The cesarean apron: description, proposed pathophysiology, classification, and prevention through scarpa fascia closure at cesarean delivery.

The "cesarean apron," also known as a cesarean bulge, pouch, or shelf, is a frequent but often overlooked postoperative deformity of the lower abdominal wall that may occur even after uncomplicated cesarean delivery. It is characterized by redundant skin and subcutaneous adipose tissue that overhangs the cesarean scar, producing a contour irregularity that ranges from a mild suprapubic bulge to a large apron extending below the mons pubis. This deformity affects both obese and nonobese patients and is frequently dismissed as a cosmetic concern or attributed to weight gain. However, it can cause physical discomfort, skin irritation, and considerable psychological distress, negatively affecting body image and self-esteem. We propose that the cesarean apron results primarily from incomplete or absent closure of the Scarpa fascia during cesarean wound repair. The Scarpa fascia is a fibroelastic membranous layer that separates the superficial (Camper's layer) and deep subcutaneous fat layers of the anterior abdominal wall. We also propose that when left open, the fascial edges retract, creating a potential space that allows deep fat to herniate upward into the superficial plane, producing a pseudolipoma-like bulge. As healing progresses, fibrosis and tissue contractions above and below the gap lead to scar tethering and depression, resulting in a persistent contour deformity. In some patients, the lower fascial edge retracts downward, pulling the mons pubis caudally and contributing to its descent or ptosis. A four-grade classification a system is outlined to describe the severity of this deformity: grade 1 involves a mild suprapubic bulge with minimal fat excess; grade 2 shows moderate bulging covering the scar; grade 3 presents a large apron extending below the scar with infraumbilical rectus diastasis; and grade 4 features a large apron extending to or below the mons pubis with generalized abdominal laxity and deep scar depression. Treatment options range from liposuction and limited scar revision for milder cases to mini- or full abdominoplasty with rectus plication for advanced deformities. Routine closure of the Scarpa fascia, a standard practice in abdominoplasty but rarely performed in obstetrics, can restore fascial continuity, reduces dead space, strengthens the wound, and helps prevent postoperative contour irregularities. This simple and rapid modification of cesarean technique can improve long-term esthetic and functional outcomes without increasing operative morbidity. Recognition of the cesarean apron highlights the importance of addressing not only immediate wound healing but also long-term structural integrity, maternal well-being, and body image after cesarean delivery. Further studies are needed to evaluate the condition and the proposed management.