What is the abdominal wall plastic (abdominoplasty)?

• History

The main cause of stretching of the muscular-fascial layer and weakness of the skin of the anterior abdominal wall is pregnancy. The degree of residual changes can range from a roundly protruding lower abdomen to a vast diastasis between the straight muscles in combination with widespread stretch marks and the formation of an "apron". Time and significant fluctuations in body weight further reduce skin tone and increase symptoms.

With severe contour violations, only surgery can significantly improve the situation.

At the beginning of the XX century. Abdominoplasty was performed only in the form of excision of the skin-fat fold in the lower abdomen (pannicullectomy). The first panniculectomy was described by Kelly in 1899 and consisted in excision of a block weighing 7450 g, measuring 9 0 x 3 1 cm and thickness of 7 cm. Subsequently, various techniques for the plasty of the anterior abdominal wall were developed. Many of these methods are of only historical interest. Others contain elements that later formed the basis of modern abdominoplasty.

• Anatomy of anterior abdominal wall

The anterior abdominal wall has a rhomboid shape and is bounded by the xiphoid process and the edge of the costal arch from above, the oblique abdominal muscles, the edge of the iliac bones and the inguinal ligament from below. The contours of the anterior abdominal wall vary depending on sex, age and body weight. The range of contours can vary from retraction in asthenics to a slight bulge in hypersthenics and the slackness of the skin-fat fold in obesity.

The navel is the most noticeable landmark on the anterior abdominal wall. It is located below the middle of the line connecting the xiphoid process with the pubic bone. The localization of the navel is relatively constant: between the waist line and the line connecting the anterior superior iliac spine.

• Surface layer of soft tissues

The skin of the abdomen is sufficiently mobile, except for the site located along the median line above the navel. The superficial fascia downwards from the level of the navel is divided into two well-defined plates. One of them - superficial - is associated with the superficial layer of subcutaneous adipose tissue, and on it are located superficial vessels of the anterior abdominal wall. The deep leaf of the superficial fascia has an aponeurotic character and at the bottom it fuses with the inguinal (puarth) ligament. With the increase in the layer of subcutaneous fat, this leaf is so compacted that sometimes it can be taken for aponeurosis of the external oblique abdominal muscle.

Subcutaneous fatty tissue of the anterolateral abdominal parts differs in that it contains numerous connective tissue bridges. They are located in different planes and divide fatty tissue into segments, layers and layers of varying length and thickness.

In contrast to these zones, the surface fascia is not expressed along the white line of the abdomen and in the navel region. But the connective tissue bridges reaching the skin from the aponeurosis of the white line and the umbilical ring are very numerous, as a result of which the subcutaneous tissue of the right and left halves of the abdominal wall is often divided by this fibrous septum almost throughout the entire abdomen. Accordingly, the skin over the white line and the navel is less mobile.

• Muscular-aponeurotic layer

The muscular aponeurotic layer of the anterior abdominal wall consists of several layers. Like the elastic belt, it covers the contents of the abdominal cavity, and its tone helps maintain normal intra-abdominal pressure. The muscular-fascial system of the anterior abdominal wall consists of four paired muscles and their aponeurotic dilations. External oblique, internal oblique and transverse muscles are lateral muscles that converge medially into one aponeurosis. The leaves of the latter form strong vaginas for vertically located rectus abdominal muscles. These vaginas, intersecting with each other, form a white belly line.

On the surface of the rectus muscles are located pyramidal muscles, which are triangular in shape and small in size. They start from the pubic bones and are weaved into the white line. In the middle of the distance between the navel and the pubis, the posterior edge of the aponeurosis of the straight muscles ends with a so-called arc-shaped line. Below, a rather strong transverse fascia covers the deep surface of the transverse muscles.

In general, the muscular aponeurotic layer of the anterior wall of the abdomen can be considered as a single complex consisting of three muscle groups, the common tendon of which is the white line of the abdomen. Its stretching is counteracted by the contraction of the rectus abdominis muscles.

• Vascular-nerve supply to the anterior abdominal wall

Blood supply and innervation of the anterior abdominal wall are discussed in detail in Part II. In this section, they are considered superfluous for the operation of plasty of the anterior abdominal wall.

The main contribution to the blood supply of the median zone of the anterior abdominal wall is made by the upper and lower deep epigastric arteries. The upper epigastric artery lies on a deep leaf of the vagina of the rectus abdominal muscle, arising as a continuation of the thoracic artery. It descends and anastomoses with the lower epigastric artery, which is the branch of the external iliac artery. The lower deep epigastric artery appears proximally from the inguinal ligament and rises obliquely anterior to the navel. It permeates the transverse fascia and enters the vagina of the rectus anterior to the semilunar line.

The anterior divisions of the anterior abdominal wall receive blood supply from the lateral branches of six intercostal and four lumbar arteries and a deep envelope of the iliac artery bone. These arteries pass together with intercostal, ilio-hypogastric and iliac-inguinal nerves, permeate laterally the vagina of the rectus and freely anastomose with the epigastric system.

Thus, normally the main sources of blood supply to the surface tissues of the anterior abdominal wall are directed from the periphery to the center (the navel region) and in the opposite direction (from the navel zone in the radial directions) due to pronounced perianum perforating arteries. After the operation with the mobilization of the skin-fat flap over a large extent, its blood supply is provided from the periphery to the center.

Lymphatic system. Lymphatic vessels are divided into draining nadpupochnuyu part that go to the thoracic parts of the axillary nodes, and drainage area below the navel with outflow into the superficial inguinal lymph nodes. Lymphatic vessels of the liver are communicated through a circular ligament with the lymphatic vessels of the anterior abdominal wall.

Innervation. The innervation of the anterior abdominal wall is provided by the lateral and anterior branches of The-u and Li. The lateral branches enter the subcutaneous adipose tissue along the middle axillary line, bend and remain in most operations. The anterior branches enter the tissue of the direct muscles, as a rule, they are damaged during abdominoplasty.