Chapter 21 Classic abdominoplasty with adhesion tension sutures

Introduction

The history of abdominoplasty starts at the end of the 19th century. Since then new approaches have been introduced continuously by various authors. Its history was published by Hakme,¹ Baroudi,² and Sinder³ in Brazil, and also by other plastic surgeons. This chapter will focus on our experience of five decades in the transverse pubic type of incision. For historical purposes, Monard⁴ in 1930 was the first to do this type of surgery with umbilicus transposition. Liposuction was used by Illouz⁵ in abdominoplasty. Pitanguy⁶ and Bozola⁷ published their classifications involving both male and female patients. These academic classifications orient the surgeons to select their technique according to the type of esthetic deformity and functional problems. Two patients were selected to illustrate the proposed technique, with different degrees of subcutaneous volume, flaccid skin, and recti diastases. In general the results are different, even performing the same procedures, based on the aspects of the trunk shape, skin quality, the patient’s age, and whether or not liposuction was performed at the same surgical stage, and also by the surgeon’s qualifications. We did not include morbidly obese or post-bariatric patients, but just those with an unesthetic abdominal shape.

Surgical Technique

We prefer general endotracheal anesthesia. The abdominal skin markings are always done after the surgical prep. When liposuction is to be used, the patient is marked in the standing position.

Three main situations occur in this type of abdominoplasty as described by Baroudi and Ferreira.⁸

1. The umbilical hole at the skin abdominal flap crosses the transverse pubic incision.

The skin demarcations are shown in Figure 21.1A–D. The surgery starts after previous skin infiltration with saline solution and epinephrine 1: 400 000 in all the demarcated areas. The skin is incised at the pubic level and the incision is extended towards the iliac spines, in general from 35 to 45 cm in length, deep to the superficial fascia level. The skin is undermined at the deep fascia plane up to the umbilical stalk, which is dissected from the skin flap. The dissection concludes near the xiphoid. Above the umbilicus, the dissection narrows to the lateral limits aside the recti muscles in order not to decrease the blood supply to the flap (Fig. 21.2A, B).

Fig. 21.1 Schematic aspects of the pubic low transversal incision.

(A) The resection involves an elliptical transverse skin shape from the hypogastrium. The demarcation starts with a vertical median (x-x′) xiphopubic line, followed by two transverse lines placed at the level of the pubis above 7 cm from the vulvar commissure and (B) at the umbilicus upper limit. At the crossing line A and the xiphopubic, points (1) and (2) are placed bilaterally at an equal distance, measuring 10 to 14 cm according to the pubis volume. From points (1) and (2) two lazy curved lines reach the anterior superior iliac spine bilaterally. This is compared to a bicycle-handlebar shape. The points (1) and (2) are placed at the line (B) bilaterally, receiving the numbers (5) and (6) and from each one two small parallel and perpendicular lines are delineated. Finally, from the umbilicus upper limit two convex lines are placed, also bilaterally directed to the iliac spine. These two lines cross the two vertical lines from points (5) and (6) at the points (3) and (4). It is important that 1–3–5 = 2–4–6, to obtain an equal amount of skin excess resection and a symmetric suture line. The photo (B) shows the patient’s anterior abdominal wall after the skin demarcations, similar to the schematic drawing, where (R) and (U) represent skin resection and undermining respectively. (C) Close-up of the skin demarcations. Routinely provisional stitches are placed at points 1, 2, 5, and 6 to avoid loss of the demarcations during the surgery. (D) The distance from the vulvar commissure and the transversal pubic demarcation goes from 6 to 7 cm. The small dark arc demarcation is selectively resected at the end of the surgery to reduce the distance vulva to pubis when it is over 8 cm in length.

Fig. 21.2 (A) No more extended skin flap undermining, but (B) limited to avoid unnecessary dead space.

The recti fascia plication is performed in two levels. From the xiphoid to the pubis with isolated nonabsorbable 2-0 stitches with the knot faced downward. Next, a second running suture is applied, also from the xiphoid area to the pubis with a 2-0 nonabsorbable suture. This suture is interrupted 3 cm above the umbilical pedicle and starts again 3 cm below it. Never cross over the umbilical stalk, in order to avoid possible contamination of the nonabsorbable suture (Fig. 21.3A–D).

Fig. 21.3 (A, B) Schematic aspects of the recti fascia plication with isolated nonabsorbable 2-0 stitches from the xiphoid down to the pubis. The 1 cm umbilicus skin island dermis is sutured to the fascia (C, D). A 2-0 second running suture line from the xiphoid to the pubis. The suture stops 3 cm above the umbilicus and starts 3 cm below it to avoid eventual contamination though the umbilicus suture line. The umbilicus is positioned inside the white square line.

The patient is then positioned with the trunk and the inferior limbs slightly elevated (each at 20°). The undermined skin flap is then stretched caudally; the umbilical hole always surpasses the pubic transverse incision and the excesses are resected. Routinely, several bilateral tunnels are made with scissors along the undermined skin flap limits to release its adhesion and augment its slide caudally, to preserve the flap blood supply (Fig. 21.4). The skin flap is then divided longitudinally in two equal halves and a provisional stitch anchors the flap to the median portion of the pubis. Each skin part is divided again and another two provisional stitches fix the flap to the points (1) and (2) on Fig. 21.4. Finally, all the skin excesses are resected. The provisional stitches are removed and the skin flap elevated with a skin retractor. The adhesion suture (quilting stitch) is applied with absorbable 3-0 stitches in lines and columns from the xiphoid down to the pubis. The distance between them should not be over 4 cm and the amount of stitches should number 40 to 45. From the xiphoid to the umbilical line the skin flap is always stretched slightly after each stitch line is applied.