laxity or standardizing operative planning. The authors reviewed the published literature on reverse abdominoplasty spanning esthetic, post-bariatric, and reconstructive applications and used it, together with clinical experience, to develop a four-tier anatomical and surgical classification system, herein termed the Gil classification. Type I describes laxity confined to the upper hemiabdomen with a preserved myoaponeurotic wall, managed through bilateral crescentic incisions confined to the inframammary fold with conservative adjunctive liposuction. Type II reflects similar aponeurotic integrity but a thicker adipofascial flap that requires a continuous horizontal inframammary incision and more extensive liposuction to achieve flat coaptation. Type III introduces myoaponeurotic compromise localized to the upper hemiabdomen and periumbilical region, requiring supra- and, selectively, infraumbilical plication. Type IV denotes generalized myoaponeurotic weakness and diastasis affecting the entire abdominal wall, requiring an extended submammary incision, plication in both vertical and horizontal planes, and a T- or H-pattern approach. For each tier, expected skin laxity, aponeurotic status, liposuction strategy, incision pattern, plication requirements, and compatible synergistic procedures (mastopexy, augmentation, or reduction mammaplasty; oncologic or burn reconstruction) were defined. This was accompanied by tier-specific technical considerations, including strategies to prevent the compensatory "pouching effect" after superior plication and principles for preserving perforator-based flap vascularity. This classification is intended to standardize preoperative assessment, guide operative planning, and provide a common reference for future comparative studies, addressing a gap that the existing reverse abdominoplasty literature has not previously addressed.