Surgical principles of abdominoplasty

The plastic of the anterior abdominal wall gives a significant cosmetic and functional effect, but can also lead to dangerous postoperative complications. The effectiveness and safety of such intervention depend on the accuracy of the principles discussed below.

• Planning for effective intervention

The decision about abdominoplasty in a particular patient is based on an analysis of a number of factors that can be divided into two groups: 1) dependent on the patient and 2) dependent on the surgeon.

The result of this evaluation is the choice of an appropriate method for correcting the deformity of the abdominal wall or refusal of the operation.

Factors that depend on the patient. Realistic expectations. The patient should be informed of the seriousness and relative severity of the upcoming intervention. Particular attention in the conversation is given to discussion of questions about the location and quality of scars, the content and duration of the postoperative period, the possibility of complications, including their dependence on the patient's behavior. Only when the latter reacts adequately to this information does the surgeon decide to carry out the operation.

• Compliance with postoperative treatment

In the postoperative period, the patient requires a high level of discipline in observing the doctor's recommendations. Slackness and untidy appearance, as well as inadequate reactions to the discussion of relevant issues should alert the surgeon. Each patient going to abdominoplasty should have the possibility of a gradual recovery in the postoperative period and, consequently, should be freed from hard domestic work for at least the first 2-3 weeks after the operation.

From patients with small children, female leaders and single mothers, it is possible to expect premature physical activity under the influence of life circumstances. This, in turn, can lead to the development of postoperative complications.

Particular attention should be paid to visiting women. For them, an important condition for consenting to an operation should be under the supervision of the operating surgeon for at least 2 weeks after the intervention. Permission to leave can be given only in the absence of suspicion of any complications.

Optimal, stable body weight. The best results of operations are achieved in patients with normal or moderately overweight. At the expressed obesity and accordingly significant thickness of hypodermic fatty tissue the possibility of development of local and even general complications sharply increases.

A certain proportion of patients can be significantly reduced by deliberate preparation for surgery. This facilitates the intervention and improves its effectiveness. However, every patient should be warned that significant fluctuations in body weight after the intervention can significantly worsen its result. It goes without saying that abdomi-noplasty is not meaningful in those women who do not rule out a repeat pregnancy.

Good health. The real severity of abdominoplasty, combined with the relatively long postoperative hypodynamia of patients, requires a sufficiently deep examination before the operation and an accurate assessment of their health status and functional reserves. In patients with chronic diseases, unstable cardiovascular system, a tendency to catarrhal diseases, the amount of intervention can be reduced or the operation can be postponed for a certain period for purposeful preparation.

Criteria, sufficient for refusal of abdominoplasty, is established by the surgeon together with an anesthesiologist. It is clear that sufficient safety of the operation can be provided only with a relatively rigid approach to assessing the health status of patients.

Factors that depend on the surgeon. Good individual theoretical training, experience in the implementation of the plasty of the anterior abdominal wall with high surgical technique are the prerequisites that make abdominoplasty a highly effective intervention. On the other hand, ignorance of vascular anatomy, non-compliance with the principles of plastic surgery and rough handling of tissues can lead to the development of dangerous postoperative complications.

The optimal way to correct deformation of the anterior abdominal wall. The individually selected method should, in the maximum permissible (and safe) degree, eliminate abnormal tissue changes and correspond to the real capabilities of the surgeon and patient.

In particular, at an increased risk of postoperative complications due to the presence of relative contraindications, the volume of the operation can be reduced (for example, before cutting off the skin-fat fold with the presence of an "apron" of soft tissues in the lower abdomen). According to the patient's wishes, abdominoplasty can be combined with liposuction in other anatomical areas, but only if the extent of the entire intervention corresponds to the possibility of carrying it out in a particular patient.

It goes without saying that, other things being equal, abdominoplasty should include all the elements necessary for the most complete correction of existing disorders.

• Complete preoperative preparation

After deciding on the operation, much depends on the full preoperative preparation of patients. The most difficult to implement requirement that is imposed on patients with significant obesity is the need to reduce body weight to acceptable values and then stabilize it. If this is not fully possible for patients, then it is advisable to perform liposuction of the anterior abdominal wall before abdominoplasty.

With a significantly overgrown anterior abdominal wall, when the operation is planned to significantly reduce the abdominal circumference, especially important is the preparation of the intestine. In addition to its standard cleansing, such patients are recommended fasting for two days prior to the operation.

When planning an extensive detachment of the skin-fat flap, the great importance is the refusal of patients to smoke for 2 weeks before the operation and a month after.

• Correct marking of the operating field

The access marking is carried out with the patient's vertical position, when the soft tissues of the anterior abdominal wall are lowered by gravity. Taking into account the individual mobility of the skin-fat layer, the surgeon marks the access line, the proposed boundaries for separation and excision of tissues. Also mark the middle line on which the navel should be located. At the conclusion of the markup, the surgeon determines the symmetry of the lines applied.

• Optimal access

Despite the variety of approaches proposed for the implementation of abdominoplasty, the horizontal incision located at the bottom of the abdomen is most often used. The maximum aesthetic effect from its application is achieved with the arrangement of even a long scar within the zone of "swimming trunks" (swimsuit). This zone is individual for each patient and must be marked before surgery. This takes into account the degree of displacement of both the upper and lower edges of the wound.

However, in many cases, the lower lateral access is inadequate and is combined with vertical median access. This is useful in the following situations:

• if there is a middle scar after laparotomy;
• with a relatively small excess of soft tissues in the anterior abdominal wall,
• which makes it impossible to move the coverslips in the caudal direction without forming a vertical suture below the navel;
• with a pronounced vertical fat trap located along the straight muscles of the abdomen and a significant thickness of the subcutaneous fat layer in the surrounding zones, which makes classical abdominoplasty performed from the lower horizontal access insufficiently effective.

• Rational detachment of the skin-fat flap

Detachment of the skin-fat flap over the deep fascia is an important element of abdominoplasty and can spread up to the xiphoid process and laterally - depending on the type of abdominoplasty performed: to the edge of the costal arch and the anterior axillary line or only to the paramedial lines.

As is known, the natural result of the detachment of the skin-fat flap is, firstly, the formation of extensive wound surfaces, and secondly, the decrease in the level of blood circulation of the tissues along the edge and in the central part of the flap.

The larger the area of the wound surface, the higher the probability of hematoma and gray formation in the postoperative period. On the other hand, a decrease in the blood supply of the skin-fat flap to a critical level can lead to the development of marginal necrosis and subsequent suppuration. That is why one of the important principles of abdominoplasty is the principle of optimal detachment of the skin-fat flap. It is realized, on the one hand, by the separation of tissues only in those minimally necessary scales that allow the surgeon to effectively solve the task of moving the flap downward with excision of excess soft tissue.

On the other hand, an important element of this stage of the operation is the allocation and preservation of that part of the perforating vessels that are located on the periphery of the skin-fat flap and can participate in its nutrition without interfering with the movement of tissues in the caudal direction.

An important role is also played by the minimal traumatization of the divided tissues, which reduces the production of serous fluid in the postoperative period. In view of this important circumstance, the detachment of the tissues should be made with a scalpel rather than with an electron knife. It is also advisable to leave about half a centimeter of adipose tissue on the surface of the muscular aponeurotic layer.

• Plasticity of the muscular aponeurotic layer

The overgrowth of the musculo-aponeurotic layer of the anterior abdominal wall is a consequence of pregnancy and, in combination with changes in the surface tissues, considerably worsens the contours of the trunk. That is why the obligatory part of radical abdominoplasty is the creation of duplication of the superficial leaf of the aponeurosis of the anterior abdominal wall. Continuous suture is imposed by a strong monofilament (makson or nylon No. 0) after preliminary marking of the lines of approach. The second layer of mattress seams can also be applied all over or only in some places (on both sides of the navel, at the extreme points of the line of duplication and in the spaces between them).

As a rule, the width of the duplication is 3-10 cm, and sometimes more. It is important to bear in mind that with a significant amount of the sutured aponeurosis section, this procedure raises intra-abdominal pressure and has a significant effect on the position of the navel and the condition of the skin-fat flap covering the given area.

When the points on the anterior surface of the vagina of the rectus abdominas come together, the tissues lying between them (including the navel) are displaced in depth, and the more the larger the area of the aponeurosis on which the duplication is created. With a width of this section of more than 10 cm, a deep belly button and a significant thickness of the fat layer to connect the navel to the skin surface without undue tension, it sometimes fails. This can be the basis for removing the navel with its subsequent plastic.

On the other hand, the convergence of the rectus abdominis leads to the formation of an excess of cutaneous fat flap along the width c, protrusion of the contour of the skin in the epigastric region and the formation of a wound cavity in which a hematoma is formed. With a relatively small excess of soft tissues, this problem can be solved by applying catgut sutures between the deep surface of the skin-fat flap and the aponeurosis.

With a larger excess of skin, the surgeon is faced with the choice of either widening the flap detachment area and thus spreading its excess over a larger area, or using additional medial access, in which the flap detachment area (in the lateral direction) may be minimal.

With pronounced relaxation of the musculo-aponeurotic layer of the anterior abdominal wall, the plasticity of the aponeurosis of the external oblique muscle can be additionally performed.

When forming the duplication of aponeurosis, it is necessary to take into account the degree of increase in intra-abdominal pressure by evaluating the degree of change in intrapulmonary pressure according to the indications of a manovacuum meter of the anesthesia apparatus. Relatively safe increase in pressure resistance should not exceed 5-7 cm of water. Art. A more significant increase in intrapulmonary pressure in the early postoperative period may lead to a disruption in the function of breathing, up to the development of pulmonary edema.

• Optimal location and shape of the navel

The "ideal navel" should be located on the median line in the middle between the xiphoid process and the pubic bone at the level of the anterior superior iliac spine or about 3 cm above. Deviations from the median line after transposition of the navel may occur: 1) in the absence of preoperative marking; 2) when inaccurately determining the level of the location of the navel in the course of the operation; 3) with asymmetrical application and tightening of the fixing navel sutures; 4) with an inaccurately formed duplication of the aponeurosis of the abdominal wall; 5) with asymmetric resection of the edges of the flap and an incorrect position of the patient on the operating table.

R.Baroudi and M.Moraes found that the structure of the body affects the shape of the navel both before and after the operation. In more obese patients, the umbilicus is deeper and broader, and in thin skin, it is small or protruding. With thin skin and a limited amount of fatty tissue, it is not possible to form a deep navel in thin people.

When conducting abdominoplasty, there are three main options for the surgeon's tactics in relation to the navel.

• The navel remains intact with the lower abdominoplasty and with dermolipectomy, when the zone of detachment of the skin-fat flap on the anterior abdominal wall does not extend to the epigastric region. This tactic is used for moderately pronounced changes in the anterior abdominal wall, occurring primarily in the lower abdominal areas, or in the case of a reduced volume of surgery, with contraindications to more extensive intervention.
• During abdominoplasty, the navel is retained and fixed (with or without plastic) in the orthotopic position at the corresponding point of the displaced skin-fat flap. This is the most frequent option used for the plastic of the anterior abdominal wall.
• Excision of the navel, which may become necessary with the extensive duplication of the aponeurosis in combination with a significant thickness of the fat layer of the anterior abdominal wall. It is understandable that the possibility of using this option must be agreed with the patient in advance.

The main options for the plastic of the navel with abdominoplasty. The new navel localization is determined with the patient's unraveled (!) Position on the operating table after the cutaneous fat flap is completely isolated, moved in the caudal direction and fixed by temporary seams along the previously marked center line. To mark the new position of the navel use a special marking clip Pitanga with long brunches.

Depending on the thickness of the subcutaneous tissue and the surgeon's preferences, three basic versions of the navel can be used.

With a relatively thin subcutaneous fat tissue at the navel location, a transverse incision of about 1.5 cm in length is made and after matching the edges of the incision with the edges of the navel, seams are seated with the capture of the aponeurosis tissue at four major points located at a uniform distance from each other.

These seams can be tightened incompletely, and only with the same tightening of the nodes of the navel is located symmetrically. The subsequent seams connect only the edges of the cut skin. This procedure can be performed both without creating the duplication of the aponeurosis, and after it.

With a greater thickness of subcutaneous fat or if the surgeon wishes to get a deeper navel, a significant tightening of the main suture leads to a deepening of the edges of the wound and to compression of the underlying fat. This can cause the development of necrosis of adipose tissue with subsequent suppuration of the wound.

In order for this to happen, the surgeon must excise the area of the subcutaneous fat, located along the deep edge of the newly created channel in the flap. After this, suturing does not lead to microcirculation disorders.

Another option is possible for the plastic of the navel, which gives a more cosmetic result. This method consists in the fact that a triangular flap with a side of about 15-20 mm is formed at the navel location, facing the base with a width of about 15 mm in the caudal direction.

The navel is dissected vertically in its distal part, and the formed triangular flap is sewn into the navel incision. In addition, 1-2 sutures are applied to the cranial part of the triangular incision, which leads to a deepening of the navel.

After removing the navel, its plastic can be performed by excision of subcutaneous fat (total or partial) at the level of the future navel with the subsequent approach of the thinned patch of the flap to the aponeurosis with the help of sutures.

• Removing excess soft tissue of the flap and suturing the wound

After displacement of the cutaneous fat flap in the distal direction with the rectified position of the trunk of the patient, the cut-off line of excess tissue is determined by a special marking clamp. After this, excess flap is removed.

An important condition for this stage of the operation is the possibility of subsequent suturing of the wound with minimal tension on the line of skin joints. At the same time, slight tension on the seam line is acceptable and expedient, since otherwise a soft tissue fold may remain in the abdomen bottom. That is why, after marking the boundaries of excision of tissues, the operating table is bent by 25-30 °, which completely relieves the seam line, including the nearest postoperative period.

When closing the wound, the following principles are used:

• for a more significant displacement of the cutaneous fat flap in the caudal direction, seams are applied with tension, but only on a dense surface fascial plate, while the seams on the skin should be superimposed with minimal tension;
• in connection with the large area of wound surfaces and the danger of their displacement relative to each other during movements (with the subsequent development of seromy), it is advisable to apply several catgut sutures connecting the deep surface of the skin-fat flap and the surface of the aponeurosis;
• The distal sections of the wound are drained by tubes (with active aspiration of wound contents), the ends of which are removed through the pubic part of the pubis;
• When suturing the wound, deep catgut sutures are applied to the fatty tissue, the dermal seam layer with Vicril No. 3/0 and matching the edges of the skin with the removed stitch with a No. 4/0 graft;
• after suturing the wound, the trunk is fixed with a special soft compression corset, which ensures the fixation of soft tissues in the postoperative period.

There are two main options for closing the cutaneous wound. With sufficient displacement of the skin-knife flap in the caudal direction, the distal edge of the wound can be compared without tension with the central edge, which along the midline of the abdomen is located on the j-junction of the selected navel.

With insufficient mobility of the skin-fat flap, the level of the navel opening is more cranial, which causes the surgeon to continue the seam line in the vertical direction by several centimeters when the wound is finally closed.

• Postoperative management of patients

The main principles of postoperative management of patients are, on the one hand, relative immobilization of tissues in the area of the operation, and on the other - early activation of patients.

Immobilization of tissues is ensured by keeping the patient's moderately bent torso from the end of the operation and throughout the first postoperative week. This is facilitated by a tightly bandaged bandage that presses the flap to the aponeurosis and prevents the tissue from moving. Finally, an important element of the patient's management is bed rest during the first 24 hours after the operation, when the patient leaves the hungry diet.

Longer immobilization of patients is fraught with the development of such dangerous complications as thrombophlebitis and thromboembolism. Therefore, in the postoperative period, special treatment regimens are used, which include:

• dosed infusion therapy aimed at improving the rheological properties of blood;
• control of the coagulating system of blood, according to the indications - the course of preventive treatment with fractasparin;
• dosed back and limb massage of the patient, performed 3-4 times a day, while maintaining the position of flexion of the trunk;
• Walking from the 2-3rd day after surgery while maintaining a semi-bent position of the trunk of the patient.

[1], [2], [3], [4], [5], [6], [7], [8]