Fleur-de-lis abdominoplasty including mons contouring

Chapter 26 Fleur-de-lis abdominoplasty including mons contouring

Preoperative Preparation

For all excisional body contouring procedures, we check a preoperative coagulation profile, complete blood count, comprehensive metabolic profile and Factor V Leiden. Risk factors for thromboembolism are ascertained, including hormone or birth control use, which we ask to be discontinued for at least two weeks preoperatively. We also discontinue aspirin and herbal medications. We ask our patients to wear a tight abdominal binder day and night for two weeks preoperatively to simulate the myofascial plication. This theoretically allows the body to adapt to the higher intra-abdominal pressure so the effect on venous return and ventilation is minimized. Lastly, we recommend a liquid diet for two days preoperatively to help reduce intra-luminal volume.

Patient Evaluation

Patients with complaints of abdominal tissue excess are evaluated for skin quality, stretch marks, subcutaneous adiposity, intertrigo, lymphedema and hanging skin. A careful evaluation of the entire abdomen, flanks, back and buttocks is carried out, noting previous surgical scars. Bimanual palpation is used to gauge redundant tissues and demonstrate to patients the degree of transverse skin tightening possible with the vertical resection (Fig. 26.1). Care is taken to diagnose hernias, particularly in patients with a history of open bariatric procedures. Repairing these hernias at the same time as body contouring is discussed with the patient, as well as the possibility of needing mesh (Fig. 26.2).

Using physical exam findings and patient wishes, a surgical plan is formulated. Patients found to have an excess of abdominal tissue in the vertical and transverse dimensions are offered a fleur-de-lis abdominoplasty. Often there is associated ptosis of the flanks and buttocks, and the patient may be best served with a circumferential body lift and fleur-de-lis abdominoplasty. Any regions of excess adiposity can be addressed with concurrent liposuction. All three procedures can be performed safely during one anesthetic.

The mons should be evaluated independently. Excess skin, adiposity and ptosis frequently remain after massive weight loss. If the patient perceives the region as unacceptably full, treatment options include liposuction and direct skin excision. Ptosis is corrected as part of the abdominoplasty closure and will be addressed later in the chapter.

Preoperative photographs are taken in five standard views for the fleur-de-lis abdominoplasty, with an additional three views for a circumferential procedure.

Preoperative Markings

The patient is asked to strongly lift their abdominal skin while in a standing position (Fig. 26.3). The low transverse marking is made at the level of the pubic symphisis, which ends up removing one third of the hair-bearing mons. This mons reduction coupled with the lift achieved during closure is typically the extent of mons contouring required. The low transverse incision is extended bilaterally to the level of the anterior superior iliac crest. The incision is measured to make sure each side is of equal length. If a body lift is planned, the markings are continued circumferentially.

The superior portion of the abdominoplasty incision is usually judged to be just above the umbilicus. The excess tissue in the transverse dimension is then marked using strong bimanual palpation (Fig. 26.1A). The planned vertical resection is elliptical, tapered at the xyphoid process superiorly and near the planned horizontal incision inferiorly (Fig. 26.1B). All markings should be double-checked intraoperatively prior to incision. Adjunctive liposuction marks are made along with existing scars and hernias. Midline scars are simply incorporated into the planned resection, but off-centered ones such as open cholecystectomy scars may require modification of the vertical resection to incorporate the previous surgical scar and bring the final planned closure off midline (Fig. 26.9).

Surgical Technique

Dilute lidocaine and adrenaline is used to infiltrate the proposed incision lines. When liposuction is anticipated, tumescent is infiltrated liberally throughout. Liposuction of the mons and abdomen is done prior to excisional contouring in the majority of patients in our current practice. If a circumferential procedure is planned, the prone portion is performed first.

After any planned liposuction, the lower incision is made into but not through the dermis. Electrocautery is used to deepen the incision through the dermis, sealing the subdermal plexus to minimize bleeding. The superficial inferior epigastric and circumflex vessels are identified, controlled and divided. Dissection is carried straight down to the abdominal wall without beveling and then proceeds superiorly. Perforating vessels, especially in the periumbilical region, are identified and secured prior to division. Dissection proceeds to the umbilical stalk, at which point an incision is made around the umbilicus in a fusiform fashion. The stalk is sharply freed from surrounding subcutaneous tissue, and superior dissection can then proceed uninterrupted to the costal margins laterally and to the xiphoid centrally.

If there is any doubt about needing the vertical component to achieve an aesthetic closure, the abdominal flap can be left intact until after rectus plication. If the decision has been made preoperatively to have a vertical scar, it is simpler to make the entire midline incision from xiphoid through the abdominal flap at this time (Fig. 26.4).

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Jul 23, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Fleur-de-lis abdominoplasty including mons contouring

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