Tense-sided abdominoplasty

In 1991, T.Lockwood described a new technique of abdominoplasty, which he called tense-lateral and which, according to his data, is capable of leading to more predictable and aesthetically better results with higher safety of the intervention. When using this technique, it should be taken into account that the body, from an aesthetic point of view, is a single whole.

Rationale and technique of the operation

The technique of tension-lateral abdominoplasty is based on two theoretical principles.

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

It is for this reason that in most patients the formation of loose skin in the epigastric region is the result of its horizontal (rather than vertical) overstretching as a result of progressive weakening of the cutaneous-subcutaneous-fascial system on the sides of the midline. This effect increases laterally with maximum expression along the lateral contour of the trunk. The laxity of the skin in the vertical direction, noted along the anterior and posterior midlines, is minimal (except for the area located below the umbilicus) due to the fusion of the superficial fascial system with the deep layer of tissue. This is not observed in patients with large fat deposits in the epigastric region and pronounced ptosis of the tissues of the anterior abdominal wall.

Statement 2. The basic element of the classical abdominoplasty technique - 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. This is supported by the data of R. Baroudi and M. Moraes, who back in 1974 recommended limited flap formation within the central triangle, the apices of which are the xiphoid process and the anterior superior iliac spines. This made it possible to reduce the risk of developing marginal skin necrosis. In addition, plastic surgeons are well aware that during liposuction of the torso and during thigh skin tightening, cannulation of the subcutaneous fat tissue is accompanied by an increase in skin mobility, almost the same as during the formation of skin-fat flaps.

Indications for surgery

Tension-lateral abdominoplasty is indicated for patients whose main components of anterior abdominal wall deformation are skin laxity and muscle-fascial system relaxation. 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 navel is mobile and flexible with sufficient subcutaneous fat thickness, then a standard technique for its transposition is needed. If the navel is relatively stable and fixed, then an umbilical incision is often not needed, and the intervention is limited to the hypogastric region.
• The surgeon uses each hand with considerable force to create a duplication of the skin on the lateral surfaces of the patient's body, who is in a lying position, and then on those of a standing patient.

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

3. With the patient in a vertical position, the skin above the pubis is moved up (by 2-3 cm), eliminating ptosis, and the distance between the hairline 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 floatation of the navel usually fluctuates within 2 cm. If it does not reach 11 cm, then a procedure called "transposition of the navel" is indicated. It is more correct to call it orthotopic umbilical plastic surgery, since in fact the surgeon performs transposition of the tissues surrounding the navel, creating its new shape and maintaining its previous position.

Deformations of the soft tissues of the trunk in the lateral and posterior sections are usually combined with deformation of the abdomen and must be eliminated simultaneously, otherwise the aesthetics of the trunk shape is impaired after abdominoplasty.

Surgical technique

Basic principles. New ideas about the mechanism of eptosis of soft tissues of the anterior abdominal wall allowed us to formulate two basic principles of tension-lateral abdominoplasty.

Principle 1. The surgeon separates the skin-fat flap from the aponeurosis of the anterior abdominal wall only at a minimum length, allowing the removal of excess tissue. In this case, above the navel, the tissue is separated only above the surface of the rectus abdominis muscles. As a result, in the epigastric zone, only those perforating vessels are ligated that interfere with the creation of a duplication of the aponeurosis. The mobility of the areas of integumentary tissue not separated from the aponeurosis (lateral sections and flanks) is achieved by treating the subcutaneous fat with cannulas or vertically installed scissors.

Principle 2. Unlike classical plastic surgery of the anterior abdominal wall (when tissues from the lateral surfaces of the body are moved to the midline and caudally), with tension-lateral abdominoplasty, the main vector of flap displacement is directed to the lower-lateral side (i.e., at an angle of 90° to the direction of traction in classical abdominoplasty).

Other key elements of tension-lateral abdominoplasty are:

• skin resection mainly in the lateral parts of the body;
• fixation of the superficial fascial system with permanent sutures along the entire access line with significant tension in the lateral sections;
• suturing the skin with slight tension on the lateral areas of the wound and practically no tension in the central part of the wound;
• performing, as indicated, concomitant liposuction in the upper abdomen and in the flank area.

Preoperative marking. With the patient in an upright position, the "floating" zone is marked, followed by the suture line. The latter consists of a short suprapubic line that goes at an angle toward the anterior superior iliac spines and then, if necessary, goes horizontally for a short distance, remaining within the "floating" zone.

The border of the flabbiness of the skin of the groin area is marked below this line by 1-2 cm, it also becomes the incision line, since after suturing the wound with tension in the lateral areas of the body, the suture line moves to a more cranial level.

Although the limits of the resected skin area are determined only at the end of the operation, it is better to mark them in advance, which facilitates the final intraoperative marking and ensures greater symmetry. The tissue resection line initially goes upward and medially at an angle of 60-90° (depending on the elasticity of the skin) for several centimeters from the edge of the lower line, and then turns towards the navel.

In patients with significant skin laxity predominantly in the lateral parts of the body, transposition of the umbilicus may not be required, and therefore the bulk of the tissue is resected laterally and to a lesser extent medially with the resection line parallel to the inferior incision line.

In cases of pronounced flabbiness of the skin in the supra-abdominal region, when transposition of the umbilicus is necessary, tissue is removed in almost equal volumes 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 division of tissues above the navel is usually limited to the area of the rectus abdominis muscles. Then, in most patients, a duplication of the aponeurosis of the rectus muscles is created.

The fat layer around this section of the anterior abdominal wall is treated with a special cannula or vertically positioned scissors. Cannulation (with or without fat suction) is performed with special care, without damaging the muscular wall.

After this, the flap is moved in the distal-lateral direction with considerable force, and sutures are placed in the lateral sections of the wound between its superficial fascial system and the fascia of the inguinal region (deep and superficial). The area of skin to be removed is marked with a marking clamp with slight tension of the skin in the lateral sections, and the excess flap is cut off. After the bleeding has stopped, two drainage tubes are installed, which are brought out in the pubic area.

After umbilical plastic surgery, the wound is closed using three-layer sutures:

• continuous suture (nylon No. 1 or No. 0) along the entire incision to the superficial fascial system;
• dermal reverse interrupted suture (with Maxon No. 2/0 or Vicryl No. 3/0);
• continuous removable intradermal suture (prolene No. 3/0 - 4/0).

In the central part of the wound, skin and deep sutures are applied with virtually no tension.

Advantages and disadvantages. The advantages of tension-lateral abdominoplasty are:

• better nutrition of the edges of the patches;
• high degree of waist correction;
• less risk of developing seromas;
• higher quality of the postoperative scar due to less tissue tension on the skin suture line in the postoperative period.

Preservation of perforating vessels makes simultaneous liposuction on the flanks, thighs and back safer. The combination of complete and partial separation of flap tissues with liposuction allows for maximum improvement of the aesthetic characteristics of the body.

The main area of the removed skin is in most cases located laterally, where the wound edges are joined with maximum tension (at the level of the superficial fascial system) and is accompanied by significant tightening of the skin of the inguinal region and moderate tightening of the tissues along the anteromedial surface of the thigh. Tissue tension in the suprapubic region, on the contrary, is reduced, reducing the risk of skin necrosis and preventing upward displacement of the hairy part of the pubic skin.

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

The disadvantage of this type of plastic surgery is sometimes the formation of "ears" at the extreme points of the wound. To prevent this, it may be necessary to slightly lengthen the incision.

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