Indications for abdominoplasty

  The main characteristics of the "ideal" abdomen:

• dense tightened lateral surface of the trunk and groin area with a deeply outlined waist;
• centrally located tissues are not strained and have a soft convexity in the hypogastric and soft concavity in the epigastric region;
• in the above-ground zone between the edges of the rectus abdominal muscles there is a median groove.

The main components of postnatal deformation of the anterior abdominal wall are:

• excess of subcutaneous fat and (or) skin;
• relaxation (overgrowth) of the muscular-fascial system;
• stretching of the skin and (or) post-operative scars.

A significant increase in the volume of contents of the abdominal cavity during pregnancy leads to a vertical and horizontal overgrowth of the musculo-fascial layer, the onset of diastase of the rectus muscles and the stretching of the skin. Subsequently, all these changes are reversed, but not completely. To a large extent, the severity of the final changes in the tissues depends on the size of the fetal sac and the individual extensibility (contractility) of the tissues.

The main indicators of anatomo-functional deficiency of the anterior abdominal wall are:

• the presence and extent of ptosis of soft tissues;
• thickness of the subcutaneous fat layer;
• the degree of divergence of the rectus abdominis muscles;
• skin condition (flabbiness, presence of skin stretch and postoperative scars);
• presence of an umbilical hernia.

The presence and degree of ptosis of the tissues of the anterior abdominal wall are the most important indicator and in many cases are characterized by the presence of an overhanging skin-fat fold ("apron"). The latter often determines the indications for the operation.

The presence of soft tissue ptosis is evaluated with the patient's vertical trunk position. A.Matarasso identifies four degrees of ptosis of the soft tissues of the anterior abdominal wall, which allows one to formulate indications for one or another type of abdominoplasty.

In connection with the fact that the main complaint of patients with ptosis of the abdominal wall tissues is the presence of an "apron", this clinical symptom is the most important. Taking into account this circumstance, it is expedient to distinguish four groups of patients with different degree of expression of ptosis of the soft tissues of the anterior abdominal wall.

Group 1: Patients with moderate stretching of the skin of the anterior abdominal wall, primarily in the hypogastric zone, without the formation of an "apron". In this case, the indications for surgery occur mainly in the presence of striae of the skin (striae gravidarum).

2 nd group: presence in the lower abdomen of a small and still not sagging skin-fat fold (almost "apron") in combination with flabbiness of the skin in the epigastric and hypogastric zones. In this situation, abdominoplasty can be performed, but the relatively small degree of possible displacement of the abdominal fatty wall in the caudal direction often prevents the surgeon from restricting only to horizontal access, and the postoperative scar may have a vertical component.

3rd group: patients have an "apron" with a width of up to 10 cm, which is located within the front abdominal wall with a transition to the lateral surfaces of the trunk.

4-th group: the width of the "apron" exceeds 10 cm, the skin-fat fold extends to the lumbar region and is combined with the folds on the posterovage surfaces of the thorax.

In the 3rd and 4th groups of patients indications for abdominoplasty are obvious, and the variant of the operation is determined taking into account the whole set of circumstances.

The thickness of the subcutaneous fat layer of the anterior abdominal wall is an important indicator, which largely determines the risk of development of gray and other complications due to the fact that the subcutaneous fatty tissue is very sensitive to any, including operational injury. Most often there are the following options for the location of adipose tissue in the anterior abdominal wall:

• relatively uniform;
• with the predominance of fat deposits in the lateral parts of the trunk with the transition to the flanks;
• with concentration in the central zone along the straight muscles of the abdomen.

With a minimum thickness of subcutaneous fat (less than 2 cm), the risk of developing seroma is minimal. With a moderate thickness (2-5 cm), the likelihood of developing a seroma increases. With a significant thickness of the subcutaneous fat layer (more than 5 cm), the risk of developing seroma is significant, and the aesthetic results of the operation deteriorate. In this situation, there are indications for a preliminary liposuction of the anterior abdominal wall.

The degree of divergence of the rectus abdominal muscles determines the magnitude of the aponeurosis duplication of the anterior abdominal wall created during abdominoplasty. In turn, this determines the degree of correction of the waist circumference, the amount of displacement of the navel in the depth of the wound when creating the duplication of the aponeurosis, as well as the danger of the hypercompression syndrome of the abdominal wall organs with the possibility of developing pulmonary edema.

You can distinguish several degrees of divergence of the rectus abdominal muscles. With an insignificant degree, the duplication of the aponeurosis is unnecessary or can be formed on a section up to 5 cm wide. With a moderate divergence of the straight muscles, the duplication of the aponeurosis region is 5-10 cm in width, and at a considerable extent in the section wider than 10 cm. In the latter case, divergence of the rectus abdominal muscles with a significant thickness of the subcutaneous fat and a deep location of the umbilicus may evidences to the removal of the latter.

Skin condition. This indicator can be the basis for the operation in the presence of stretch bands. When the latter are located predominantly in the hypogastric region, their main part can be removed during abdominoplasty. This, however, is not always possible, since stretch bands are often formed with a minimum thickness of the subcutaneous fat layer. In this case, a significant shift of the cutaneous fat flap in the caudal direction is often impossible, so the stretch bands are only partially removed, and the postoperative scar may have an additional vertical component.

The presence of umbilical hernia is possible at any degree of anatomical and functional insufficiency of the anterior abdominal wall and can significantly complicate the operation.

[1], [2], [3], [4]