The technique of classical abdominoplasty was developed in North America in the 60s. Despite the fact that over the past 30 years, various modifications of this operation have been proposed, its principles have remained the same. These include:
- transverse incision in the lower abdomen;
- wide allocation of the skin-fat flap to the edge of the costal arch;
- strengthening the muscular wall by creating an aponeurosis duplication;
- resection of the excess part of the flap with the maximum removal of tissues in the central zone;
- transposition of the navel;
- suturing the wound with bent hips.
This technique is fairly simple, relatively safe and, as a rule, leads to a good result.
The main conditions necessary for conducting classical abdominoplasty are: 1) a significant excess of soft tissues in the hypogastric region with the presence of an overhanging skin-fat fold ("apron") and 2) sufficient mobility of the navel and skin of the anterior abdominal wall with an average or significant thickness of the subcutaneous fat layer.
Marking of the operating field
When the patient is in a vertical position, the median line is drawn from the xiphoid process through the navel to the pubic symphysis. The anterior superior iliac joints are connected by a transverse line. The access line is located about 1.5-2 cm above the pubic level within the zone of "swimming trunks". In most cases, the cut line has a W-shaped shape with a small protrusion located along the median line. This projection unloads the seam line and is not needed if the excess soft tissue in the upper abdominal wall is significant and the edge of the flap at the navel level can be freely displaced in the caudal direction until it touches the opposite edge of the wound.
The surgeon determines and marks the expected boundaries of excision of tissues, creating a skin-fat fold on his anterior abdominal wall with his fingers. At the end of the markup, symmetry of the lines is determined. With a larger ptosis of soft tissues, the incision is easy to place in the pubic part of the pubic region and the inguinal fold. With less mobile skin, the incision can be performed higher.
Technique of operation
In the zone of the median line, the incision is made with a bevel upward, which makes it possible to accurately compare its edges along the entire depth when closing the wound and thereby reduce the likelihood of a painful retraction above the pubis.
Superficial lower epigastric vessels intersect and bandage. An abruption of the skin-fat flap is performed over the aponeurosis of the abdominal wall, leaving a thin layer of adipose tissue on its surface.
The navel is mobilized by means of a circular incision and isolated on a pedicle. After this, the cutaneous fat flap is dissected to the navel and gradually separated to the level of the xiphoid process and the edges of the costal arch. Large perforating vessels are bandaged and crossed. With classical abdominoplasty, wide separation of the flap to the level of the anterior axillary line is necessary to move the navel to the suprapubic line if there is no true vertical excess of the skin. In this case, the relaxed tissues from the lateral sections move in the central caudal direction, ensuring that the skin is moved along the middle line.
After preparation of the flap, mark the median line on the aponeurosis, after which create its duplication from the xiphoid process to the pubic bone. In this case, the nodal back stitches are applied (by a knot in the depth, so that later they are not probed under the skin) or (and) a continuous continuous suture. Use a strong non-absorbable suture (spill No. 1-2 / 0) or a material that dissolves over a long time (max No. 0).
One of the reliable options for the operation is the overlap of two segments of a continuous seam (from the xiphoid process to the navel and from the navel to the pubic symphysis) with the addition of several nodal seams unloading and strengthening the continuous suture. When applying the suture seam, in addition to reducing the circumference of the waist, the vertical abdominal wall is shortened.
The next step removes excess skin-fat flap. For this, the flap is shifted with a certain effort in the distal-medial direction and a central fixing suture is applied.
Then, using the marking clip, the line for cutting the flap is marked (with the patient's horizontal position), the excess tissue is excised, the operating table is bent to an angle of 25-30 °, layered seams are applied and the wound is actively drained.
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