Stress and side abdominoplasty

In 1991, T. Lockwood described a new technique for abdominoplasty, which he called the side-strained and which, according to him, could lead to more predictable and aesthetically better results with higher intervention safety. When using this technique, it should be borne in mind that the trunk, from the aesthetic point of view, is a single whole.

Justification and technique of the operation

The technique of stress-lateral abdominoplasty is based on two theoretical propositions.

Position 1. With age and with changes in body weight (including pregnancy), the vertical relaxation of the skin of the anterior abdominal wall in most cases does not occur throughout the midline of the abdomen (from the xiphoid process to the pubic symphysis), as was previously thought, but only at the site below the level of the navel. In the same zone there is a significant horizontal overstretch of the skin. Above the level of the navel, the formation of a true excess of the skin (along the course of the white line of the abdomen) is possible only in very limited limits due to the strong fusion of the superficial fascial system and skin.

It is for this reason that in most patients the formation of sagging skin in the epigastric region is the result of its horizontal (and non-vertex) overgrowth as a result of the progressive weakening of the cutaneous-subcutaneous-fascial system along the sides from the median line. This effect increases in the lateral direction with maximum expression along the lateral contour of the trunk. The flabbiness of the skin in the vertical direction, marked along the anterior and posterior median lines, is minimal (except for the area below the navel) due to the fusion of the superficial fascial system with a deep layer of tissues. This is not observed in patients with large deposits of fat in the epigastric region and pronounced ptosis of the tissues of the anterior abdominal wall.

Position 2. The main element of the technique of classical abdominoplasty - the separation of the skin-fat flap to the level of the costal arch and the anterior axillary line - can be revised towards a significant reduction in the tissue separation zone. In favor of this are the data of R.Baroudi and M.Moraes, who, as early as 1974, recommended the limited formation of a flap within the central triangle, the apex of which are the xiphoid process and the anterior superior iliac spine. This allowed to reduce the risk of developing edge necrosis of the skin. In addition, plastic surgeons are well aware that with liposuction of the trunk and lifting the skin of the thighs, cannulation of subcutaneous fat is accompanied by an increase in skin mobility, almost the same as in the formation of skin-fat flaps.

Indications for operation

Stress-side abdominoplasty is indicated in patients whose flaccidity and relaxed muscular-fascial system are the main components of the anterior abdominal wall deformity. Indications for this type of intervention are confirmed by three clinical tests.

• The surgeon determines the mobility of the navel by moving it. If the umbilicus is mobile and mobile, if the thickness of the subcutaneous fatty tissue is sufficient, then a standard technique of its transposition is needed. If the navel is relatively stable and fixed, the umbilical incision is often not needed, and the intervention is limited to the hypogastric region.
• The surgeon with each hand with considerable effort creates a duplication of skin on the lateral surfaces of the patient's torso, which is in a prone position, and behind those standing.

In this case, the main thrust should be in the lower-lateral direction. If there is no significant displacement of the navel (and the skin above it), then its transposition in most cases is not needed.

3. For the patient's vertical position, the skin above the pubis is moved upwards (by 2-3 cm), eliminating ptosis, and the distance between the hair growth line and the navel is measured. Normally, the minimum aesthetically acceptable distance between the navel and the hairline should be at least 9 cm, taking into account that the total distance is about 11 cm, and the navel flotation usually varies within 2 cm. If it does not reach 11 cm, The procedure, which was named "transposition of a folder". It is more correct to call it orthotopic plastic of the navel, since in reality the surgeon performs a transposition of the surrounding navel tissues, creating its new shape and retaining its former position.

The deformations of the soft tissues of the trunk in the lateral and posterior parts are usually combined with the deformity of the abdomen and must be eliminated simultaneously, otherwise the aesthetics of the trunk shapes are disrupted after abdominoplasty.

Surgical technique

Basic principles. New ideas about the mechanism of eptosis of the soft tissues of the anterior abdominal wall made it possible to formulate two basic principles of stress-lateral abdominoplasty.

Principle 1. The surgeon separates the skin-fat flap from the anterior aponeurosis of the anterior abdominal wall only at the minimum extent, allowing to remove excess tissue. For this, the navel of the tissue is only divided above the surface of the rectus abdominis muscles. As a result, only those perforating vessels are bandaged in the epigastric zone, which interfere with the creation of an aponeurosis duplication. Mobility of sections of integumentary tissues (side sections and flanks) not separated from the aponeurosis is achieved by treating the subcutaneous fatty tissue with cannulas or vertically mounted scissors.

Principle 2. Unlike the classical plasty of the anterior abdominal wall (when tissues from the lateral surfaces of the trunk are moved to the median line and caudally) with the stress-side abdominoplasty, the main displacement vector of the flap is directed to the lower lateral side (ie, at an angle of 90 ° to the direction traction with classical abdominoplasty).

Other key elements of the stress-side abdominoplasty are:

• resection of the skin mainly in the lateral sections of the trunk;
• fixation of the superficial fascial system by permanent sutures along the entire access line with considerable tension in the lateral sections;
• application of a seam on the skin with a slight tension on the lateral sections of the wound and practically without tension - in the central part of the wound;
• Compliance with indications of concomitant liposuction in the upper abdomen and in the flank region.

Preoperative marking. When the patient is in the vertical position, mark the zone "smelting", and then - the seam line. The latter consists of a short suprapubic line that at an angle extends toward the anterior superior iliac spine and then, if necessary, runs horizontally for a short distance, remaining within the zone of "swimming trunks".

The border of the flabby skin of the inguinal region is marked below this line by 1-2 cm, it becomes the line of the incision, since after sewing the wound with tension in the lateral areas of the trunk the seam line moves to a more cranial level.

Despite the fact that the limits of the resected part of the skin are determined only at the end of the operation, it is better to mark them in advance, which facilitates the final intra operating markings and provides greater symmetry. The line of resection of tissues first goes upward and medially at an angle of 60-90 ° (depending on the elasticity of the skin) a few centimeters from the edge of the lower line, and then turns toward the navel.

In patients with significant skin flaccidity predominantly in the lateral parts of the trunk, the transposition of the navel may not be required, and therefore the bulk of the tissues are laterally and less medially disposed along the line of resection parallel to the line of the lower incision.

With severe flabbiness of the skin in the ocular region, when the transposition of the navel is necessary, the tissues are removed in almost the same volume, both centrally and laterally.

The main stage of the operation. The skin-fat flap of the anterior abdominal wall is raised to the level of the navel above the muscular fascia. The separation of tissues above the navel is usually limited to the zone of the rectus abdominis muscles. Then, in most patients, duplicate aponeurosis of the rectus muscle is created.

The fat layer around this part of the anterior abdominal wall is treated with a special cannula or vertically arranged scissors. Cannulation (with or without suctioning fat) is carried out with extreme caution, without damaging the muscular wall.

After this, the flap with significant force is displaced in the posterior-lateral direction and in the lateral sections of the wound, seams are placed between its superficial fascial system and the fasciae of the inguinal region (deep and superficial). The removed area of the skin is marked with a marking clamp with little skin tension in the side sections, and the excess flap is cut off. After stopping bleeding, install two drainage tubes, which are removed in the pubic area.

After plastics of the navel, the wound is closed, applying three-layer seams:

• continuous seam (nylon No. 1 or No. 0) along the entire incision to the surface fascial system;
• dermal back nodal suture (with a moxon No. 2/0 or with a vikril No. 3/0);
• continuous removable intradermal suture (by the spill No. 3/0 - 4/0).

In the central part of the wound, dermal and deep sutures are applied almost without tension.

Advantages and disadvantages. Advantages of stress-side abdominoplasty are:

• better nutrition of the edges of the flaps;
• greater degree of waist correction;
• less danger of development by sulfur;
• higher quality of postoperative scar because of less tension of tissues on the skin line in the postoperative period.

Preservation of perforating vessels makes safer liposuction performed simultaneously on flanks, hips and back. The combination of complete and incomplete separation of the flap tissues with liposuction allows to maximize the aesthetic characteristics of the trunk.

The main part of the skin being removed is in most cases located laterally, where the connection of the edges of the wound occurs with the maximum tension (at the level of the superficial fascial system) and is accompanied by a significant tightening of the skin of the inguinal region and a moderate pulling of the tissues along the anterior medial surface of the thigh. The tension of the tissues in the suprapubic region, on the contrary, decreases, reducing the risk of skin necrosis and preventing the hairy part of the pubic skin from moving upward.

Fixation of the superficial fascial system with permanent sutures reduces the risk of unwanted effects, including the formation of a late suprapubic cavity, which can occur if the superficial fascial system is not restored.

The disadvantage of this type of plastic is sometimes the formation of "ears" in the extreme points of the wound. To prevent this, some lengthening of the cut may be required.

[1], [2], [3], [4], [5]