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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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https://t.me/med1917
9 Abdominoplasty
Pulling the Navel Out of the V-Shaped Incision with Curved Forceps
(Fig. 9.18)
With the aid of long curved forceps, the navel is gripped at the holding
sutures and pulled upward.
Positioning the Navel (Fig. 9.19)
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The navel is positioned outwardly and fits into the correct position in
the external cutaneous incision without tension.
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Fig. 9.18
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9 Abdominoplasty
Fig. 9.19
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9 Abdominoplasty
Trimming of the Skin of the Navel and Adaptation to the V-Shaped Incision
(Fig. 9.20)
To interrupt a circular nave l scar line, the lower third of the navel is
removed to correspond with the V-shaped incision in the abdominal
wall. This simple and effective method of reconstruction of the navel
prevents disturbances to wound healing, necrosis of the navel, and
cosmetically unpleasant changes in the area of the navel. The navel thus
has a natural appearance.
Closure of the Navel in Three Layers (Fig. 9.21)
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Inordertoavoidlaterdisturbancestohealingandnecrosis,thenavel
must be fixed in place in three layers. At the base, this is with deep fixation with absorbable suture material of strength 3.0. To allow further
perfusion and stabilization of the navel using the periumbilical adipose
tissue, 5.0 Monocryl™*
interrupted sutures are then inserted. The skin
is adapted with continuous intracutaneous suturing with 4.0 Monocryl.
This ensures that the navel is well stabilized, has contact with the dermofatflaponallsides,andthatnoserousswellingscanforminspaces.
* Ethicon GmbH, Ro bert-Koch-Str. 1, 22851 Norderstedt, Germany
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Fig. 9.20
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Fig. 9.21
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Fixation of the Surplus Sections of Skin with 2.0 Monocryl Key Sutures
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The surplus skin is pulled down under slight traction to define the
resection boundaries. 2.0 Monocryl key sutures are placed at equal
intervals,andthisallowsthesurgeontoidentifyasearlyasthisstageof
the operation how far the resection must be taken laterally if “dog ears”
aretobeavoided.Theincisioncanbeextendedinalateraldirectionat
this stage of the opera tion, depending on this. The trick for all tightening opera tions is that the amount of skin that must be removed can be
defined exactly prior to resection by positioning key sutures. This
ensures that the later result will be good and the scar pleasing.
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The individual key sutures are placed one after the other so that individual corrections can be made at any time.
Fig. 9.22
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Resection of the Skin in Stages
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Resection of the skin is performed with regular checks on the tension
of the remaining skin. The skin/fat resection should be performed at an
angle of 70° so that the lower border of the incision of 30° meets the
upper border of the incision section by section with no retraction or
bulging.
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After the resection has been completed, particles of fat and surplus skin
that spoil the result should be removed. The lateral edges of the incision
should also be checked and any “dog ears” must be evened out.
Fig. 9.23
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Insertion of Redon Drains
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Two size 12 Redon drains leading out onto the shaved mons pubis are
inserted into two sections of the lower abdomen before the skin is
closed. The Redon drains are remov ed after the second postoperative
day and the catheter is removed after 24 h.
Fig. 9.24
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Wound Closure in Three Layers
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Skinclosureiscarriedoutlayerbylayer,firstwithconcealed2.0Monocryl interrupted sutures, then with concealed 3.0 Monocryl subcutaneous interrupted sutures. Finally, the wound is closed with running
4.0 Monocryl sutures. For this, it is important that suturing begins at
the lateral ends on both sides so that the two sutures meet at point a.
This preven ts the skin being uneven in the lateral area and produces
the desired traction in a medial direction.
Fig. 9.25
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Fig. 9.26
Dressing
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The navel is packed with a fine gauze soaked in betadine (Beta-isadona)
ointment and covered with Cutiplast®. The other incisions are closed
with adhesive Steri-Strip™ dressings. These dressings can be removed
after 8 days when the wound is checked. The Tensoplast® adhesive
dressing remains in place until the Redon drains are removed. A special
compressio n girdle is then fitted that should be worn for 6 weeks. The
fresh scars are treated with dexapanthenol ointment for 14 days after the
operation, then with silicone ointmen t or silicone plasters for 2 months.
Fitting the Abdominal Belt
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In addition to a Tensoplast® bandage, an abdominal belt is also used
until the Redon drains are removed. This ensures good compression on
the detached wound surfaces, which prevents serous swellings and
bleeding. During this time, the patient should have bed rest in a slightly
angled supi ne position with the upper body raised.
Fig. 9.27
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9 Abdominoplasty
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The abdominal belt should be fitted with traction. It should be loosened
if the patient has difficulty breathing. Thrombosis and infection proph ylaxis must be carried out during the patient’ s stay in the hospital.
Note:
For safe dissection of the navel, it is important to ensure that the tissue is fully supplied with blood. However, if too much adipose tissue
is left, this may cause elevated pressure on the repositioned navel. In
addition, the ‘steal phenomenon’ may result, since the adipose tissue
left behind may require part of the blood supply.
Compression of the abdominal wall using the abdominal bandage
shouldnotbetoosevere,asthismaycausenecrosesofthedistalend
oftheflap(“mostpoorlyperfusedarea”).
The distal end of the wound must never be undermined!
Deep fixation of the navel requires precise localization of the navel
opening. A two-layer wound closure may be used if desired.
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