Abdominoplasty with “Scarpa Fascia” preservation: Case Report

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InternationalJournalofSurgeryCaseReports47(2018)100–103

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

Abdominoplasty

with

“Scarpa

Fascia”

preservation:

Case

Report

Antonio

Iannelli

_,

_Francesco

_Ciancio

_,

_Paolo

_Annoscia

_,

_Michelangelo

_Vestita

_,

Rosario

Emanuele

Perrotta

_,

_Giuseppe

_Giudice

_,

_Michele

_De

_Robertis

a_{DepartmentofPlasticandReconstructiveSurgery,UniversityofBari,Italy} b_{DepartmentofPlasticandReconstructiveSurgery,UniversityofCatania,Italy} c_{U.O.ChirurgiaPlastica–OspedaleMadonnadelleGrazie,Matera,Italy}

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Articlehistory:

Received6February2018 Accepted29April2018 Availableonline9May2018

Keywords: Abdominoplasty Tummytuck ScarpaFascia Weightloss Seroma Lipectomy

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INTRODUCTION:AbdominoplastyisoneofthemostperformedoperationsinPlasticSurgeryintheworld.

Postoperativeseromaisoneofthemostfrequentlycitedcomplicationsinliterature.Theaimofthisstudy

istoproposeourexperiencewithabdominoplastywithScarpaFasciapreservationandcompareitwith

recentscientificliterature.

PRESENTATIONOFCASE:Wepresentthecaseofa55-year-oldwomanunderwentbariatricsurgeryin

2014,afterwhichshelost55kgofweight.Wedecidedtoperformanabdominoplastywithtransposition

oftheumbilicusandpreservationoftheScarpaFascia.Infact,thistechniqueseemstohaveapositive

impactonreducingseromaformation,reducingtheamountofdrainedfluidsandthedrainagetime.

DISCUSSION:Thesavingoftheadipose-fasciallayeraccordingtodifferentAuthorswouldallowthe

reductionofthevolumeofdrainedfluid,ofthetimespentbythedrainsandtheaveragehospitalstay.

CONCLUSION:TheabdominoplastywiththeScarpaFasciapreservationisasafe,repeatabletechnique

withgoodaestheticresults.Thesavingofdeepadiposetissueallowstoreducethetimeandthequantity

ofdrainedliquids.Inourexperiencepatientundergoingthistechniquehasshorterhospitalstayswith

nocomplications.

©2018PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopenaccessarticle

undertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Abdominoplastyis oneof themostperformedoperations in PlasticSurgeryintheworld[1].Severalsurgicaltechniqueshave beenproposedover theyearsand,especiallyinthelastdecade, therehasbeenaremarkableevolutionofthisprocedure[2–3]. Post-operativeseromaisoneofthemostfrequentlycitedcomplications inliteratureandinrecentyearstheadvantageofpreservationofthe ScarpaBelthasbeenincreasinglyaffirmed[4–5].Infact,the sav-ingofdeepadiposetissue,intheinfra-umbilicalarea,wouldallow asavingofvascularandlymphaticstructureswithareductionin seromaformation,areductionintimeandquantityofdrainageand areductioninhospitalstaytime.Despitethefactthatforseveral yearsnowa reductionofthesevariableshasbeenaffirmed,few jobshavebeenabletoleadtoanunambiguousinterpretationof theeffectsofthistechnique,sothatitisstillnecessarytocarryout studiesonlargesamples.

Theaimofthis studyistopropose ourexperiencewiththis techniqueandcompareitwithrecentscientificliterature.Thework hasbeenreportedinlinewiththeSCAREcriteria[6].

∗ Correspondingauthorat:DepartmentofPlasticandReconstructiveSurgery,CAP 70124,PiazzaGiulioCesare11,Bari,Italy.

E-mailaddress:francescociancio01@gmail.com(F.Ciancio).

2. Casereport

We present the case of a 55-year-old woman underwent bariatric surgery in 2014, after which shelost 55kgof weight (Fig.1).Thepatientdidnothaveassociatedco-morbidities.Given thesignificantweightloss,witha stablebodyweightforabout 1year,thepatientshowedacommonskinlaxity,especially rep-resented in the abdominal region. The cutaneous laxity of the abdominalregion,withptosisofthedermo-adiposetissues, clas-sifiedthepatientasagrade3accordingtoMatarasso[7],alsohad adiastasisoftherectusmusclesoftheabdomen,withindication for surgical intervention. We decide to perform an abdomino-plastywithtranspositionof umbilicusand strengtheningofthe rectus abdominis muscles by plication of the muscular fascia. Givenourexperiencewithpatientsundergoingbariatricsurgery, wedecidedtoperformanabdominoplastywithpreservationof theScarpaFascia. In fact,this technique seemstohavea posi-tiveimpactonreducingseromaformation,reducingtheamount ofdrainedfluidsandthedrainagetime.Inourexperience,patients undergoingmassiveweightlossshowagreatertendencyinthe formationofseromasforwhichitisdecidedtoconductthis proce-dure.

https://doi.org/10.1016/j.ijscr.2018.04.038

2210-2612/©2018PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.

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A.Iannellietal./InternationalJournalofSurgeryCaseReports47(2018)100–103 101

Fig.1. Pre-operativephoto.

Weevaluatedthefollowingvariables:age,BMI,comorbidity, drainageremovaltimes,totalvolumeofdrainedfluids,lengthof hospitalstay.Thefollow-upwas18months.

3. Surgicaltechnique

Inourclinicalpractice,weperformantibioticprophylaxiswith cefazolin2giv30minbeforesurgery.Accordingtotheliterature [4–5] theabdominal flapwassculpted in two differentplanes, superficialprefascial(abovetheScarpaFascia)intheinfraumbilical regionandpreaneuroticregionintheepigastricportion.Theskin incisionismadeaccordingtothepreoperativedesign[8](Fig.2), thentheabdominalflapissculptedwithultrasoundscalpels. Dur-ingthismaneuverwepreferamanualtractionoftheflaptakingcare topreservetheScarpaFasciauptoabout1cmbelowthe umbili-calscarasdescribedintheliterature.Oncethislevelisreached, dissectioniscarriedoutaccordingtoapremuscular (preaponeu-rotic)plane.Thedissectionuptothexiphoidprocessisconfined totheareabetweenthemedialmarginsoftherectusabdominis musclesinordertopreservetheperforatingvesselsoftheupper abdomen.Thetrabecularligamentofthexyphoidprocess,inour case hasbeensectionedsothesliding ofthe abdominalflapis facilitated.Oncethetunnelhasbeencompleted,themusclefascia oftherectumisplicatedwithitsapproachintheupper abdom-inalportions,thena medialportionoftheadipofascialtissue is removedandthepremuscularplaneisexposed(Fig.3).Reposition oftheumbilicalscarapproximately2cmabovetheprojectionon theabdominalflap.Withthepatientinsemi-Fowlerpositionthe abdominalflapisapproachedatthesuprapubicmarginand posi-tioningof2suctiondrainsJP(JacksonPratt).Suturesin3layersin latero-medialdirectionanddressingwithsteri-strip.Thepatient

Fig.2. Intra-operativephoto. Wecan distingueetwodifferentsurgicalplane: superficialprefascial(abovetheScarpaFascia)intheinfraumbilicalregionand preaneuroticregionintheepigastricportion.

Fig.3. Plicationoftherectusoftheabdomen.Theadipose-fascialtissueexeresisis notedalongthemidlineoftherectusabdominis.

wore a compressive sheath for 40 days. Drains were removed in seconddaywhen theamount drainedin 24hwasless than 30ml.

4. Discussionandconclusion

theabdominoplastywithtranspositionoftheumbilicusisone ofthemostperformedsurgicalproceduresinPlasticSurgery[1–9]. Severalsurgicalstrategieshavebeendescribedinliteratureto reducetherateof complicationsof traditionalabdominoplasty: selectivedissection,theuseofclosedsuctiondrains,avoidtheuse ofelectrocautery whennecessary,bindthepiercingvessels,the useofnegativepressure,sclerotherapy,theuseoffibringlueand delayedmobilization[10–14].Theseromarepresentsthe compli-cationmostpresentintheliteraturealsocomingtoratesof40% [4–5].

Over the last few years the technique with preservation of theScarpaFasciahasarousedconsiderableinterestinthe litera-ture.ThistechniquehasbeendescribedbyLouarnwhosuggests avoidingthedissectionexclusivelyonthepremuscular planeof therectusoftheabdomenbutpreservingthefasciainthe infra-umbilical region [15].The subcutaneous tissue structure of the

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102 A.Iannellietal./InternationalJournalofSurgeryCaseReports47(2018)100–103

Fig.4. Photographiccontrolafter45days.

abdominalwall comprises two distinct adipose,superficial and deeplayersseparatedbytheScarpaFascia[16–17]Inthis proce-durehasbeenpreservedandwithitalsothedeepadiposetissue, withtherespectivelymphaticvessels,arteriesand veins. Prob-ablythesavingofdeepadipose-fascialtissueis thekeystonein reducing therate ofcomplications related to seroma and lym-phaticdrainageintummytuckwithtranspositionoftheumbilicus. Theabdominalwall,infact,hastwodifferentareasoflymphatic drainage,dividedanddefinedbya horizontalplaneatthelevel oftheumbilicalregion:theepigastricareadrainstothearmpits andthehypogastricareadrainstotheinguinalregions.The inci-sionperformedin this techniquenot interrupt theconnections betweenthedeepadiposetissueandtheinguinallymphatic sta-tions.

The saving of the adipose-fascial layer according to differ-entAuthorswouldallowthereductionofthevolumeofdrained fluid,of thetime spent bythedrains and theaveragehospital stay[4–5].Inourcase weobservedashorter hospitalstay time than conventionallyabdominoplasty, in fact in clinicalpractice we preferto discharge patientswithoutdrainage, ie when the volumeofliquiddrainedin 24hisless than30mlalternatively weremovethedrainagenolaterthan thetenthday.Giventhe loweramountoffluidsdrainedinpatientundergoing abdomino-plastywithScarpaFasciasavings,weremovedthedrainsabout 3 daysearlier than classical procedurewithout preservation of ScarpaFascia,withshorter hospitalizationtimes.Thisfactorhas beenoneoftheelementsthathasallowedustoreducethecosts relatedtohospitalization anddeservesfurthereconomic-health study.

TheabdominoplastywiththeScarpaFascia preservationis a safe,repeatabletechniquewithgoodaestheticresults(Fig.4).The savingofdeepadiposetissueallowstoreducethetimeandthe quantityofdrainedliquids.Inourexperiencepatientundergoing thistechniquehasshorterhospitalstayswithnocomplications. Theindicationfor theuseofthis technique isin thedefinition phasebutitisabsolutelyavalidalternativeincasesof abdomino-plastywithtranspositionoftheumbilicus.Itcouldbeinteresting totrytoidentifythepatient ¨model¨thatcanbeappliedtothis tech-nique.

Conflictsaveapositiveimpactonreducingseromofinterest Theauthorshavenoconflictsofinteresttodisclose

Fundingsources

Authorshavenotreceivedfundingorsponsorforpaper produc-tion

Ethicalapproval

Tocarryoutthisscientificwork,therewasnoneedtoresort totheethicscommittee.Ethicalapprovalhasbeenexemptedfrom ourinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonreques

Authorcontribution CiancioFrancescowriting PaoloAnnosciawriting AntonioIannelliDatacollection

ProfPerrottaRosarioEmanuelecoordinator ProfGiuseppeGiudicecoordinator

MicheleDeRobertisSurgeonOperator Registrationofresearchstudies

Notnecessary Guarantor

FrancescoCiancioMD References

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