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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_611_Библиотеки_им_академика_М_И_Перельмана
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C. G. Cabrero and R. C. Nájera
DIASTASIS OF THE RECTUS ABDOMINIS MUSCLESSUPRAUMBILICAL CUTANEOUS LAXITUDE
Absent
or
minimal
Absent
or
minimal
Medium
Fig. 24.2 Decision process of the modied abdominoplasty procedure variants
24.6.1 First Variant: Modied
Abdominoplasty
Modified
abdominoplasty
Modified abdo-
minoplasty with
supraumbilical scar
Modified
abdominoplasty
with infraumbilical
middle scar
ity of a traditional abdominal ap. We are
going to deal with this case specically at the
end of the chapter.
24.6.1.1 The Ideal Candidate
The ideal candidate is one with lack of excess
skin at the supraumbilcal area, but presents some
degree of musculofascial accidity.
This procedure is indicated primarily in four
groups of patients:
24.6.1.2 Surgical Technique
Marking of this surgery begins in the lower
abdominal fold. The location of the future scar
should be located about 7 cm from the bulbar
fork and laterally 1 or 2cm above the inguinal
fold. We avoid incision over the inguinal skin
1. When the cutaneous excess affects the supra-
umbilical area but not excessively. In this case,
the lower abdominal incision will be longer but
without overcoming both anterior iliac spines.
2. Those cases in which we cannot perform a
complete abdominoplasty because there is not
enough skin to eliminate the entire segment
that goes from the navel to the lower abdominal incision.
3. Cases in which there is moderate sagging at
the level of the aponeurotic muscle system.
4. The existence of contraindications to perform
a traditional abdominoplasty such as the presence of scars that may compromise the viabil-
because it is sometimes excessively thin. In the
case of modied abdominoplasty, the incision
does not usually go beyond the anterior iliac
spines. In any case, we always keep in mind that
the future scar should be perfectly covered by
underwear or bathing clothes even if it is of the
right size (Fig.24.3).
The intervention begins with liposuction that
can involve the entire abdominal surface. Prior
to liposuction, we must be sure there is no defect
in the abdominal wall in order to preserve the
integrity of the abdominal content. An ultrasound study could be necessary in case of doubt.
Next we perform the detachment of the abdomi-
Minimal
Present
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Fig. 24.3 Modied abdominoplasty technique. The
green line represents the delimitation of the area of
undermining. As we can see in this case, the undermining
goes up to above the navel unlike the mini abdominoplasty.
The solid red line represents the skin incision and the
interior area, symbolized by the red dots, representing the
excision. The middle zone with the transverse black lines
is the plication. The blue arrows represent the liposuction
zones
nal ap beyond the navel. With a penrose drain,
we can hug the belly button and pull its stem
inferiorly. In this way, we can perform a short
distance plication at the supraumbilical level. At
that moment, the navel can be left intact or
detached from the umbilical ligament when the
distance from the navel to the pubis is long. In
patients with supraumbilical sagging or muscular weakness at that level, the navel can be transposed to a lower level losing its original
position.
This technique is especially useful in patients
with supraumbilical sagging or periumbilical
401
cutaneous excess. In this maneuver, the presence
of umbilical hernia should be ruled out. The
detection of the hernia is facilitated through the
forced traction of the navel and its trans section at
the level of its entry into the abdominal wall. The
defect is repaired by suturing and approaching
the edges of the straight muscles, then the navel
is displaced inferiorly never more than 2 or 3cm,
and nally must be placed no less than 10 cm
from the upper edge of the pubic hair.
The navel is reinserted after the plication of
the rectus muscles with four zeros sutures in a
position that can be slightly higher than what
would happen when suturing the abdominal ap.
This causes an aesthetically pleasing result with
the formation of a small skin fold in the upper
half of the navel. When the skin is sutured, the
lower traction produces this effect. The rectus
abdominis are sutured in an elliptical way to
resolve the diastasis.
The operating table exes approximately 30°,
and the at is advanced in the medial inferior
direction; at this time, we assess the necessary
skin resection and balance the discrepancies
between the upper and lower edges of our wound
in terms of length and thickness of the fat. The
wound is closed by planes looking for a meticulous closure of the supercial fascia and avoiding
any tension in the skin suture that could lead to
hypertrophic scarring. Aspiration drains can be
used. The cavity created can be closed by some
stitches from the supercial fascia to the muscular aponeurosis producing its obliteration.
Personally, we prefer the second option, and this
technique also avoids, in most cases, the use of
drains and the possible appearance of a postoperative seroma.
24.6.2 Second Variant: Modied
Abdominoplasty Without
Umbilical Deinsertion
24.6.2.1 The Ideal Candidate
The ideal candidate must have the navel in a high
position. Never less than 10cm from the pubic
hair.
For patients with marked supra and infraumbilical abdominal fullness, diastasis that affects
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C. G. Cabrero and R. C. Nájera
all the rectus muscles and without supraumbilical
skin sagging or minimum cutaneous laxitude
(Fig.24.4).
24.6.2.2 Surgical Technique
We perform the plicature of the upper abdomen
through a semicircular incision in the upper half
Fig. 24.4 Before and after of a patient who had signicant rectus diastasis with abdominal bulging and adiposity. Six months postoperatively, the patient demonstrates
an ideal female abdomen. This is a good example of an
ideal candidate for modied abdominoplasty without
umbilical disinsertion
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of the navel. This requires the use of specic
instruments that facilitate this action. The abdominal panniculus is elevated in the supraaponeurotic plane with the aid of beroptic
retractors. In this type of patients, there should be
no superior skin sagging, or this should be minimal. In the case of plications of 4 or more centimeters, the skin detachment must laterally exceed
what is necessary to undertake the plication
because the skin must subsequently adapt to the
new situation (Fig.24.5).
24.6.3 Third Variant: Modied
Abdominoplasty Without
Umbilical Desinsertion
andSupraumbilical Skin
Tension
24.6.3.1 The Ideal Candidate
For patients in whom we do not want to vary the
umbilical position, who have supraumbilical sagging but not enough to perform a classic abdominoplasty, there is the possibility of completely
tightening the abdominal skin (Figs.24.6, 24.7,
and 24.8).
24.6.3.2 Surgical Technique
Skin resection must be done only after being sure
about the quantity of skin to resect. Sometimes
“looks are deceiving” (Fig.24.9).
We perform abdominal detachment as in classical abdominoplasty. After performing the plication (Fig.24.10), the cutaneous ap is pulled as
much as necessary, and the excess skin is removed
(Fig. 24.11). In these cases, we see that the
umbilical opening cannot be included in the
resected segment, so it closes in planes, leaving a
suprapubic vertical scar (Fig.24.12). We recommend that once the wound closure is nished,
inltration with PRP (platelet rich plasma) of the
wound edges to improve healing, maturation, and
nal appearance of the scars [6].
Fig. 24.5 Modied abdominoplasty without umbilical
desinsertion technique. The green line represents the
delimitation of the area of undermining. The solid red line
represents the skin incision and the interior area,
symbolized by the red dots, representing the excision. The
middle zone with the transverse black lines is the plication
24.6.4 Modied Abdominoplasty
inPatients
withaPreviousScar
Paracostal incisions frequently used prior to the
advent of cholecystectomies through video surgery limited regular abdominoplasties due to the
risk of necrosis in the triangular area between the
previous scar, the mid-line, and the edge of the
ap (Fig.24.13). The best option would be limited undermining association with liposuction. In
these cases, the undermining area can be limited
to the infraumbilical area only to expose the mus-
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C. G. Cabrero and R. C. Nájera
Fig. 24.6
of the rectus muscles with abdominal bulging and
adiposity throughout the abdomen, anks, and back. The
modied abdominoplasty technique is complemented
Before and after of a patient who had diastasis
with the following procedures: liposuction of the
abdomen, anks, and back and back lipolling to improve
skin quality and decrease the appearance of the skin folds
and rmness of the tissue (Fig.24.7)
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Fig. 24.6 (continued)
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Fig. 24.7 Liposuction of the back rolls gives better result
and lipolling of the sulcus contribute to achieving it
culoaponeurotic system that will be plicated on a
horizontal way. In this way, we completely avoid
the devascularization of the abdominal ap.
For vertical scars associated with discreet accidity on the upper third but accentuated on the
lower half of the abdomen, we perform a classic
abdominoplasty, improving and centralizing the
scar or ending in an inverted T.The preexistence
of a vertical scar allows the surgeon to supplement its resection by removing a vertical strip
and improving the waistline.
Scarring in the middle third of the abdomen
and periumbilical area: scars in this position are
not common but, when they occur, it is hard to
move them to a less obvious place, except when
massive accidity is present. The best option is to
remove some excess skin through the existing
scar while improving its appearance. Liposuction
may help with the outcome.
Scarring in the upper third associated with
accidity can be treated with reverse
abdominoplasty.
Key Points
Paracostal incisions frequently used prior to the
advent of cholecystectomies through video surgery limited regular abdominoplasties due to the
risk of necrosis in the triangular area between the
previous scar, the mid-line, and the edge of the
ap.
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C. G. Cabrero and R. C. Nájera
Fig. 24.8 Pre- and post-operative photos of a more complex case to solve, because the patient, with sequelae of
pregnancy, had marked sagging around the navel and a
prior abdominoplasty. We chose to proceed with the
technique of a modied abdominoplasty without umbilical
desinsertion and supraumbilical skin tension. To resolve
sagging optimally, in this case, we had to lengthen the
infraumbilical scar, performing a complete vertical scar
between the navel and the horizontal scar. Three months
postoperatively, the patient had a remarkably good
contour and demonstrates complete recovery of the
fullness of the abdominal muscles and signicant
improvement of the skin, leaving few stretch marks and
irregularities compared to her previous situation. Despite
the skin mass around the navel, there was not enough skin
accidity at the supraumbilical area to perform a
traditional abdominoplasty. This a very important point
because before resecting the skin excess, we must be sure
about the quantity of skin to resect
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Fig. 24.11 Skin resection must be done only after being
sure about the quantity of skin to resect
Fig. 24.9 Abdomen is marked with necessary lines to
perform the surgery. It is important to mark the middle
line to correctly position the navel. This can also help us
to perform a high denition liposuction [5]
Fig. 24.10 Rectus muscle plication. Closure of the muscular diastasis is performed vertically with 2-0 or 0 sutures of
permanent braided lament in two imbricating layers to
enhance muscular corset. Additional muscle tightening pro-
cedures that focus on the internal oblique and transverse
abdominal muscles can be performed at this moment. We
can also dene the waist line by suturing the supercial fascial system from side to side vertically after liposuction
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C. G. Cabrero and R. C. Nájera
Fig. 24.12 Modied abdominoplasty without umbilical
desinsertion technique (left image) and postoperative
result (right image). Left image: the green line represents
the delimitation of the area of undermining. The solid red
line represents the skin incision and the interior area,
symbolized by the red dots, representing the excision. The
middle zone with the transverse black lines is the plication.
Right image: red line represents the scars
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Fig. 24.13 The green line represents the delimitation of
the area of undermining. The solid red line represents the
skin incision and the interior area, symbolized by the red
dots, representing the excision. The middle zone, with the
transverse black lines, is the plication
24.7 Surgical Techniques [7]
24.7.1 Sutures
For the plication of the rectus abdominis muscles,
we use non absorbable synthetic sutures—
ethibond excell or ticron—of 0. We prefer to use
a continuous two-layer suture, which seems to
ensure the integrity of the tissue approach more
efciently. These polyester sutures provide us
with permanent support and resistance that is
maintained indenitely, making them especially
409
suitable for this procedure. The inammatory
reaction in the tissues is minimal and is followed
by a gradual encapsulation of the suture by
brous connective tissue. The retention of the
indigo pensil force does not show signicant
changes over time.
For the cutaneous and fascial suture, we can
use synthetic absorbable monolament
sutures—Monocryl or Serafast—of 3/0 or 4/0.
These sutures offer resistance to wound retention to support the tissue during the critical
healing period from the fth to the seventh day.
Additionally, there is minimal trauma to the
tissue due to the monolament design that
reduces drag resistance two or three times
compared to braided absorbable sutures and an
appropriate polymer that uses a hydrolytic process to minimize tissue reaction during
absorption.
At fascial level, sometimes stiffened sutures
may be necessary -Vicryl 2/0-. Multilamentous
and interlaced synthetic absorbable sutures that
maintain tensile strength will be used for
3–4 weeks. The adequate approximation of the
supercial fascial system will promote the local
conditions of zero tension for the skin suture.
This is a critical detail if we want to obtain a skin
scar of the best quality.
24.7.2 Mesh
In the cases of umbilical hernias associated with
a diastasis of the rectal abdominal muscles, the
general surgeon is summoned to operating room
for taking care of repairs. It is executed with a
Ventralex™ Hernia Patch mesh of 8cm, ePTFE
coated polypropylene. Visceral side of the mesh
is covered by hydrogel to reduce adhesions to the
bowel. Absorbable ring of the patch keeps the
mesh at.
It is placed in the intrabdominal plane and
uses polypropylene strips to reinforce the plication. The polypropylene strip then stays embedded in the plication. Polypropilene low density
mesh is preferred for better tolerance.
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