Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана

for its later reimplantation into the abdominal wall. Making an adequate evaluation of the panniculus resection is the main surgical principle introduced by Sinder, R. (1975a, b, c), which represents an important approach in that it avoids exerting excessive tension on the abdominal ap after the nal suture (Figs. 4.2a, 4.3b, and 4.4a).

However, I also used to employ Sinder’s technique, without panniculus under­mining (Avelar 1999, 2000a, b), but in combination with liposuction (Fig.4.6), which is also a safe surgical option. In such an associated procedure, the surgical demarcation is similar to that already described above, but the operation is per­formed without panniculus undermining, following previous descriptions (Avelar

Predemarcation is a useful procedure when the patient is already in the hospital and awake as long as it occurs before they have been given medication. When the patient is in the operating room under general or epidural anesthesia, the denitive marks are made. The lower line lies on the suprapubic region with lateral prolongation up to the iliac spine (Fig.4.1). Another curve line is made by passing by umbilicus with lateral prolongation until it has reached the end of the previous one. The umbilicus can also be demarcated by following Avelar’s technique (Avelar 1976a, b, 1979,

Next, the new umbilical region is demarcated by using Avelar’s surgical instru­ment, creating three small triangular aps on the abdominal ap (Fig.4.10), and the wound is next sutured as a part of a routine procedure.

However, following Sinder’s technique, a triangular dermal-adipose ap is ade­quately prepared in the suprapubic region to embed it underneath the abdominal panniculus ap, which will expand its thickness. Quite often, the protuberance or salience at the level of the muscle masses, the suprapubic adipose tissue, or the mons pubis do not meet enough of the anatomic conditions to improve the thickness of the abdominal ap.

Sinder’s technique is a very useful and safe approach for performing abdomino­plasty. The operation starts by making an incision into the superior border of the area to be resected and according to the surgical plan (Figs.4.1, 4.2, and 4.3). The superior panniculus is then undermined on the supra-aponeurotic level until it has reached the border of the rim’s costal cartilage. Meticulous hemostasia must be caried out (Fig.4.4b). At this time in the operation, bend the surgical table such that the extension of the resection of the lower panniculus can be properly evaluated. After correct demarcation, the panniculus of the infraumbilical region is removed, and the new umbilical region is marked by using my surgical instrument (Fig.4.5) (Avelar 1976a, b, 1983). A similar procedure may be performed for a type of lipoab- dominoplasty where the abdominal panniculus is not undermined, which is the basic surgical principle of this method (Figs.4.6, 4.7, 4.8, 4.9, and 4.10). If the patient already has some abdominal scars caused by previous surgeries, then, depending their location and size, use Sinder’s technique to determine the adequate placement of the nal surgical scar (Figs.4.11 and 4.12).

At the beginning of an operation that uses Sinder’s technique, a suprapubic trian­gular dermal-adipose ap with an inferior pedicle should be prepared to embed it underneath the medial part of the abdominal panniculus ap. The behavior of the dermal-adipose ap replaces the thickness of the supraumbilical zone, or the linea albae.