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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
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24.6 Abdominoplasty (Surgical Technique)
[15]
24.6.1 Dissection andElevation
ofAbdominalFlap
First step in the contouring of the body includes liposuction
of the areas which do not have to be excised namely in the
upper abdomen and in the anks. Once the liposuction has
been completed, the lower abdominal incision is rst made
through the skin, subcutaneous tissue, and Scarpa’s fascia to
reach the deep abdominal fascia. The umbilicus is incised
through a peri-umbilical incision and the stalk of the umbilicus is separated taking care that it is not completely skeletonized. Infraumbilical skin is now undermined at the level of
the deep fascia leaving behind a thin lm of soft tissue on the
abdominal muscle. The abdominal pannus can be incised in
the midline to help in the dissection of the pannus and to
facilitate exposure of the muscle for tightening of the abdominal muscle if indicated.
Superior to the level of umbilicus, dissection is carried
out laterally to the linea semilunaris and superiorly to the
xiphisternum. This dissection is at the level of the abdominal
deep fascia which preserves the blood supply to the abdominoplasty ap coming from the superior epigastric and the
musculophrenic artery and limits the amount of dead space
in the supraumbilical area (Fig.24.8).
Diastasis recti repair with continuous barbed sutures (if
indicated).
A preoperative clinical diagnosis of a diastasis recti
necessitates tightening of the muscular divarication in the
midline. Any hernia which has been conrmed with a CT
scan of the abdomen can also be repaired at the same time.
Diastasis recti will be seen as an increased distance
between the medial edges of the rectus abdomini muscles,
typically greater than 2cm at the widest point. The goal of
repair is approximating the medial edges of the rectus abdominus muscle without opening the rectus sheath. The rectus
sheath in the midline is invaginated during the process. The
defect in the rectus sheath is marked along with the planned
reduction in the width between the rectus muscles of the two
sides. This is done with ink as a fusiform shape along the
medial edges of rectus abdominis muscles from xiphoid to
pubic symphysis (Fig. 24.9a). The tightening of the rectus
sheath and thus the repair is performed with #1 polypropylene suture (PROLENE) Ethicon (Fig.24.10a, b). This is bidirectional barbed suture. The rst throw of the suture is in the
area of xiphoid process where the needle is passed through
the fascia in the midline. The tightening of the rectus sheath
and thus the repair is performed with #1 Ethibond staring
R. Calderon
Fig. 24.8 Supraumbilical dissection area
from just below the umbilicus down to the pubic area, afterwards the suture is continued, starting from above the umbilicus up to the xiphoid. This is gure of eight suturing to tighten
in the vertical as well as the horizontal directions. The rst
throw of the suture is in the area of xiphoid process where the
needle is passed through the fascia in the midline (Fig.24.9b).
This technique prevents the need to use ink to draw the tightening edges. Each suture placed individually dictates the next
suture and prevents over tightening. A two-layered diastasis
recti repair is performed. The rst layer is undertaken as a
continuous, horizontal mattress suture starting from the
xiphoid to the pubic symphysis. The suture should pass only
through the anterior layer of the rectus sheath. One assistant
should keep a continuous tension on the suture as the suturing
progresses. As this suture reaches the umbilicus, it is taken
through one side of the umbilicus so as not to compromise the
vascularity of the umbilical stump. This suture is now continued inferiorly to the umbilicus to above the pubis symphysis.
The suture is then continued back in a superior direction to
lock it in place. The second layer of the suture can be an interrupted suture or as a continuous manner and the suture should
be passed on the same side of the umbilicus that the rst arm
was passed to avoid strangulation (Fig.24.11).
ab
a
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Fig. 24.9 (a) Medial edges
of rectus abdominis muscles
from xiphoid to pubic
symphysis have been marked
with ink. (b) Figure of 8
suture placement to tighten
the rectus sheath
383
b
Fig. 24.10 (a, b) Tightening of the rectus sheath using prolene 1 suture
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Fig. 24.11 The completed second layer of suture
24.6.2 Marking andExcision ofExcess Skin
Once the rectus sheath has been tightened, the operating
table is exed at the patient’s waist by about 135° so that
the abdominal skin can be sutured easily without tension.
The upper abdomen skin ap is pulled down to overlap the
lower incision and is marked to check for the extent of
excision. The aps are pulled medially so that there are no
dog ears on the anks. This marking is now compared to
the one marked preoperatively and right and left symmetry is conrmed. The excess skin is now resected by making an incision perpendicular to the skin surface. The
incision is deepened through the subcutaneous tissue for a
through and through resection of the tissue. Any excess
sub-Scarpa fat is excised distally to get a ap edge of even
thickness.
24.6.3 Creating aNeo-umbilicus
The new umbilicus is marked in the midline by having a
superior traction on the umbilicus and transposing the marking onto the skin. We use umbilicus round-shape with a sin-
Fig. 24.12 Round-shaped umbilicus
gle horizontal slit excision or in an H-shape (Figs.24.12 and
24.13a).
I use inverted U-shaped incision for the umbilicus and
ap on the skin is based in the inferior portion so as to hide
the scar where it will be visible the most in the standing position (Fig. 24.13b). This will be closed with 2-0 monocryl
superiorly and inferiorly tacking down the suture to the rectus fascia.
24.6.4 Abdominoplasty Closure
The lower abdominoplasty incision is closed in multiple
layers. Scarpa’s fascia is closed with interrupted suture 2-0
vicryl. The skin is reapproximated with 3-0 nylon interrupted, inverted deep dermal sutures, followed by a continuous horizontal mattress deep dermal suture, and 3-0 monocryl
by a continuous intradermal suture. The closing of the lipectomy in the sequence previously stated, allows for a better
distribution of opposing forces and therefore leads to thinner
and better scarring as seen in Fig.24.14.
The umbilicus is inset with 3-0 nylon interrupted, dermal
suture.
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ab
Fig. 24.13 (a) H-shaped umbilicus. (b) U-shaped umbilicus
abc
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Fig. 24.14 (a) Closure of abdominoplasty and breast implant surgery. (b, c) Pre- and post-closure of abdominoplasty with augmentation
mastopexy
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24.7 Breast Surgery
24.7.1 Subglandular Pocket Dissection
Local anesthetic with epinephrine (20cc per side; 1% lidocaine with 1:100,000 epinephrine) is rst inltrated into the
incision as well as the borders of the breast dissection pocket.
After waiting for 7min post-inltration, a skin incision is
made in the inframammary crease using a 15 blade. The incision is deepened to the muscular fascia. Retractors are now
placed on the upper incision edge and the dissection is carried out in an oblique manner to reach the origin of the pectoralis major muscle inferiorly. While making the incision
we encounter two fascial layers—the rst is the supercial
layer of the supercial fascia which is also called the breast
capsule and the second fascial layer is the deep layer of
supercial fascia. The mammary tissue lies between the two
layers. A layer of fat lies between the deep layer of supercial fascia and the deep fascia of the muscle. These layers are
very important as they will be sutured as part of the closure
to recreate the infra mammary crease.
Dissection is now continued with an electrocautery and
the loose areolar tissue is identied between the pectoralis
major muscle fascia and the breast parenchyma. The pocket
for the breast implant is dissected in the subglandular plane
which is aided by a lighted breast retractor which helps in
achieving hemostasis under direct vision. The extent of
pocket dissection should be the premarked areas with slight
overdissection allowed superiorly. Overdissection should not
be undertaken on the lateral aspect to prevent lateralization
of the implant nor medially to prevent palpation and visibility of the implant edge. During dissection of the pocket, a
radial cut of the breast capsule is performed, both medial and
lateral to the incision employing sharp scissors. Division of
these transverse dermal anchoring bers of the IMF allows
the expansion of the tight lower pole of the breast. Performing
this radial release early on during pocket dissection will
make it easier to retract and facilitate visualization of the
subglandular space.
The same procedure is carried out on the opposite side
taking acre that the incisions are well hidden and the symmetry of pockets is ensured. Hemostasis should be meticulous and the pockets should be absolutely dry before
proceeding with the implant insertion [16].
The implant is placed by a no-touch technique and the
breasts are checked for symmetry by making the patient in a
back-up position. Closure is started by rst doing a 3-point
suture with vicryl 2-0 which brings helps in repairing the
breast capsule to the deep fascia thus creating the inframammary crease. The supercial breast capsule is now closed
using interrupted inverted sutures of 3-0 PDS and the skin
edges are re-approximated using 3-0 monocryl in a subder-
mal manner. It is very important to have this multi-layered
closure so as to achieve a repair of individual layer as well as
ensure a good seal of the implant, separating it from the skin
incision. Attention is now focused on lifting if necessary,
using a superior or inferior pedicle technique. I prefer the
superior pedicle in order to remove the most ptotic tissue that
is more inferiorly.
24.8 Changes ofBlood Supply
oftheAbdominal Wall After
Abdominoplasty [17]
It is very important to understand anatomically the blood
supply of the abdominal wall specially when abdominoplasty is combined with suction-assisted liposuction (SAL)
techniques. Huger in his landmark paper studied the vascular
changes in the abdominal wall after the patient had undergone a full abdominoplasty. He described the area as zones
with Zone I consisting of areas supplied by the deep epigastric arcade which includes the central mid abdomen. Zone II
is the area supplied by the supercial and deep inferior epigastric artery which is the area below the umbilicus and Zone
III is supplied by the cutaneous branches of the intercostal
and lumbar arteries and lies laterally along the anks
(Fig.24.15).
The abdominal wall can be divided into four regions
depending on the extent of suctioning and the procedure carried out often referred to as suction areas 1–4 (SA1–4).
The topography of each of these areas is based on the
safety with regards to vascular supply when liposuction is
combined with a full (type 4) abdominoplasty. If full
abdominoplasty is combined with liposuction then the
maximum risk to the ap will be in SA-3 specially if liposuction is carried out in that area as it is in a completely
undermined zone. When undertaking full abdominoplasty,
the area where liposuction can be very safely carried out is
SA-1 and SA-2. SA-4 is the area where liposuction is not
required as this tissue will be removed during type 4
abdominoplasty but needs suctioning in type 1–3 abdominoplasty procedures.
When combining SAL with abdominoplasty, it is important to modify the surgical plan based on vascular changes
that may be expected postsurgery. The epigastric cascade in
zone I is preserved in type 1–3 abdominoplasty and hence
liposuction can be safely carried out in all areas. Consideration
has to be specially given when undertaking liposuction along
with type 4 abdominoplasty as due to extensive undermining
the dominant blood supply now comes from Zone III. If
extensive liposuction is required along with a full abdominoplasty, then a staged procedure or just a panniculectomy with
SAL should be considered.
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Fig. 24.15 Blood supply after abdominoplasty and SAL
Vascularity in the abdomen is deep in the central area
coming from the periumbilical perforators and is supercial
laterally. During traditional abdominoplasty the periumbilical perforators are divided and the ow of blood
reverses from being deep centrally to deep supercially. The
tissue deep to Scarpa fascia then can be viewed as being
somewhat parasitic to the abdominal wall itself [18].
Many innovations and changes in the technical aspects of
abdominoplasty and for that matter body lift was introduced
by Lockwood in 1995 who advocated a high lateral tension
approach to address lower abdomen skin laxity along with
selective undermining to preserve perforators and lymphatics and keep the position of the scar low. These changes help
in undertaking extensive SAL along with complete abdominoplasty and keep the ap safe [19].
24.9 Abdominoplasty andBreast Surgery
Complications
Even in the best surgical hands, complications occur; the
American Society for Aesthetic Plastic Surgery (ASAPS)
report complications rates after abdominoplasty including
seroma with rates as high as 42.8%, necrosis (5.4%), contour
irregularity (5%), and hematoma (1.4%). Cumulative data
suggest 1in 3 patients experience at least one minor complication [20].
24.9.1 Seroma
Seroma is one of the commonest complications seen after
abdominoplasty due to extensive undermining and associated liposuction in people who may have been obese. This
happens due to surgical division of the lymphatic channels which then leak lymphatic uid in the dissected
areas. Use of suction drain and quilting sutures helps in
reducing the prevalence of seroma. Sometimes these
closed suction systems may not be functioning well cause
uid to retain in the space. Moreover, there can be infection through the drain channel into the seroma causing
more scarring.
Furthermore, seromas have been implicated as a contributing factor in scar asymmetry, which can also have a signicant impact on the patient satisfaction [1].
Seroma requires percutaneous drainage and regular
assessment to reduce the risk of pseudobursa formation.
Chronic seromas can be managed with sclerotherapy using
bleomycin or doxycycline. If recalcitrant, open pseudobursa
excision is usually denitive [21].
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24.9.2 Necrosis
Necrosis can happen without any specic cause but is a signicant risk in people who smoke and in diabetics. The vascularity of the abdominal ap may be compromised due to
excess mobilization of skin, aggressive liposuction causing
injury to dermal plexus, increased resection, and excess tension on closure. “Operative conservativism” should be the
norm in people who smoke, are diabetic, or have a high BMI
as the risk of necrosis varies from 1 to 5.4% [22].
Small areas of necrosis very close to the suture line will
be asymptomatic and will heal without any symptoms, however extensive necrosis will cause infection and may need
surgical exploration and excision [23].
24.9.3 Venous Thromboembolism
The leading cause of mortality and morbidity in plastic surgery is venous thromboembolism (VTE) with the overall
incidence being 0.02–2% and the highest risk of 10% with
body contouring procedures.
The VTE risk increases signicantly when procedures are
combined, in the postbariatic surgery population, or in obese
patients.
Risk reduction with enoxaparin was only found in the
high-risk patients (Caprini score greater than or equal to 7)
[24].
24.9.5 Infection
Abdominoplasty is considered a clean procedure with the
infection rate being 1–2%. Wound infection is one of the
most common complications following seroma and hematoma. The administration of preoperative prophylactic antibiotics is important, but, as noted above, they are only part of
the strategy in reducing surgical site infection [26].
24.9.6 Symmastia
Symmastia after breast augmentation is caused by the overdissection of the implant pocket medially causing disruption
of the sternal fascia in the midline, placing oversized implants
which communicate with each other medially and over
release of the medial pectoral bers from the sternum [27].
The treatment includes closure of the pocket medially after
removal of the implant.
24.9.7 Capsular Contracture
Capsular contracture is usually a long-term complication
which was very common with smooth breast implants placed
subglandular which causes the breast to feel tight, rm, distorted, and painful. The incidence of capsular contracture in
primary breast augmentation is believed to range from 2 to
15% [4].
24.9.4 Hematoma
One of the most common postoperative complications in
aesthetic surgery is hematoma formation. They can be
small with signs and symptoms of local swelling, warmth,
erythema, and tenderness which usually resolve without
any incident. Large hematomas may cause hemodynamic
changes and if left untreated may cause poor cosmesis,
scarring, ischemia of the skin causing necrosis and
infection.
The incidence of hematomas depends on factors such as
patient being on blood thinners, uncontrolled hypertension
and sometimes the surgical technique. The treatment of choice
for a prominent hematoma is surgical evacuation [25].
24.10 Conclusions
Body contouring procedures offer patients the opportunity to
truly improve their body image and quality of life. Despite the
many choices available to the surgeon, by balancing the aesthetic demands of each individual patient with their unique
surgical risk, one can select a body contouring procedure that
is at the same time the most effective and the safest.
24.11 Pre- andPost Surgery Photos
See Figs.24.16, 24.17, 24.18, and 24.19.
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Fig. 24.16 This 26-year-old
woman underwent breast
augmentation and extended
abdominoplasty (a)
preoperative view and (b)
2months postoperative view
a
b
Fig. 24.17 This 26-year-old
woman with BMI of 30
underwent breast
augmentation and extended
abdominoplasty (a)
preoperative view and (b)
3months postoperative view
a
b
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Fig. 24.18 This 28-year-old
woman underwent breast
augmentation and extended
abdominoplasty (a)
preoperative view and (b)
6weeks postoperative view
a
b
a
Fig. 24.19 (a–e) Pre- and postoperative photographs of patients who underwent simultaneous abdominoplasty as well as augmentation
mastopexy
b
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c d
e
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Fig. 24.19 (continued)
Acknowledgment We acknowledge Dr. Tarick Smiley as being the
coauthor for this chapter for his valuable contribution of the procedure
videos and we thank him for the same.
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