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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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8 Brachioplasty
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a
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b
Fig. 8.19
a A 49-year-old patient with upper arm ptosis preoperative
b The same patient 12 months after upper arm lift
Tips and Tricks
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– The resection pattern must be chosen such as to ensure that the
most normal positioning of the resulting scar as possible is
achieved with no restriction in mobility, as well as a good, symmetrical tightening result is achieved.
– The length of the cut is accurately marked before the operation
and kept as short as possible. Overlapping of the medial epicondyle of the elbow is to be avoided under all circumstances.
– Improper dissection of the lipocutaneous flap involves the risk of
severe complications, such as vascular or neural injuries, cutaneous necrosis, etc.
– During positioning, traction at the brachial plexus is to be
avoided under all circumstances.
– Intensive scar treatment for six months.
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9 Abdominoplasty
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Introduction 381
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Tightening of the Abdominal Wall 381
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Anatomical Overview 382
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Instruments 384
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Duplicate Patient Information 388
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Preliminary Examinations 388
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Photographic Documentation 388
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Surgical Planning 389
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Postoperative T reatment 390
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Typical Findings: Indications for Tightening the Abdominal Wall 390
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Marking the Individual Incision Line 392
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Positioning, Disinfection 394
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Tumescence 394
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Incision 394
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Dissection of the Lower Abdomen 396
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Incision Around the Navel 396
9 Abdominoplasty
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Mobilization and Dissection of the Navel 398
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Vertical Splitting of the Dermofat Flap as Far as the Base of the Navel
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Complete Mobilization of the Umbilical Stalk 400
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Dissection of the Upper Abdomen 400
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Doubling of the Rectus Abdominis Fascia 402
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Defining the Resection Boundaries with Up per Body Flexed at 30°
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Repositioning of the Navel Using a V-Shaped Incision 405
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Pulling the Navel Out of the V-Shaped Incision with Curved Forceps
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Positioning the Navel 406
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Trimming of the Skin of theNavel and Adaptation
to the V-Shaped Incision 408
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9 Abdominoplasty
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Closure of the Navel in Three Layers 408
Fixation of the Surplus Sections of Skin
with 2.0 Monocryl Key Sutures 410
Resection of the Skin in Stages 411
Insertion of Redon Drains 412
Wound Closure in Three Layers 413
Dressing 414
Fitting the Abdominal Belt 414
Results 416
Mini Abdominoplasty 418
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Markings and Tumescence 419
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Incision 420
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Dissection 420
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Central Positioning Suture 426
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Resection 426
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Wound Closure 428
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Dressing 428
Tips and Tricks 430
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Results 431
The symbol indicates parts of the procedures shown in the video.
Introduction
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Iftheresultofliposuctionintheabdominalareaisinadequateorthere
is an excessive overhang of abdominal skin and subcutaneous adipose
tissue, it may be beneficial to perform an abdominoplasty to impro v e
the functional and aesthetic result. In the abdominoplasty, the surplus
section of abdominal skin is removed with the attached subcutaneous
adipose tissue. In a few cases, resection of the infraumbilical surplus
tissue will be sufficient, but usually a complete abdominoplasty with
umbilical translocation must be performed to achieve optimal results.
In this procedure, tightening of the periumbilical area is also extremely
significant, for example, with extreme fold formation following pregnancies. Rarely, there is also slackening of the abdominal muscles. This
should be treated prior to tightening of the abdominal wall (e.g., by
physiotherapy).
The patient’s skin type and age play an important part in this operation. In many cases, it is not possible to remove all the folds and striae
and this must be explained to the patient. Furthermore, female patients
must avoid pregnancy in the foreseeable future. It is not necessary to
achieve a specific weight for this procedure, but a few conditions relating to this should be fulfilled. The body weight should have stabilized
several months before the procedure, and this should be at a level the
patient can maintain after the procedure.
9 Abdominoplasty
Tightening of the Abdominal Wall
An experienced aesthetic surgeon must look carefully at the indications
for liposuction and for tightening of the abdominal wall. At present,
unfortunately, a decision is taken to carry out liposuction too often,
and the patient is later disappointed if the skin then hangs down
loosely. Frequently, tightening of the abdominal wall is requested by
patients who have increased skin accumulation around the umbilical
area and a slack lower abdominal wall following pregnancies. It is also
frequently requested by patients who have lost a lot of weight (20–40 kg)
and by older patients who have a slack abdominal wall.
If performed correctly, the operation itself will be successful in the
long-term and satisfactory for the patient. In relation to the surgical
technique, in addition to precise dissection of the abdominal fascia
with immediate hemostasis, the incision line in the bikini area must be
marked carefully and the repositioning and reconstruction of the navel
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9 Abdominoplasty
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must be performed well so that the result is satisfactory for the patient.
It must be ensured that there are no umbilical or abdominal wall hernias.
For reconstruction of the navel, we have described the method that we
find the easiest and most comprehensible and which has provided the
best results. When making the incision in the bikini area, it should be
ensured that no “dog ears” are formed at the side and that, following
complete dissection as far as the costal arch with the upper body
slightly angled, resection of the skin is carried out in stages with key
sutures in such a way that the skin flap is resected precisely, section by
section, and without any significant tension so that necrosis is avoided.
The video shows that the fat is resected obliquely, also stage by stage,
to avoid any postoperative retraction of the flap. Immediate hemostasis
is important so that the Hb value does not fall below 8 mg/dl. It is
recommended that obese patients give an autologous donation of blood
4 weeks before the operation. Patients must also be given thrombosis
proph ylaxis and infection prophylaxis intra-operatively and for 10 days
after the operation.
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Anatomical Overview (Fig. 9.1)
1. M. pectoralis major
2. Xiphoid process
3. M. serratus anterior
4. Costal arch
5. Linea alba
6. Tendinous intersections of recti. abd.
7. M. recti abd.
8. Umbilicus
9. M. obliquus ext. abd.
10. Anterior superior iliac spine
11. Superficial epigastric vein
12. Inguinal ligament
13. Subinguinal sulcus
14. M. sartorius
15. M. rectus femoris
16. Mons pubis
9 Abdominoplasty
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Fig. 9.1
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Instruments* (Fig. 9.2–9.4)
1 Sterile centimeter rule
2 Sterile marking pen
3 Scalpel size 10 blade
4 Scalpel size 11 blade
5 Adson tweezers with plate
6 Surgical tweezers
7 Monopolar electrocoagulation
8 Insulated anatomical tweezers for hemostasis
9 Metzenbaum dissection scissors
10 Rake retractor
11 Backhaus clamps
12 Cooper scissors
13 Langenbeck retractor (large)
14 Needle holder, large
15 Needle holder, small
16 Redon introducer
17 Curved forceps (for hemostasis)
18 Delicate, long, single-pronged wound retractor
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* Robumed, Stephansfelderstr. 6, 78532 Tuttlingen, Germany
Aesculap AG&CoKG, Am Aesculap-Platz, 78532 Tuttlingen, Germany
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9 Abdominoplasty
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3
4
5
6
7
Fig. 9.2
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