Surgical principles of abdominoplasty

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

• Planning an effective intervention

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

The result of this assessment is the choice of the appropriate method of correction of the abdominal wall deformation or refusal of surgery.

Patient-dependent factors. Realistic expectations. The patient must be informed of the seriousness and relative severity of the upcoming intervention. Particular attention in the conversation is given to discussing issues such as 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 if the patient reacts adequately to this information does the surgeon decide to perform the operation.

• Compliance with the postoperative regimen

In the postoperative period, the patient is required to have a high level of discipline in following the doctor's recommendations. Sloppiness and unkempt appearance, as well as inadequate reactions to the discussion of relevant issues should alert the surgeon. Each patient undergoing abdominoplasty should have the opportunity for gradual recovery in the postoperative period, and therefore should be freed from heavy housework for at least the first 2-3 weeks after the operation.

Patients with small children, female managers and single mothers may be expected to become prematurely physically active due to life circumstances. This, in turn, may cause postoperative complications.

Particular attention should be paid to visiting women. For them, an important condition for consent to surgery should be to remain under the supervision of the operating surgeon for at least 2 weeks after the intervention. Permission to leave can only be given if there is no suspicion of any complications.

Optimal, stable body weight. The best results of operations are achieved in patients with normal or moderately overweight. With pronounced obesity and, accordingly, significant thickness of subcutaneous fat, the possibility of developing local and even general complications increases sharply.

A certain proportion of patients can significantly reduce their excess body weight by means of targeted preparation for the surgery. This facilitates the intervention and increases its effectiveness. However, each patient should be warned that significant fluctuations in body weight after the intervention can significantly worsen its outcome. It goes without saying that abdominoplasty is not advisable for women who do not exclude a second pregnancy.

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

The criteria sufficient for refusing abdominoplasty are established by the surgeon together with the anesthesiologist. It is clear that sufficient safety of the operation can be ensured only with a relatively strict approach to assessing the health condition of patients.

Factors depending on the surgeon. Good individual theoretical training, experience in performing plastic surgery of the anterior abdominal wall with high surgical technique - these are the mandatory conditions that make abdominoplasty a highly effective intervention. On the other hand, ignorance of vascular anatomy, failure to follow the principles of plastic surgery and rough handling of tissues can lead to the development of dangerous postoperative complications.

The optimal method for correcting the deformation of the anterior abdominal wall. The individually selected method should eliminate pathological changes in tissues to the maximum permissible (and safe) extent and correspond to the real capabilities of the surgeon and the patient.

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

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

• Complete preoperative preparation

Once the decision to operate has been made, much depends on the full preoperative preparation of patients. The most difficult requirement to implement for patients with significant obesity is the need to reduce body weight to acceptable values and then stabilize it. If patients are unable to do this completely, then sometimes it is advisable to perform liposuction of the anterior abdominal wall before abdominoplasty.

In the case of a significantly overstretched anterior abdominal wall, when the operation is planned to significantly reduce the abdominal circumference, bowel preparation is of particular importance. In addition to its standard cleansing, such patients are recommended to fast for two days prior to the operation.

When planning extensive detachment of the skin-fat flap, it is of great importance that patients quit smoking for 2 weeks before the operation and a month after.

• Correct marking of the surgical field

The access marking is performed with the patient in a 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 expected boundaries of separation and excision of tissues. The midline on which the navel should be located is also marked. At the end of the marking, the surgeon determines the symmetry of the applied lines.

• Optimal access

Despite the variety of approaches proposed for performing abdominoplasty, the most commonly used is a horizontal incision located in the lower abdomen. The maximum aesthetic effect from its use is achieved when even a long scar is located within the "swimming trunks" (bathing suit) zone. This zone is individual for each patient and must be marked before the operation. In this case, the degree of displacement of both the upper and lower edges of the wound is taken into account.

However, in many cases the lower transverse approach is insufficient and is combined with a vertical median approach. This is advisable in the following situations:

• in the presence of a median scar after laparotomy;
• with a relatively small excess of soft tissue on the anterior abdominal wall,
• which makes it impossible to shift the integumentary tissues in the caudal direction without forming a vertical suture below the navel;
• with a pronounced vertical fat "trap" located along the rectus abdominis muscles, and a significant thickness of the subcutaneous fat layer in the surrounding areas, which makes classical abdominoplasty performed from the lower horizontal approach insufficiently effective.

• Rational detachment of the skin-fat flap

The detachment of the skin-fat flap over the deep fascia is an important element of abdominoplasty and can extend upward 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 paramedian 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, a decrease in the level of blood circulation in the tissues along the edge and in the central part of the flap.

The larger the wound surface area, the higher the probability of hematomas and seromas in the postoperative period. On the other hand, a decrease in the blood supply to the areas 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 implemented, on the one hand, by dividing the tissues only in the minimum necessary scales that allow the surgeon to effectively solve the problem of shifting the flap downwards with excision of excess soft tissue.

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

Minimal trauma to the tissues being separated also plays an important role, which reduces the production of serous fluid in the postoperative period. Taking this important circumstance into account, it is better to separate the tissues with a scalpel rather than an electric knife. It is also advisable to leave about half a centimeter of fatty tissue on the surface of the muscular-aponeurotic layer.

• Musculoaponeurotic layer plastic surgery

Overstretching of the muscular-aponeurotic layer of the anterior abdominal wall is a consequence of pregnancy and, in combination with changes in the superficial tissues, significantly worsens the contours of the torso. That is why a mandatory part of radical abdominoplasty is the creation of a duplication of the superficial layer of the aponeurosis of the anterior abdominal wall. A continuous suture is applied with a strong monofilament (Maxon or nylon No. 0) after preliminary marking of the convergence lines. The second layer of mattress sutures can also be applied along the entire length or only in certain places (on both sides of the navel, at the extreme points of the duplication line and in the spaces between them).

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

When the points located on the anterior surface of the rectus abdominis sheath are brought together, the tissues lying between them (including the navel) are displaced in depth, and to a greater extent, the wider the section of the aponeurosis on which the duplication is created. If the width of this section is more than 10 cm, the navel is deep and the fat layer is significantly thick, it is sometimes impossible to connect the navel with sutures to the skin surface without excessive tension. This may be the basis for removing the navel with subsequent plastic surgery.

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

With a more significant excess of skin, the surgeon is faced with a choice: either to expand the area of flap detachment and thereby distribute its excess over a larger area, or to use an additional median approach, in which the area of flap detachment (in the lateral direction) can be minimal.

In case of pronounced relaxation of the muscular-aponeurotic layer of the anterior abdominal wall, additional plastic surgery of the aponeurosis of the external oblique muscle can be performed.

When forming aponeurosis duplication, it is necessary to take into account the degree of increase in intra-abdominal pressure by assessing the degree of change in intrapulmonary pressure according to the readings of the manovacuummeter of the anesthesia apparatus. A relatively safe increase in resistance pressure should not exceed 5-7 cm H2O. A more significant increase in intrapulmonary pressure in the early postoperative period can lead to respiratory dysfunction, up to the development of pulmonary edema.

• Optimal location and shape of the navel

"The ideal umbilicus" should be located on the midline midway between the xiphoid process and the pubic bone at the level of the anterior superior iliac spines or approximately 3 cm higher. Deviations from the midline after umbilicus transposition may occur: 1) in the absence of preoperative markings; 2) inaccurate determination of the umbilicus level during surgery; 3) asymmetrical placement and tightening of the sutures fixing the umbilicus; 4) inaccurately formed duplication of the abdominal wall aponeurosis; 5) asymmetrical resection of the flap edges and incorrect patient positioning on the operating table.

R. Baroudi and M. Moraes found that body structure affects the shape of the navel both before and after surgery. In obese patients, the navel is deeper and wider, while in thin patients it is shallow or protruding. With thin skin and a limited amount of fatty tissue, it is impossible to form a deep navel in thin people.

When performing abdominoplasty, there are three main possible surgical tactics in relation to the navel.

• The navel remains intact in lower abdominoplasty and dermolipectomy, when the area of detachment of the skin-fat flap on the anterior abdominal wall does not extend to the epigastric region. This tactic is used in case of moderate changes in the anterior abdominal wall, occurring primarily in the lower abdomen, or in case of a reduced volume of surgery in the presence of contraindications to a more extensive intervention.
• During abdominoplasty, the navel is preserved and fixed (with or without plastic surgery) in an orthotopic position at the corresponding point of the displaced skin-fat flap. This is the most common option used in plastic surgery of the anterior abdominal wall.
• Excision of the umbilicus, which may become necessary in the case of extensive duplication of the aponeurosis in combination with a significant thickness of the fat layer of the anterior abdominal wall. It is quite clear that the possibility of using this option should be agreed upon with the patient in advance.

Main variants of navel plastic surgery during abdominoplasty. The new location of the navel is determined with the patient in an extended (!) position on the operating table after the skin-fat flap has been completely isolated, moved in the caudal direction and fixed with temporary sutures along a previously marked central line. A special Pitanguy marking clamp with long branches is used to mark the new position of the navel.

Depending on the thickness of the subcutaneous tissue and the surgeon's preference, three main options for shaping the navel can be used.

With relatively thin subcutaneous fat tissue at the location of the navel, 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, sutures are applied with the capture of aponeurosis tissue at four main points located at an equal distance from each other.

These sutures may not be tightened completely, and only with the same tightening of the knots the navel is located symmetrically. Subsequent sutures connect only the edges of the skin incision. This procedure can be performed both without creating a duplication of the aponeurosis, and after it.

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

To prevent this from happening, the surgeon must excise a section of subcutaneous fat located along the deep edge of the newly created channel in the flap. After this, the application of sutures does not lead to the occurrence of microcirculation disorders.

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

The umbilicus is cut vertically in its distal part, and the formed triangular flap is sutured into the umbilical incision. In this case, 1-2 additional sutures are applied to the cranial part of the triangular incision, which leads to a deepening of the umbilicus.

After removal of the navel, its plastic surgery can be performed by excising the subcutaneous fat (completely or partially) at the level of the future navel, followed by bringing the thinned area of the flap closer to the aponeurosis using sutures.

• Removal of excess soft tissue flap and wound suturing

After the skin-fat flap has been distally displaced with the patient's torso in an upright position, the line of tissue excess excision is determined with a special marking clamp. The excess flap is then removed.

An important condition of this stage of the operation is the possibility of subsequent suturing of the wound with minimal tension on the skin suture line. At the same time, slight tension on the suture line is acceptable and advisable, since otherwise a fold of soft tissue may remain in the lower abdomen. That is why after marking the boundaries of tissue excision, the operating table is bent by 25-30°, which allows for complete unloading of the suture line, including for the immediate postoperative period.

When closing a wound, the following principles are used:

• for a more significant displacement of the skin-fat flap in the caudal direction, sutures are applied with tension, but only on the dense superficial fascial plate, while sutures on the skin should be applied with minimal tension;
• due to the significant area of the wound surfaces and the risk of their displacement relative to each other during movements (with the subsequent development of seroma), 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 parts of the wound are drained with tubes (with active aspiration of the wound contents), the ends of which are brought out through the hairy part of the pubis;
• when suturing the wound, deep catgut sutures are applied to the fatty tissue, the dermal layer is sutured with No. 3/0 Vicryl and a removable suture with No. 4/0 Prolene is applied to match the edges of the skin;
• After suturing the wound, the body is fixed with a special soft compression corset, which ensures the fixation of soft tissues in the postoperative period.

Let us note two main variants of skin wound closure. With sufficient displacement of the skin-fat flap in the caudal direction, the distal edge of the wound can be aligned without tension with the central edge, which is located along the midline of the abdomen at the level of the isolated navel.

With insufficient mobility of the skin-fat flap, the level of the umbilical opening is located more cranially, which forces the surgeon to continue the suture line in the vertical direction for several centimeters during the final closure of the wound.

• Postoperative management of patients

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

Immobilization of tissues is ensured by maintaining the patient's body moderately bent from the moment the operation is completed and throughout the first postoperative week. This is facilitated by a tightly applied bandage that presses the flap to the aponeurosis and prevents tissue displacement. Finally, an important element of patient management is bed rest during the first 24 hours after the operation, when the patient comes out of the fasting 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;
• monitoring of the blood coagulation system, if indicated - a course of preventive treatment with fraxiparine;
• dosed massage of the patient's back and limbs, performed 3-4 times a day, while maintaining the position of flexion of the torso;
• walking from the 2nd-3rd day after surgery while maintaining a semi-bent position of the patient's torso.

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