Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 200 - файл
.pdf
236
Linea alba Recto del abdomen
Transverso del abdomen
https://t.me/medicina_free
A. Perez
Fig. 14.1 Showing the layers
of the abdominal wall as seen
in the Transverse plane with
(a) showing the abdominal
wall in the supraumbilical
region and (b) showing the
abdominal wall in the
infraumbilical region below
the Arcuate line
a
b
14.2.3 Nerves
The anterior abdominal wall is innervated:
Fascia transversal
Peritoneo parietal
Fascia transversal
Peritoneo parietal
Oblicuo externo
Oblicuo interno
Transverso del abdomen
Linea alba Recto del abdomen
Oblicuo externo
Oblicuo interno
• Subcostal nerves.
• Iliohypogastric.
• Ilioinguinal.
14.2.4 Muscles
The muscles of the abdominal wall are divided into two
groups:
1. Two vertical muscles are located near the midline, the
rectus abdominis, and the pyramidalis.
2. Three at muscles are located laterally, the external
oblique, the internal oblique, and the transversus
abdominis.
Flat muscles ex and rotate the torso. The bers of all the
muscles crisscross and connect to strengthen the abdominal
wall, this reduces the risk of hernias Varacallo [2].
14.2.5 Flat Muscles
• External oblique (Fig. 14.2)—This is the largest and most
supercial at muscle of the abdominal wall. Its bers
form an aponeurosis that merges with the linea alba at the
midline. It extends from the fth to seventh ribs to the
pubic symphysis.
Fig. 14.2 The origin and insertion of the external oblique muscle
14 Hi-Def Liposuction- My Way
https://t.me/medicina_free
237
Fig. 14.3 Origin and insertion of the internal oblique muscle Fig. 14.4 Origin and insertion of the transversus abdominis muscle
• Internal oblique (Fig. 14.3)—Origin: Anterior two-thirds
of the iliac crest, iliopectineal arch, thoracolumbar fascia.
Thinner and smaller than the external oblique.
• Transversus abdominis (Fig. 14.4)—it originates from the
thoracolumbar fascia, anterior iliac crest, and the
iliopectineal arch and ends in the lower edges of 10–12
The lateral border of the muscle is called the linea
semilunaris.
• Pyramidalis (Fig.14.6)—A triangle-shaped muscle, it is
located supercial to the rectus abdominis and in the base
of the pubic symphysis. It continues in its apex through
the linea alba.
ribs, linea alba, cremaster muscle, and the pectineal line.
14.2.6.1 Rectus Sheath
It is the aponeurosis formed by the ve abdominal muscles.
14.2.6 Vertical Muscles
The sheath is formed in the upper two-thirds of the rectus
muscle, anteriorly, by the aponeurosis of the external oblique
• Rectus abdominis (Fig. 14.5)—It is a paired, long, attened, even muscle, interrupted by three or four aponeurotic or tendinous intersections, divided medially by a
band of connective tissue called the linea alba, superior
to the arcuate line, and is contained in the rectus sheath.
and deeper by the internal oblique.
The linea semilunaris of Spiegel’s line is formed by the
fusion of the external oblique, internal oblique, and the transversus abdominis at the external border of the rectus abdominis. It extends from the ninth rib cartilage to the pubis [2].
238
https://t.me/medicina_free
A. Perez
14.3 Thoracic Muscles (Fig.14.7)
• Thoracic wall.
– Intercostal muscles.
– Subcostalis.
– Transversus thoracis.
• Posterior thorax.
– Supracostal muscles.
– Serratus superior and inferior.
• Anterior/supercial thorax.
– Pectoralis major and minor.
– Subclavius muscle.
– Serratus anterior.
• Floor.
– Diaphragm.
Fig. 14.5 Origin and insertion of the rectus abdominis muscle with the
brous intersections
Fig. 14.6 The origin and insertion of the pyramidalis muscle
Superficial thorax muscles
r
Deltoid
Sternum
Biceps
14 Hi-Def Liposuction- My Way
https://t.me/medicina_free
Fig. 14.7 Shows the various
muscles of the thoracic wall
which need to be assessed for
dening the chest
239
Sternocleidomastoid
Pectoralis major
brachii
14.4 Patient Evaluation andPreparation
The evaluation of the patient and his/ her preoperative preparation starts the moment he/she comes in for the rst consultation, and it is a process of discussions including the
surgeon, the anesthesiologist, staff, and the patient [3].
A detailed medical history is rst taken as part of the consultation. The technique is designed as a shaping procedure
rather than a debulking technique, selecting the right patient
with good muscle tone and without an excess of fat and skin
laxity (BMI<30) [4].
Once the physical examination is complete, lipodystrophy throughout the trunk is assessed, there are three basic
criteria to evaluate: muscle tone (including the presence of
rectus diastasis), skin laxity, and volume of fat (intra- and
extra-abdominal fat) [5, 6].
In the male, patient, along with the abdomen we evaluate
the presence of gynecomastia and the chest contour. The
areas to be assessed in the female patient include the anks,
the buttocks, the lumbosacral angle, fat deposits in the lateral
thighs, and the trochanteric depression and fat disposition in
the perigluteal area is made.
In men, the most requested result is to have a six-pack
abdomen, which denes an athletic and masculine appearance; on the other hand, women prefer a atter abdomen
with a softer denition of the abdominal muscles, such as the
midline, obliques, and the semilunaris lines.
It is important to note the existence of adherent scars,
hypertrophic scars, hernias, and other routine ndings.
Subcalvius
Clavicle
Subscapularis
Pectoralis minor
Coracobrachialis
Serratus anterio
Humerus
Before surgery, the patient receives a detailed list of products to avoid or suspend if necessary, such as aspirin, vitamins, contraceptives, and some specic food. For all
contouring procedures, patients need to cease nicotinecontaining products at least 3weeks before their procedure.
All patients undergo a series of studies, including complete
blood count, urinalysis, basic metabolic panel, comprehensive metabolic panel, lipid panel, coagulation panel, HIV,
syphilis, and C-reactive protein test.
All patients received 500mg IV of levooxacin, 1 gr IV
of acetaminophen, 500 mg IV of dicynone, 16 mg IV of
dexamethasone, 8 mg IV of ondansetron, 200 mg IV of
lysine clonixinate, and 100mg IV of tramadol.
14.5 Surgical Technique [7–10]
In order to improve the denition of the human body, a careful process is involved, selecting lipoplasty to reveal underlying structures such as tendons, muscles, and bony areas.
Every aesthetic surgeon needs to have a vast knowledge
of the musculoskeletal system for high-denition body
sculpting; “you have to know what you are dening before
you can learn how to dene it.”
High-denition liposuction in normal-weight patients
focuses on revealing, whereas traditional liposuction focuses
on removing.
Intraoperatively, there are three main steps in highdenition body sculpting: inltration, emulsication, and
240
https://t.me/medicina_free
A. Perez
Fig. 14.8 Surgical marking
is performed with the patient
in a standing position. (a)
Rectus abdominis and
obliques. (b–d) Marking of
the back and lumbar zone,
with marking of the targeted
areas to perform the fat
transfer
a
c
b
d
aspiration. Autologous fat grafting follows to complete the
contouring procedure.
The rst and most important step is surgical marking
(Fig.14.8). It is performed in the operating room with the
patient in a standing position. To avoid deformities and
abnormal appearances, the surgeon must have a good understanding of the supercial anatomy and topography of the
body.
It varies between women and men, since both desire different aesthetic results. Women tend to avoid the transversal
line in the rectus abdominis since it is more “masculine,”
preferring a more aesthetic and soft denition of the midline,
semilunaris lines, and obliques.
In men, the preferred landmarks to work with are the serratus anterior, rectus abdominis, obliques, semilunar lines,
and pectoralis major. It is very important to work the lateral
14 Hi-Def Liposuction- My Way
https://t.me/medicina_free
Fig. 14.9 Inltration with modied Klein’s solution is performed in both deep and supercial planes
241
body since it is a zone where a large amount of fat is found.
Posterior torso anatomy is also important, so we can work
and mark the paraspinal muscles, perigluteal area, venus
dimples, and gluteus maximus.
14.5.1 Inltration
Both deep and supercial inltration is performed using a
modied Klein’s solution, which is prepared using 1000ml
of Hartmann’s solution and 3 ampules of epinephrine 3:1000,
with symmetric volumes inltrated on each side (Fig.14.9).
The exact amounts of inltration in each area are noted by
the anesthesiologist. For more effective vasoconstriction, a
10-mins period is granted after inltration.
14.5.2 Emulsication
In high-denition liposuction, the second step is to apply a
moderated amount of ultrasound to the area we want to treat
to emulsify fat. It is important so the 3 layers of fat become
1, and to break the brosis in secondary liposuctions. Thirdgeneration ultrasound is employed to optimize safety and
efcacy. Normally, ultrasound is applied for 1min for every
100ml of Klein’s solution inltrated. Frequencies used must
be adjusted to the zone and layer we are working on.
14.5.3 Debulking (Fig.14.10)
Atraumatic cannulas are used for debulking. They provide
gentle suction that minimizes trauma. Debulking begins at
the areas of fat deposits in the deep layer, using
4.0mmx30 cm or 5.0 mmx35cm spiral cannulas, and
continues in the mid-layer and between muscle groups,
avoiding aspiration against the delicate subdermal layer.
First, the obliques are debulked and marked, with a general
suction of the anterior wall, switching between cannulas for
a more precise result. At last, posterior debulking is done
with sacral and thoracic incisions, focusing on the lower
back and hips.
14.5.4 Controlled Deformities (Fig.14.11)
The most challenging step in the procedure is to create
controlled deformities, by using compression and pinching
techniques. A concavity is gradually formed by the
repeated passage of the cannula, and with the guiding
hand, we can verify where does the compression need to
be applied. Pinching facilitates the removal of subdermal
fat by grasping the skin and squeezing it around the cannula tip.
Our method nishes with a fat transfer to the buttocks for
a more aesthetic result.
242
https://t.me/medicina_free
A. Perez
Fig. 14.10 We begin to debulk the anterior wall and dening desired muscle regions. Then, the patient is turned to a prone position to debulk the
back and lumbar region. The fat is collected in a sterilized jar, for its measure and use for future fat transfer
14 Hi-Def Liposuction- My Way
https://t.me/medicina_free
Fig. 14.11 Showing the
depressions created to
highlight the Linea Alba, linea
semilunaris, and the
horizontal brous
intersections
243
14.6 Postoperative Management
Targets of postoperative revisions:
1. Monitor the capillary rell time.
2. Monitor healing incision wounds.
3. Prevent the formation of brosis.
4. Treat forming hypertrophic scars and keloids.
5. Continuous patient care and answer questions about their
healing process.
6. Identify early complications.
14.6.1 Drainage
Open drainage is important so serohematic uid and bloodtinged tumescent uid exit the body. Some surgeons prefer to
leave physical drainages like Penrose over a lapse of 4–5days.
Superabsorbent pads are commonly placed over the drain to
improve comfort. Drainage usually ceases after 6–7 days [11].
14.6.2 Compression
The second most important thing in postoperative care is the
use of compression garments, which helps the patient to
close potential spaces, provide hemostasis, and reduce
edema. Adherent foam dressings below the compression garment provide extra uniform pressure [12].
Second-stage compression garments are recommended
after 15–20days after the surgery.
The purpose of compression in the rst few postoperative
days is to ensure adequate hemostasis and facilitate open
drainage.
14.6.3 Ambulation
In the first hours after the surgery, ambulation is
extremely recommended to reduce venous stasis and
combined with TED stackings, the risk of thromboembolism is reduced.
244
https://t.me/medicina_free
A. Perez
We encourage the use of low molecular weight heparin
[13]. Subcutaneous enoxaparin can be administrated
6hours after surgery, with a 40mg every 24hrs dose, for
6days.
14.6.4 Manual Lymphatic Drainage
Manual lymphatic drainage plays an extremely important
part in the postoperative healing process. The serohematic
uid is rich in collagen, elastin, and proinammatory components, so the action of emptying initial lymphatics and
increasing their transport is important to reduce the risk of
infection and brosis.
A combination of movements and different applied pressures stretches the skin and improves microcirculation, further ameliorating postoperative pain and edema [11].
Fig. 14.12 A 30-year-old
lady came for ne denition
of her abdomen and anks.
Photographs taken before,
during, and after the
procedure
Patients are given oral antibiotics and anti-inammatory
drugs for a short period. Almost 100% of the patients present
nausea, so the use of ondansetron 8mg IV is used in the rst
24h. After 24h, postoperative lymphatic drainage massages
start, with adjunctive external ultrasound (1-h session once a
day for a minimum of 10days).
Patients are followed postoperatively at 1, 3, 6, 12, and
24weeks. The denition from surgery is lost during the rst
weeks because of swelling but starts to re-emerge at
3–4weeks postoperatively. Patients also experience indurations during the rst 6–8weeks postoperatively that tended
to be migratory, particularly in areas of denition where contour was created by supercial and transitioning work
(Figs.14.12, 14.13, 14.14, and 14.15).
14.7 Before andAfter Photos
14 Hi-Def Liposuction- My Way
https://t.me/medicina_free
Fig. 14.13 A 25-year-old wanted ne denition of the abdomen, anks, and augmentation of the buttocks
245
Fig. 14.14 A 30-year-old Samba dancer who wanted to get in shape after putting on 10kgs secondary to PCOS
Соседние файлы в папке @xirurgi_2025