10 Abdominoplasty Technique: A Personal Approach

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10 Abdominoplasty Technique: A Personal Approach

Oscar Ramirez, Keith M. Robertson, Anjum Khan

10.1

Introduction

The abdominoplasty procedure needs to be tailored to the trunk anatomy and to the aesthetic goals. Those with a small amount of infraumbilical protuberance without excess skin may be treated with endoscopic muscle plication and abdominal liposuction [1, 2]. An open approach is used when the skin tone is poor.

There is a moderate to large amount of excess fat and moderate to severe abdominal wall laxity. Procedures range from a mini-abdominoplasty with inferior trans- lation of the umbilicus with or without muscle plication to the most extensive version with massive dermatoli- pectomy, plication of the rectus sheath (for the treatment of the muscle diastasis) and transposition of the umbilicus to a new location in the abdominal wall skin [3, 4]. High lateral tension with fascial suspension, ad- vancement of the external oblique fascia and liposuction have been useful additional maneuvers to define the waistline further, especially when dealing with severe abdominal wall deformities [5 – 7].

All the functional and cosmetic concerns of the abdominal wall may be met by utilizing our comprehensive approach. A significant elevation of the mons pubis and the upper anterolateral thigh occurs with this technique. By restoring appropriate tension to the abdominal musculature, the individual’s posture im- proves and tension is diminished in the lumbar spinal muscles [8].

10.2 Markings

Many of the previously designed abdominoplasty incisions violated the aesthetic units of the thighs or abdomen. They tended to produce “dog-ears”, which often needed to be dealt with as a second procedure. The re- sulting scars are not hidden by the high cut style of bathing suits. The “UM” shape of incision does not have these problems [9]. If a panniculus is present, it is very helpful to have an assistant hold this so that both the surgeon’s hands are free for marking. Reference

lines are drawn to facilitate symmetry and to appreciate better any excess of tissue on one side versus the other.

When significant asymmetry is present, the position of the incision is modified as necessary. The reference lines are: (1) the midline joined to xyphoid, umbilicus and vulvar commissure; (2) lines marked 10 cm on ei- ther side of the midline; (3) the outlines of the anterior and posterior silhouettes of the body as we see the patient from the front and from the back; (4) the line that starts in the groin crease and extends in a straight line towards the iliac areas; and (5) a circumferential line at the narrowest part of the waist.

The lower incision of the area of resection is shaped like a U. This is marked first. The pubis is lifted and a horizontal line is marked 7 cm from the anterior vulvar commissure. The ends of this marking are extended lateral to the groin crease while the anterolateral thigh skin is elevated manually. The marking moves towards the waistline. The upper incision is marked from the ends of the U incision. It is shaped like an M. Its central portion usually lies just above the naval. The peaks of the M are usually at the paramedian vertical line or the level of the linea semilunaris. The area of skin to be resected is grasped to confirm that the wound can be closed without excessive tension. The symmetry is ob- served on the flaps to be closed, not on the tissue being resected. All palpable hernias and the degree of rectus diastasis are marked. Markings are done with the patient naked standing with the feet about 60 cm apart.

10.3

Preoperative Concerns

The main aim of the operation is to obtain a flatter abdomen and a smaller, more defined waistline. Tighten- ing of the abdominal wall causes a significant inward pressure on the abdominal contents. The outward pressure of the bowels may cause pain and ileus. Sometimes this results in suture line dehiscence or vomiting. The Valsalva maneuver will further increase the tension against the line of muscle and skin repair. Increased intra-abdominal pressure pushes the diaphragm up- wards and decreases the respiratory functional residual

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capacity (FRC), which predisposes to atelectasis. It compresses the vena cava, decreasing the venous re- turn and increasing venous stasis, one of the biggest risk factors for pulmonary embolus and deep venous thrombosis. The preparation consists of a clear liquid diet for 3 days, enemas and laxatives. Oral antibiotics are also administered for 3 days prior to surgery to decrease the amount of intestinal bacterial flora, thus decreasing the production of intestinal gas. To avoid de- hydration, plenty of oral fluids and electrolytes are rec- ommended. Chlorpropamide, 10 mg, is taken orally every 6 h for the first 5 days after surgery to decrease production of succus entericus and to stimulate peristalsis.

Opioids slow peristalsis and are avoided when possible.

As a consequence of using this perioperative plan, we have earlier recovery of bowel function with no cases of postoperative ileus or abdominal distention. The patients have less pain and rarely have deep venous thromboses.

After the surgery, all patients will have difficulty breathing deeply. This is due to pain, muscular tight- ness and upward pressure on the diaphragm from the compressed intra-abdominal contents. Those who pri- marily use their abdominal muscles for breathing present a special challenge. They need to strengthen their diaphragms, intercostal muscles and accessory muscles because their abdominal muscles will function poorly for the first few days. In order to train the diaphragm, the patient is given breathing exercises that may be performed under the direction of a respiratory therapist.

They are given an abdominal binder to wear preopera- tively so that they may practice diaphragmatic breathing.

Smoking compromises the circulation of the raised abdominal wall flap and contributes to the develop- ment of skin necrosis. Everyone who has recently smoked including those who have already stopped is prescribed pentoxifylline 400 mg t.i.d. for 6 weeks before surgery. This increases the flexibility of the red blood cell membrane. They are also given bupropion to help them to stop smoking.

10.4

Operative Technique (Fig. 10.1)

Saline with adrenaline (1 : 1,000,000) is infiltrated at the fat/fascia level. The waistline and iliac areas are treated with standard liposuction techniques using cannulas between 3.7 and 6 mm in diameter. The flaps to be advanced inferiorly are suctioned at the intermediate level of the subcutaneous layer in order to protect the vas- cularity. Suctioning is performed following the orienta- tion of the segmental intercostal blood supply. The new midline above the new umbilicus is the only area that is suctioned more aggressively. This produces the illusion

of a more sculpted abdomen. The flap is not suctioned below the level of the new navel since this may damage the blood supply [5, 8]. The lower incision is performed first. The large vessels are suture-ligated and the rest of the dissection is performed with cautery. The flap is raised leaving the fine areolar tissue and their lymphat- ics over the fascia. This may diminish the rate of seroma formation. Large perforators are suture ligated and di- vided before they retract into the muscle or the subcutaneous tissue. These large vessels might tend to bleed postoperatively, particularly with coughing or other Valsalva maneuvers. The ensuing hematoma can lead to postoperative pain or seroma. The navel is excised from the surrounding skin and fat. If there is a large amount of extra skin and fat, especially in the supraum- bilical portion, the flap is dissected over the costal margins and the xyphoid cartilage. This allows better red- raping of the upper abdominal tissues and minimizes folds and skin creases. There are no important perforators in the upper central abdomen, so it is unlikely that dissection and mobilization in this area leads to tissue necrosis.

The upper incision is made after a trial of advance- ment of the upper flap. Adjustments are made at this point as needed to prevent excessive tension or redundancy. The incision through the cutis is made at right angles to the surface. Then, the blade bevels to lie at 45°

to the surface of the flap so the Scarpa’s fascia portion of the flap is about 1.5 cm shorter than the skin portion.

However, the deeper part tends to retract. Repair of the diastasis is performed by splitting the rectus fascia.

The diastasis is noted and an ellipse is marked on the anterior rectus sheath from xyphoid to pubis with the widest portion of the ellipse located 3 cm above the navel. This will ensure that the upper abdomen is tighter and flatter than the lower abdomen. A slight convexity below the umbilicus is a normal feature of the young fe- male abdomen. Overzealous liposuction or too tight a fascial closure also flattens the lower abdomen; the result is a masculine appearance. The anterior rectus fascia is incised along the markings of the ellipse by plac- ing a hemostat deep to the fascia and cutting the fascia over it. All musculocutaneous perforators are suture ligated. The inner margins of the fascial split can be sutured to each other to increase the imbrication and to deepen the naval. The external margins of the split fascia are sutured in the midline with inverted horizontal figure of eight mattress sutures using non-absorbable material, usually 0 to #2 Tevdek (Deknatel DSP, Full River, MA).

To further define the waistline, the external oblique fascia and muscles may be advanced towards the midline. This may be done with the rectus fascia attached also. About 100 cc of 0.25 % bupivacaine with 1 : 100,000 epinephrine is injected just beneath the external fascia of the rectus and the external oblique muscles with 116 10 Abdominoplasty Technique: A Personal Approach

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a b

blunt needles or thin cannulas to anesthetize the re- gional nerves to the abdominal muscles. The trajectory of the needle or the cannula should be visualized by translucency through the fascia to avoid inadvertent in- jection into the peritoneum. This local anesthetic injec- tion greatly decreases the patient’s need for narcotics for the first postoperative day.

The umbilicus is removed from the abdominal skin with a heart-shaped incision around the navel. Using two permanent sutures, the long umbilical stalk is tele- scoped from the dermis to the rectus fascia. The new position of the navel on the abdominal skin flap may be located with an umbilical demarcator. A triangular incision is made on the abdominal skin at this point. The incision becomes a heart shape when the skin of the abdominal flap is pulled. A small amount of defatting is performed so the new periumbilical skin will sit more flush with the naval. The navel is inset in two layers us-

Fig. 10.1 d The umbilical stalk is sutured to the fascia and a V cut from the inferior aspect of the umbilicus

Fig. 10.1. a UM incision is marked. The approx- imation of the lateral humps relieves the ten- sion from the midline closure. b Closure slims the waist. c The rectus fascia is sutured to close the diastasis

c

d

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ing 3 – 0 Nylon. The abdominal flap is closed in three layers: Scarpa’s fascia with 2 – 0, 3 – 0 Tevdek, deep sub- dermis layer with 4 – 0 Prolene and 4 – 0 subcuticular pull out skin sutures. First, three aligning sutures are applied. The first is applied to the Scarpa’s fascia in the midline to centralize the flap. The paramedian sutures are applied while the upper flap is pushed medially. The upper flap has a tendency to drift laterally. They are placed midway between the midline and the end of the incision. The incision is closed starting with the cor- ners. Any redundancy is compensated toward the midline. Thus, there is minimal tension during wound closure at the midline. Two closed system suction drains are left under the flaps with the ends towards the flanks in a criss-cross fashion to avoid kinking of the drains.

Topifoam (Lysonic, Inc., Carpenteria, CA) and a tight- fitting abdominal binder are applied.

10.5

Postoperative Management

The patients are given intravenous fluids and antibiotics for the first postoperative day. A clear liquid diet is started the next day and the diet is advanced gradually as tolerated. Supportive stockings and pneumatic boots are used until the patient is walking. A walking frame is used to help mobilize the patient early. Every- one receives chlorpropamide 10 mg q.6 h. orally and a stool softener until regular bowel movements start. The drains are advanced on the fourth postoperative day and removed when the drains are less than 20 cc per drain in 24 h. Oral antibiotics are continued until the drains are removed. A binder is worn for the first 8 weeks. Patients may drive after 4 weeks and perform light exercise at 8 weeks. All restrictions are lifted at 14 weeks.

10.6 Results

Since 1986, over 150 people have had an abdominoplasty performed by the senior author. Over 80 % had concurrent muscle repair. No patients in this series were repaired with alloplastic materials. The most common significant complication has been that of infraumbilical skin slough (2.7 %). The largest area seen was 10 × 7 cm. This was in a patient who continued smoking in the perioperative period. This patient was lost to follow-up. Two other patients with smaller areas of necrosis (5 × 4 cm and 4 × 3 cm) have had revisions performed.

Less than 7 % of patients had seromas requiring re- peated aspiration. One patient needed re-excision of a pseudobursa. She also underwent further tightening of

the musculature of her lower abdomen. One patient had a drain tract infection treated with drainage and antibiotics. One patient developed an abdominal wall abscess just inferior to her xyphosternum. We believe this was introduced with a liposuction cannula. She was treated with open drainage, antibiotics and dressing changes. Her abdominal flap was readvanced 4 months later with an excellent cosmetic result. One patient developed a deep venous thrombosis in her calf.

No secondary hernias have been seen. Back pain and posture were significantly improved. We have mea- sured the decrease in waist circumference to be from 6 – 20 cm with an average of 10.5 cm.

10.7 Discussion

Those with small infraumbilical pouches will benefit from liposuction alone or from a mini-abdominoplasty. Those with a pannus, severe muscle laxity or a diastasis have a more severe deformity that requires a more extensive approach. The UM abdominoplasty ad- dresses ptosis of the mons pubis, ptosis of the anterolateral thigh skin, excess abdominal skin, poor abdominal muscle tone and the ill-defined waistline.

The scars are placed so that they do not violate aesthetic units. They are not visible when wearing high cut bathing suits.

The umbilicoplasty method avoids a circular scar that may produce constriction. It anchors the superior part of the flap, decreases the dead space and takes tension off the inferior part of the flap.

Liposuction of the upper midline produces a xypho- umbilical groove. This simulates the groove seen between the bellies of the rectus muscles in athletic indi- viduals.

The shape of the incision facilitates removal of skin and fat around the waist. This is frequently combined with circumferential liposuction to further define the waistline. Suction also helps eliminate “dog-ears” at the lateral ends of the incisions. The optimal location of the final suture line is medial and superior to the anterior superior iliac spine. Incisions that lie lower often produce a “tenting pole” effect on the flap so that it does not lie directly on the abdominal wall. This potential space can give rise to a seroma.

Although this incision creates a flap with a high length to width ratio and diminution of blood supply to the tip of the flap, we have had few cases of skin necrosis. We feel that this is because the maximum tension is at the lateral ends of the flap.

The myofascial release directs the pull of the external and internal oblique muscles towards the midline.

The myofascial repair decreases the abdominal circumference, permitting the removal of more fat and skin.

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Because the rectus muscles are relocated in the midline, they will flex the trunk more efficiently and act as an anterior pillar of support for the torso. All of our patients with preoperative symptoms of back pain noted an improvement after their abdominoplasty. Graco- vetsky [10] postulated that the internal oblique and transversalis muscles pull the lumbodorsal fascia and decrease stress on the intervertebral joints.

a1 a2

b1 b2

Fig. 10.2. a Preoperative showing poor abdominal tone, large amounts of iliac fat, and a ptotic pubis. Ob- serve the position of the cholecystectomy scar. b Post- operatively showing a slim- mer waistline, a raised pubis, and a more pleasing contour, especially around the iliac region. Observe the new location of the cholecystectomy scar. She also underwent a reduction mammoplasty

10.8 Conclusions

The four components of the UM abdominoplasty pro- vide a comprehensive treatment of the abdomen, even in the most severe cases. The patients get both func- tioning and cosmetic improvement (Figs. 10.1 – 10.3).

The endoscopic abdominoplasty and the mini-abdominoplasty with a floating navel are used only for minor defects.

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a1 a2

b1 b2

Fig. 10.3. a Preoperative pa- tient with a protuberant abdomen after a twin pregnan- cy. She complained of dis- abling back pain. b Postoper- atively showing the patient with improved posture and a flat abdomen

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