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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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Fig. 25.2 A 34-year-old patient with classical abdominoplasty and breast lift with implants
Fig. 25.3 A 52-year-old patient with classical abdominoplasty (Note the previous scars) with limited ank liposuction
and breast reduction
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Fig. 25.4 A 48-year-old patient underwent HLT abdominoplasty
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middle part and the detachment of lateral abdominal wall is made from the tunnels of the liposuction cannula. Selective detachment while
preserving perforators as well as removing fat
excess is the key to understand this technique
[33–39].
Markings are variable depending on surgeons
but are much similar than in classical abdominoplasty. Saldanha described a 12 cm horizontal
line with two ascending arms of 8cm each. These
marks can be customized by the surgeon for the
patient.
It is started with extensive liposuction on the
upper abdomen and subcostal area. The lower
abdomen is aspirated in the supercial layer to
help visualize the plane for dissection afterward.
Then, incision is made, and dissection is followed in a sub-Scarpa plane [40]. Umbilicus is
isolated and above the insertion, dissection is
done only in the central part within the inner rectus limits to facilitate fascial plication. Additional
open liposuction is made, if necessary. Fascial
plication is done after defatting the central portion. If needed, additional undermining is done
to prevent central deformities after plication.
The skin’s taylor-tack is removed and umbilicoplasty and wound closure are done (Figs.25.5
and 25.6).
25.5.4 Technical Tips toImprove
Outcomes andAvoid
Complications
25.5.4.1 Skin Incision/Excision
This is the start of every approach, and it is a
standard but has to be customized for each
patient. The lower incision is planned in the lowest position possible without harming the pubic
area. Length of lower incision depends on the
patient needs and surgeon’s preferences.
Depending on the technique, lateral extension is
slightly curved upward or a bit more
horizontally.
Superior skin mark for skin excision is usually
planned near the umbilicus. Some may not mark
this line as the skin excision is carried out in a
Taylor-tack fashion. It is desirable that the
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Fig. 25.5 A 53-year-old patient underwent lipoabdominoplasty
J. B. Pérez
Fig. 25.6 A 45-year-old underwent combined lipoabdominoplasty and implants exchange
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removed skin contains the periumbilical scar but
sometimes a short vertical scar is placed in the
midline.
Assessment of tissue removal is usually done
by pinching the panniculus but depends on skin
properties and dissection extension. The nal
amount of skin removed is decided intraoperatively by bending the patient and custom-resecting the desired tension.
25.5.4.2 Plane ofDissection
There are mainly two options for this issue. The
rst and classical is detaching the skin and fat
from the abdominal wall from the muscle/deep
fascia. This is a natural plane, and its dissection is
carried out quickly and easily. It guarantees an
even dissection and correct visualization of rectus edges. On the other hand, a subscarpal plane
is preferred by many modern authors [41–45]. It
is believed to preserve lymphatic tissue intact so
that seroma rates may decrease. It also has the
advantage of thinning the upper ap which is
similar to the lower ap in width. Conversely, it is
a more difcult plane to dissect, and it may end a
bit uneven. It is also can result in less accurate
localization of rectus borders.
25.5.4.3 Liposuction
Liposuction has become more and more important in this procedure in the last decades. As it is
incorporated to the abdominoplasty procedure, it
was believed to damage abdominal ap vascularization [46], so its application has varied widely
from just anks lipoaspiration to a combination
of skin resection, selective detachment, and
extensive liposuction [47], as in lipoabdominoplasty described by Saldanha.
Applying liposuction [48] in deep [49] and
supercial [50] layers has changed the concept of
abdominoplasty from aggressive skin excision
and signicant wound tension to a well-contoured abdominal ap with less wound tension
[51–54]. A lower tension would decrease complications related to skin perfusion. However, some
authors advocated that liposuction may cause
trauma to abdominal perforators impairing
abdominal ap perfusion. Nowadays, it is well
accepted that perfusion of abdominal ap is preserved applying extensive liposuction when limited central undermining is done, so that lateral
perforators are preserved [55–58]. The lipoaspiration makes selective detachment of the lateral
abdominal ap which makes mobilization possible toward the lower incision. We prefer standard
or power- assisted liposuction in order to minimize nourishing vessels damage (Fig.25.7).
25.5.4.4 Level ofUndermining
Depending on the preferred approach, the level of
the undermining varies. In classical concepts, the
undermining limits are from costal borders to
xiphoid process. With the application of liposuction, undermining is usually restricted to skin
resection area and upward within the cephalic
portion of the rectus abdominis. Selective undermining of lateral portions is carried out by means
of lipoaspirate tunnels or carefully blunt dissected under direct vision preserving perforator
vessels [59, 60].
25.5.4.5 Umbilicus Transposition
Patient characteristics such as skin elasticity, tissue excess, position of the umbilicus, grade of
diastasis, and striae distribution determine the
need to transpose the umbilicus. Contrary to mini
abdominoplasty, where the umbilicus is not transected, in modern abdominoplasty approaches,
patients who have high position of navel and very
elastic skin may benet from an umbilicus transection without transposition. It is important to
consider the nal position of the umbilicus,
which if placed too low would impair normal
appearance of the abdomen. We usually perform
a circular incision and remove the underlying fat.
If fascia was already sutured, no stalk plication is
performed, on the other hand, if umbilicus stalk
is too long, a few 3/0 reabsorbable stiches are
placed to x umbilicus to fascia. Finally, skin is
sutured with nylon thread of 4–5/0.
25.5.4.6 Fascia Plication
From the previous exploration, rectus diastasis is
assessed. The most common plication is vertical,
suturing the medial edges of the rectus fascia.
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Fig. 25.7 Procedure step by step. Inltration (a). Liposuction (b). Flap dissection (c). Abdominis rectus plication (d).
Tissue excised (e). Closure (f)
Sutures can be placed in one or two layers with
running or simple stiches. Recently, modern
barbed sutures have simplied this aspect providing secure xation with signicant reduction of
surgical time [61–63]. The use of absorbable or
non-absorbable sutures or a combination is chosen by the surgeon.
If umbilicus is transected, care should be
taken not to injure the bowels, and a layer-bylayer closure must be applied in that part. Once it
is closed, fascia plication may be easier and can
be done in a running fashion from top to bottom.
If umbilicus is not transected, which happens
more often leaving it attached to abdominal wall,
care should be taken not to strangulate its irrigation with fascial sutures.
Additionally, horizontal or oblique plications
may be performed depending on the fascia bulging and preferences of the surgeon.
25.5.4.7 Strategies toControl Seroma
Seroma is well accepted as the most common
complication in abdominoplasty. Depending on
the surgeon’s preferences and the technique
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employed, several options are available [64]. The
most common is placement of drains, which may
be uncomfortable especially if the patient is discharged with it. Usually, they are maintained
from 24h to 5–7days. We usually prefer 14G
Blake™ drains.
Another way to prevent seroma is by using
brine sealants. Since the price of these products
is higher than simply drains it requires perfect
application. They are not usually combined with
drains because they could beobliterated .
Other maneuvers entail placing progressive
tension sutures to obliterate the space between
planes and, as mentioned earlier, the use of a subScarpal plane of dissection [65–71].
Finally, compression garments are well
accepted as a crucial part of the postoperative
care.
25.5.4.8 Wound Closure
This is probably the most standard aspect of the
surgery. It is a standard to close rst the Scarpa
fascia, then the dermis and nally the cutis.
Variations are mostly in the kind of suture used.
As in fascia plication, barbed sutures (V-loc™
from Covidien™ or Stratax™ from Ethicon™)
have gained popularity by means of a quicker
closure time and a lesser amount of implanted
material because they are knotless. As for intracuticular suture, the options are running monolament/barbed suture or cyanoacrylate glue.
Umbilicus is usually sutured with interrupted
stitches of 4–5/0 nylon thread.
Recently, application of diode laser at the end
of surgery is suggested to improve scar appearance and improve aesthetic results [72].
25.6 Video Case Report
A 37-year-old patient with history of umbilical
hernioplasty (mesh) and two C-sections.
Lipoabdominoplasty was performed (Fig.25.8).
Umbilicus was saved but due to extreme thinning
of skin in the infraumbilical area, a vertical scar
was made (Videos 25.1, 25.2, 25.3, 25.4, 25.5,
and 25.6).
Fig. 25.8 Preoperative and postoperative pictures of the patient
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25.7 Pre/Postoperative Care
After consultation, patients may be informed of
all the processes they are undergoing. Avoidance
of antiaggregant drugs or smoking should be
reinforced. We usually educate patients for adequate preparation of skin and wound care after
surgery. Compression garments and stockings
should be prescribed and tried before to ensure
correct t.
Once the surgery is complete, early mobilization is mandatory in order to prevent venous
thrombosis. Compression garments are placed,
and patient is educated to wear them correctly.
Chlorhexidine is applied every day to the wound
within the rst 5–10 days. Drains are removed
when total drainage is less than 30mL in 24h.
Patients are encouraged to prevent traction of the
wound by hip exion while resting. After drain
removal, lymphatic drainage massage can be
made. As its benets are not measurable, the
patient is continuously re-explored after the surgery and any possible complication is advised on
time.
Compression garments are used for at least
1month, and sports practice is not recommended
during the rst 4 weeks. Silicone patches for
scars are recommended after the third week for
the next 3months.
25.8 Outcomes andPrognosis
Abdominoplasty is a very popular procedure.
While major complications rates are very low
(<2%), the overall complications (up to 30%)
rates are not negligible fundamentally related to
wound healing. There is also high revision rates
related to ne-tuning procedures. Satisfaction
rates are very high (>86%) and previous symptoms improvement are also very consistent
(>95%) [73–78].
Considering all these factors, abdominoplasty
(even associated with other procedures) is considered to be a safe and satisfying procedure.
25.9 Complications
Complications pose a challenge to the surgeon,
especially considering that almost all of these
cases are selective procedures where healthy
patients have high expectations [79, 80].
25.9.1 Seroma
This is the most common complication in abdominoplasty. As mentioned earlier, there are different strategies to avoid it but no single maneuver is
proven to be 100% effective. The use of drains is
very popular, but they may increase the infection
rate and the time to remove them remains uncertain. The sub-Scarpa plane is believed to improve
seroma rate but there is still lack of blinding on
the studies supporting the benets. Progressive
tension sutures or obliterating dead space sutures
as described by Baroudi [81] are a good alternative but may cause pain and bleeding at some
point. Fibrin glue adhesives can also be used but
they may be costly [82].
Fortunately, when seroma is detected, its
treatment is usually easy and effective.
Most seromas are solved by simple
puncture and drainage. If necessary, some
agents such as corticosteroids can be
administrated locally, but the evidence of
these treatments remains unclear despite
they being common.
25.9.2 Infection
Infection is the second most common complication following abdominoplasty. It may occur
after seroma is developed or alone. However,
infections rates are low (1–4%) when patients are
carefully selected. It is usually presented as erythema or inammation.
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Fig. 25.9 Supercial infection resulting in wound
dehiscence
In most cases, infections are well controlled
with a standard antibiotic therapy [83, 84].
Smokers, sub-optimal controlled diabetic, or
obese patients in conjunction with excessive tension of wound closure raise infection rates [85].
If more aggressive infections are developed,
such as necrotizing fasciitis [86], debridement is
mandatory (Fig.25.9).
It is well accepted that in any soft-tissue
surgery longer than 1–2 h, prophylactic
antibiotics decrease the risk of infection.
Antibiotic therapy should be adapted to the
particular setting in each case, but usually
rst-generation cephalosporin is sufcient
as a prophylactic antibiotic.
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Risks factors other than surgical technique
include hypertension, previous coagulopathy,
and higher BMI.
25.9.4 Skin Necrosis
Adequate skin perfusion is the most important
objective in abdominoplasty. Perfusion may be
jeopardized by different factors. Excessive tension at the wound should be avoided, preservation of perforator vessels should be done as much
as possible and smoking habit must be avoided in
order to achieve a well-perfused ap. Recently,
the use of nitroglycerin ointments has demonstrated better ap survival in mastectomy aps
and may be used in abdominoplasty with the
same objective.
When skin necrosis is present, it usually
begins as skin epidermolysis which may advance
to wound dehiscence/infection (Fig.25.10). This
process may be tortuous and may require surgical
debridement or other therapies [90] such as negative pressure devices [91, 92] (Fig. 25.11). In
most cases, conservative treatment is the best
option and wound healing is completed by second intention.
25.9.5 Venous Thrombosis
25.9.3 Hematoma/Bleeding
Although they are not very frequent, postoperative hematoma may result in hemodynamic instability and require urgent revision surgery [87].
Cautious hemostasis must be done in every procedure [88]. Usually, these events happen during
the rst 24h. After that period, hematomas can
appear but usually are asymptomatic since the
accumulated volume is not high, and there is no
active bleeding [89]. If present, needle aspiration
can be done to remove the liquid but, in most
cases, it could be coagulated, and conservative
treatment is the option.
Although it is not a risky procedure, it can be lifethreatening, which is usually underestimated
[93]. Risk factors include elevated BMI [94],
general anesthesia, long operative time, immobilization, etc. [95]. Patients at utmost risk are
those undergoing combined procedures [96, 97].
Different stratication scales have been reported
[98], but commonly patients are classied into
four groups of risk: low, moderate, high, very
high [99]. Each patient should be assessed preoperatively, and precautionary measures are adopted
depending on each risk group including early
mobilization, correct positioning, compression
stockings, intermittent pneumatic compression
boots, and low- molecular- weight heparin.
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Appropriate use of chemoprophylaxis of venous
thrombosis does not increase hematoma or bleeding rates.
25.9.6 Hypertrophic Scars/Keloids
A correctly positioned thin scar is the most desirable aspect of the surgery for patients. However,
personal predisposition may affect the quality of
the scar. Tension on the wound may lead to
hypertrophic scar. In our opinion, it is better to
make a little inverted T scar rather than a stiffer
wound closure. Recently, immediate treatment of
the wound at the end of the surgery with 1210-nm
laser has been described as an effective method to
improve scar quality. After surgery is recommended, use local compression at the scar to prevent or treat hypertrophy, usually silicone
patches.
Treatment of hypertrophy may require local
inltration of steroids, laser treatment, or local
excision.
Fig. 25.10 Umbilicus necrosis
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Fig. 25.11 Skin necrosis and treatment with NPWT
25.10 Conclusion
Abdominoplasty is a surgery which is very much
in demand in the postpartum. Pregnancy entails
big transformation in women’s body within a
short period. Thus, different aspects of body contour and muscle integrity should be carefully considered. Restoring abdominal anatomy may be
challenging and cautious evaluation of expectations with the patient is key for a better outcome.
Despite it not being a very technically demanding surgery, different factors inuence the nal
result making the whole procedure seem complex. Considering this, a customized plan for each
patient should be made. Careful physical evaluation detecting hidden hernias is the rst and very
important aspect to consider in case of liposuction
so as to avoid major complications [100].
Different surgical techniques are available in
the armamentarium to provide the best option in
each case [101]. Familiarity with all procedures
makes the surgeon condent in order to obtain
the best possible results. Each technique has
advantages and disadvantages which is left to the
surgeon to choose.
Depending on the designed surgical plan,
postoperative care may vary but it is well accepted
that prophylactic antibiotics reduce wound infection, and early mobilization reduces thromboembolic episodes. Seroma is the most common
complication but usually is easy to manage with
serial punctures. The overall complication rate is
low, when patient is well and surgical techniques
are selected correctly.
Patient satisfaction with abdominoplasty is
often very high, and it is a very safe procedure
considering all precautions mentioned before. In
most cases, not only we correct physical problems, such as the rectus diastasis, but we also
improve patient’s quality of life.
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