Abdominoplasty in perspective
Fabio Nahas MD PhD*
* Associate Professor of the Plastic Surgery Division, Federal
University of São Paulo
National Secretary of the International Society of Aesthetic Plastic
Surgery - Brazil
Aspects of the diagnosis and treatment of the abdominal wall
deformities and the prevention of the complications of abdominoplasty are the
main points to be addressed in this summary.
The diagnosis will depend on the excess skin, fat and
musculoaponeurotic deformities. An objective classification for abdominoplasty
based on subcutaneous and skin deformities is described1. Type 0 patients are
those who present excess fat with very little excess skin or without surplus skin,
on which liposuction is indicated. Types I, II, III are patients that demonstrate
various degrees of excess skin and three basic patterns of skin resection are
described. Type I patients present mild excess skin with a high positioned
umbilicus. Type II patients are those with mild excess skin and a well positioned
umbilicus as well as patients with moderate excess skin. Type III patients present
severe excessive skin. A specific skin removal is indicated for each group.
Another classification based on musculo-aponeurotic deformities is described2.
Type A display rectus diastasis secondary to pregnancy and plication of the
anterior rectus sheath is indicated. Type B patients present laxity of the lateral
and inferior areas of the abdominal wall after approximation of the anterior recti
sheaths. An “L” shaped plication of the external oblique aponeurosis is
performed in addition to the correction of rectus diastasis. Type C patients are
those whose recti muscles are laterally inserted on the costal margins. Release
and undermining of the recti muscles from their posterior sheath and
advancement of these muscles, attached to the anterior sheath, is the procedure of
choice in these cases. Type D patients display a poor waistline definition;
external oblique muscle rotation associated with plication of the anterior rectus
sheath is the procedure used to correct this deformity. Each one of these
techniques is supported by previous researches of the author3,4,5.
Prevention of complications such as recurrence of rectus diastasis,
seroma and loss of skin sensibility can be achieved using specific surgical
techniques. The advancement of the recti muscles as opposed to the simple
plication of the anterior rectus sheath may be indicated in patients that present a
lateral congenital insertion of the recti muscles in the costal grid. This deformity
is usually diagnosed in the intraoperative and prevents recurrence of the diastasis
as show in our previous study6. The use of quilting sutures prevents seroma
formation, as demonstrated in our study of 23 patients with high risk to develop
this complication7. This technique also distributes evenly the tension on the skin
edges. These sutures decrease dead space and avoid the shearing forces caused
by the natural movement between the abdominal flap and the musculoaponeurotic layer. Skin sensibility after abdominoplasty was also measured when
two different techniques of correction of abdominal deformities were employed:
abdominoplasty and lipoabdominoplasty8. It was found that the abdominal skin
presented more sensibility in patients who were undergone lipoabdominoplasty.
In cases of associated incisional hernias, the “components
separation” technique can be considered for abdominal wall reconstruction9. Two
other alternative techniques of dissection of musculo-aponeurotic components for
the correction of specific defects were also described by our group10,11.
The quality of life, self-esteem and self-image showed the benefits
achieved by the abdominoplasty after a 6-month follow-up study12.
Also, the risk of medical litigation after abdominoplasty was
demonstrated by our group when the cases of the Brazilian state of Rio Grande
do Sul were analyzed13.
Correction of abdominal deformities can be considered not a single
operation, but a group of techniques which experienced an important
development along the last few years. Most importantly, this technical progress
allowed applying a specific technique for the individual deformity.
References
1. Nahas FX. A pragmatic way to treat abdominal deformities
based on skin and subcutaneous excess. Aesth Plast Surg. 2001;
125(5):365-71.
2. Nahas FX. An aesthetic classification of the abdomen based on
the
myoaponeurotic
layer.
Plast
Reconstr
Surg.
2001;
108(6):1787-95.
3. Nahas FX, Augusto SM, Ghelfond C. - Should Diastasis Recti
Be Corrected? Aesth Plast Surg. 1997; 21:285-9.
4. Nahas FX. Advancement of the External Oblique Muscle Flap to
Improve Waistline: A Study in Cadavers. Plast Reconstr Surg.
2001; 108(2):550-5.
5. Nahas FX, Augusto SM, Ghelfond C. Nylon versus PDS
(polydioxanone) in the correction of rectus diastasis*. Plast
Reconstr Surg. 2001; 107:700-6.
6. Nahas FX, Ferreira LM, Mendes JA. An efficient way to correct
recurrent rectus diastasis. Aesth Plast Surg. 2004; 28(4):189-96.
7. Nahas FX, Ferreira, LM, Ghelfond C. The use of quilting suture
to avoid seroma. Plast Reconstr Surg. Plast Reconstr Surg.
2007;119(3):1060-4.
8. Farah AB, Nahas FX, Ferreira LM, Mendes JA, Juliano Y. Skin
sensibility of the abdomen after abdominoplasty. Plast Reconstr
Surg. 2004; 114(2):577-82.
9. Nahas FX, Ishida J, Gemperli R, Ferreira MC. Abdominal Wall
Closure After Selective Aponeurotic Incision and Undermining.
Ann Plast Surg. 1998; 41(6):606-17.
10. Barbosa MV, Nahas FX, Garcia EB, Ayaviri NA, Juliano Y,
Ferreira LM. Use of the anterior rectus sheath for abdominal
wall reconstruction: a study in cadavers. Scand J Plast Reconstr
Surg Hand Surg. 2007;41(6):273-7.
11. Jardini Barbosa MV, Nahas FX, Santos de Oliveira Filho R,
Montecinos Ayaviri NA, Novo NF, Ferreira LM. A variation in
the component separation technique that preserves linea
semilunaris: a study in cadavers and a clinical case. J Plast
Reconstr Aesthet Surg. 2009; Feb 12. [Epub ahead of print]
12. Rocha MJA, Nahas FX, Kimura A, Barbosa MVJ, Ferreira LM.
Quality of life, Self-esteem, Self-Image after abdominoplasty.
Ann Plast Surg. Accepted for publication.
13. Batista D, Nahas FX, Barbosa MVJ, Ferreira LM. Lawsuits
against Plastic-Surgery: social costs and doctors-patients
relations. Aesth Plast Surg. Accept for publication.