The aesthetic correction of abdominal deformities. Ideas and Innovations

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1 Ideas and Innovations Long-Term Ultrasonographic Evaluation of Midline Aponeurotic Plication during Abdominoplasty Eduardo José Passamai de Castro Henrique N. Radwanski, M.D. Ivo Pitanguy, M.D., Ph.D. Fábio Nahas, M.D., Ph.D. Vitória, Espirito Santo, Brazil Background: The purpose of this study was to evaluate the efficiency of the plication of the anterior rectus sheath during abdominoplasty and the anatomical characteristics of patients with recurrence. Methods: Thirty-eight patients were selected. Patients had undergone abdominoplasty between 1 and 5 years previously. Patients were divided into two groups: group A, 18 patients who had undergone surgery 5 years previously; and group B, 20 patients who had undergone surgery 1 year before. All patients were submitted to a complete physical examination by the plastic surgeon to evaluate the abdominal wall. In addition, an ultrasound examination was performed by the same radiologist in all patients to evaluate rectus diastasis recurrence at two levels: in the supraumbilical region and in the infraumbilical region. The insertion of the recti muscles in the costal margin was also assessed. Groups were compared using Fisher s exact test and the t test. Groups were similar regarding age, body mass index, number of smokers, physical activity, and number of pregnancies. Results: There was no recurrence of diastasis in any cases of the group with a follow-up of more than 5 years, whereas in the 1-year follow-up group there were two cases of recurrence of the diastasis. Only one of the patients who had recurrence of rectus diastasis had a clinical complaint. Conclusions: Recurrence of rectus diastasis is not directly related to the length of the follow-up. It may occur within the first year after abdominoplasty. Recurrence of diastasis diagnosed by ultrasound is not related to a clinical complaint. (Plast. Reconstr. Surg. 132: 333, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. The aesthetic correction of abdominal deformities is one of the most commonly performed procedures in plastic surgery in the United States and in Brazil. 1 Correction of the musculoaponeurotic laxity of the abdomen may vary according to the type of deformity presented by the patient. The most frequently performed procedure during abdominoplasty is the correction of rectus diastasis by the plication of the anterior rectus sheath. 2 As opposed to some authors 3 5 who perform the anterior rectus sheath plication using a two-layer suture, in the present study, the plication was performed in a single layer according to Pitanguy s technique, 6 8 which has proven to be From Hospital Dr. Dorio Silva/Cooperativa de Cirurgia Plastica do Espirito Santo. Received for publication June 22, 2012; accepted December 19, Copyright 2013 by the American Society of Plastic Surgeons DOI: /PRS.0b013e ad2 stable in most cases. However, there are opposing forces acting against the plication of the anterior rectus sheath, such as the pressure exerted by the abdominal organs; scar retraction; tissue elasticity; and the physiologic increase of the intraabdominal pressure caused by physical activities, coughing, and obesity. These forces may contribute to recurrence of the diastasis on both short- and long-term follow-up. As hernias may recur years after correction, 2 it is important to evaluate a longterm follow-up of these patients. 9,10 Another important issue is the type of rectus diastasis that the patient presents. Some patients present a congenital lateral insertion of the recti muscles at the costal margins. In these cases, the Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article

2 Plastic and Reconstructive Surgery August 2013 repeated contraction of the recti muscles may lead to recurrence of diastasis in the superior abdomen. This has been described elsewhere. 4 Therefore the purpose of this study was to evaluate the short- and long-term recurrence of rectus diastasis and verify the preoperative position of the insertion of the recti muscles. PATIENTS AND METHODS All of the patients in this study operated on from January to March of 2004 and within the same date period in 2008 were contacted, resulting in a total of 87 patients, and these patients were all women. A total of 43 responded to the call, of whom 38 met the eligibility criteria. A staff of five different surgeons at the Pitanguy Institute operated on these patients, all of them using the same technique as described by Pitanguy. When comparing responders to nonresponders, no significant differences regarding age, body mass index, number of smokers, physical activity, or number of pregnancies were found. The 38 patients were divided into two groups: group A, those who had been operated on 5 years (from January to March of 2004) previously (n = 18); and group B, those who had been operated on 1 year previously (from January to March of 2008) (n = 20). Five years is considered a long-term followup because, if recurrence should occur, it would be noticed; whereas 1-year follow-up will reveal what occurs during the short term. Only patients who cooperated fully in completing the questionnaire and consented to undergo ultrasonographic examination were included in this study. All patients were submitted to ultrasonographic evaluation of the abdominal wall preoperatively, according to an established protocol. Patients were weighed and their body mass index was calculated at the moment of the preoperative and postoperative evaluations. Physical examination included a general observation to note the aspect of the operated abdomen. Palpation of the abdominal wall was performed with the patient standing up and in the prone position, with tensing of the musculature (i.e., Valsalva maneuver). The finding of hernias and/or diastasis was noted in the files. Only two measurements were performed in each patient: one between the umbilicus and the xiphoid (representing the diastasis at the upper abdomen) and another between the umbilicus and the pubis (representing the lower abdomen). The measurements were then passed on to the radiologist for reference during the examination. All ultrasound examinations were performed by the same investigator, following the same protocol used at the preoperative evaluation, to decrease observational errors. Surgical Technique All patients that were included in the study were submitted to the same procedure. Only relevant aspects of the Pitanguy standard abdominoplasty are mentioned here. Once the undermining has been completed, the medial edges of the rectus abdominis are delineated with methylene blue, from the xiphoid to the pubis. Strong hooks are used to bring the aponeurosis toward the midline, checking for excessive tension on the abdominal wall. Suturing is then performed with 2-0 nylon in an inverted-x fashion, to bury the knot deeply. 11,12 Ultrasonographic Evaluation Preoperative and postoperative ultrasound in all patients was performed at the Radiological Department of the Santa Casa General Hospital, with the same protocol and equipment: Ultrasonics, EX model, with a multifrequency linear probe at 10 to 13 MHz (Ultrasonics; Canada). A gel medium was used as an interface. The patient was examined in the prone position, with a relaxed abdominal musculature. The ultrasonographic examination began by scanning the midline from the xiphoid down to the pubis, evaluating diastasis and the presence of hernias. Then, the probe scanned the suprapubic region transversally. Next, measurements were taken between each border of the rectus abdominis at two points: halfway between the pubis and the umbilicus and halfway between the umbilicus and the xiphoid. The investigators established that points 1 and 2 represent the medial border of the rectus abdominis, and ultrasonographic examinations were considered satisfactory if measurements 1 and 2 were equal to 0 (i.e., there was no appreciable distance between the two medial borders of the rectus abdominis from the xiphoid down to the pubis). 13 The ultrasonographic examination was finalized with image reconstruction using the PANO resource, which allows for a panoramic view with a linear scan, as shown in Figure 1. This enhances the visualization of the abdominal wall musculature and the elements that concerned this study, such as diastasis and hernias. In Figure 1, the rectus abdominis muscles can be seen along the vertical axis of the abdominal wall from the xiphoid down to the pubis. The dark image between the upper and lower abdomen is the umbilical region. 334

3 Volume 132, Number 2 Evaluation of Aponeurotic Plication Fig. 1. Reconstruction of the abdominal wall using the PANO protocol. Statistical Analysis The F test was used to compare the variance between both groups. The t test was used to compare the average age between groups. The program used was BioStat (AnalystSoft, Inc., Alexandria, Va.) 14 and Windows Excel (Microsoft Corp., Redmond, Wash.). The Sturges test was used to evaluate the characteristics of the groups. The Z test was used to evaluate the efficacy of plication. The Shapiro test was used to evaluate the distribution of diastasis measurements. The statistical tests were performed at the significance level of RESULTS Results are listed in Table 1. Patients in group A were compared with those from group B regarding age, body mass index, number of smokers, physical activity, and number of pregnancies using the t test, the F test, and the Sturges test. The Sturges test was used for comparisons regarding class variance, the t test was used for Table 1. Comparison between Groups Regarding Age, Body Mass Index, Number of Smokers, Physical Activity, and Number of Pregnancies Characteristics Group A (%) Group B (%) Age, yr* Average Range BMI at time of surgery Average Range No. of smokers 4 (22.22) 3 (15) No. of patients with regular physical activity 10 (56) 11 (55) No. of previous pregnancies 18 (100) 19 (95) BMI, body mass index. *p = (t test). comparisons regarding age variance, and values of p 0.05 were considered statistically significant. In group A, body mass index ranged from to kg/m 2 at the time of postoperative ultrasonography (average, kg/m 2 ). In this group, four patients had lost weight and 14 patients had gained weight after surgery. In group B, these numbers varied from to kg/m 2 (average, kg/m 2 ), with two patients showing no weight variation, six patients having lost weight, and 12 patients having gained weight. Evolution of body mass index from 2004 to 2008 is shown in Figure 2. Five small hernias were found intraoperatively and were promptly corrected: one patient from group A (6 percent) and four patients from group B (20 percent). The greatest prevalence was that of umbilical hernia, followed by mixed hernia (epigastric plus umbilical) and then epigastric, and all cases were without use of surgical repair with Marlex screens (Cirurgica Brasil, São Paolo, Brazil). These hernias had not been detected by the preoperative ultrasonographic evaluation. Surgical correction of these hernias was performed by the simple approximation of the aponeurotic edges. The seroma rate in this group of patients was similar to that found in the literature, 2 and none of these complications presented recurrence of diastasis. As regards complications, only one patient in group A had a significant hematoma within the first 24-hour postoperative period, requiring a surgical revision. Two other patients from group B presented with serosanguineous collection, which was treated with serial aspirations. No other complications were noted. Clinical examination revealed a slight diastasis of the upper abdomen in one patient from group B. All other patients denied any complaints of pain or discomfort along the midline while performing exercises, suggesting that there was only a single case of clinical recurrence of muscle diastasis. In group A, all measurements of the distance between the aponeurotic edges were equal to 0 after surgery. Two patients in group B (1 year postoperatively) presented recurrence of the diastasis, in which an increase in the distance between the aponeurotic edges in the upper abdomen was noted. This distance was cm on one patient and 1.3 cm on the other patient. In both of them, diastasis recurred in the vicinity of the xiphoid. It was also noted with the ultrasonographic examination that there was a lateral insertion of the recti muscles on the costal margins. In these patients, there was a minimal bulging along the midline. However, these two patients presented no clinical complaint regarding this finding. 335

4 Plastic and Reconstructive Surgery August 2013 Fig. 2. Evolution of body mass index (BMI) from 2004 to As shown in Figure 3, there is no recurrence of rectus diastasis in this patient. Note that the recti muscles are close together in the midline 5 years after the application of the anterior rectus sheath. In Figure 4, the ultrasonographic examination reveals a distance of 0.86 cm between the aponeurotic edges in one of the two patients in group B that presented recurrence of diastasis. DISCUSSION Correction of the separation of the recti muscles has been performed since the 1960s. 6 9,15 17 Plication of the anterior rectus sheath to correct rectus diastasis is the most frequently performed procedure in this layer. As the distention of the musculoaponeurotic layer is a common event after pregnancy, most of the patients studied were women who had already had at least one pregnancy. Both groups were composed of typical patients that search for this type of operation. The average age was 42 years and the average body mass index was approximately 24 kg/m 2 in group A and 25 kg/m 2 in group B. These two groups are therefore typical of patients that present for consultation seeking correction of abdominal deformities. Groups were also similar regarding age, body mass index, number of smokers, physical activity, and number of pregnancies. The highest body mass index of the patients in this study was kg/m 2 in 2004 and kg/m 2 Fig. 3. No recurrence of rectus diastasis. Fig. 4. Detailed view showing no recurrence of rectus diastasis. 336

5 Volume 132, Number 2 Evaluation of Aponeurotic Plication in Although there were no influence of body mass index in patients who had recurrence of diastasis, a high intraabdominal pressure caused by intraabdominal fat in obese patients can be a risk factor for recurrence of this complication. Ultrasound is a good instrument with which to evaluate rectus diastasis. 18 Specific types of correction of the musculoaponeurotic layer have been described, depending on the deformity presented by the patient. 2 Previous studies have shown that correction of rectus diastasis is effective when the plication of the anterior rectus sheath is performed using either nonabsorbable 3,4 or absorbable sutures. 5 Also, long-term follow-up (up to 82 months, on average) has shown that this type of plication is effective. 19,20 This correction is so effective that, even after a pregnancy, diastasis does not recur. 21 Although there are a large number of studies supporting the efficacy of this technique, this point of view is not unanimous. Van Uchelen et al. have shown a 40 percent recurrence rate in their patients with a mean follow-up of 64 months. 22,23 The main criticism of this study is that most of the patients had undergone wide rectus plication (i.e., in these patients, plication was performed laterally to the medial edge of the recti muscles). Therefore, more tension was applied to the suture at the aponeurotic edges, which may lead to dehiscence of the aponeurotic edges. This study has shown that two patients in the short-term follow-up group (1 year postoperatively) presented recurrence of diastasis, whereas none of the patients in the long-term group (5 years postoperatively) presented this complication. Therefore, it seems that recurrence of rectus diastasis is not related to the length of follow-up. Some hypotheses should be considered to explain the recurrence of rectus diastasis in these patients. The increase of intraabdominal pressure is one possible cause. It can also be related to the alteration of the amount of collagen in the muscle that occurs with age. 13 The other possibility is an uncommon anatomical variation of the recti muscles. In some patients, these muscles present a lateral insertion at the costal margins. This anatomical condition has been described by Nahas et al., 24 who classified these patients as having a type C musculoaponeurotic deformity. The repositioning of the recti muscle by the advancement of the recti sheaths should be performed in these cases, as opposed to the classical plication of the anterior sheath. The rationale for the efficacy of this technique is that the repeated contractions of the laterally inserted recti muscles may cause recurrence of the diastasis because of a violin string effect, thus forcing the recti muscles back to their original positions at the supraumbilical area. As revealed in this study, the recurrence of diastasis in the two patients of our series occurred in the supraumbilical area. The efficacy of the advancement of the recti sheaths has been demonstrated in a previous study of patients who presented recurrence of supraumbilical diastasis. 4 When patients from both groups are analyzed together, two of 38 (5.3 percent) have presented supraumbilical recurrence of the diastasis. This number is very similar to those classified by Nahas et al. as type C (7 percent) in a study of 88 patients. 25 It is important to stress that the clinical complaint was not proportional to the width of rectus diastasis recurrence. This can be explained because recurrence of diastasis does not correlate with clinical symptoms, as observed by Brauman. 4 Another interesting finding is that a muscle overlap was found in most patients, with no clinical repercussion. This means that, even if the surgeon is aiming to correct only the rectus diastasis, the technique of plication as described by Pitanguy, without opening of the sheath, promotes an overcorrection in most cases. Some studies have shown recurrence of diastasis. It is probably because in some of these studies the plication is performed lateral to the medial edge of the rectus muscle. A future study is necessary to establish a relationship between the recurrence of rectus diastasis in the upper abdomen and the lateral insertion of the recti muscles. CONCLUSIONS Recurrence of rectus diastasis is not directly related to the length of follow-up. Recurrence of diastasis diagnosed by ultrasonography is not always related to a clinically identifiable deformity. Eduardo José Passamai de Castro Vila Velha Hospital/Cooperativa de Cirurgia Plastica do Espirito Santo Vitória, Espirito Santo, Brazil passamai@eduardopassamai.com.br REFERENCES 1. American Society of Plastic Surgeons. Available at: e da SBCP-Datafolhade 2008) info-cirurgiaplastica.com/2009/06/pesquisa-datafolhasobre-cirurgia.html). 2. Mendes Dde A, Nahas FX, Veiga DF, et al. Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cir Bras. 2007;22:

6 Plastic and Reconstructive Surgery August Nahas FX, Ferreira LM. Concepts on correction of the musculoaponeurotic layer in abdominoplasty. Clin Plast Surg. 2010;37: Nahas FX. An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg. 2001;108: Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesthetic Plast Surg. 1997;21: Pitanguy I. Advantages of the use of plaster-of-paris containment in abdominal plastic surgery (in Italian). Minerva Chir. 1967;22: Pitanguy I. Abdominal plastic surgery (in Portuguese). Hospital (Rio J.) 1967;71: Pitanguy I. Abdominal lipectomy: An approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg. 1967;40: Jaimovich CA, Mazzarone F, Parra JFN, Pitanguy I. Semiologia da parede abdominal: Seu valor no planejamento das abdominoplastias. Rev Bras Cir Plast. 1999;27: Pitanguy I, Salgado F, Radwanski HN, Junior RM. Abdominoplastia: Classificação e técnica cirúrgica. Ver Bras Cir. 1995;85: Pitanguy I. Technique for trunk reductions. In: Transactions of the Fifth International Congress Plastic and Reconstructive Surgery. Australia: Butterworths; 1971: Pontes R. Plástica Abdominal: Importância de sua associação à correção das hérnias incisionais. Ver Bras Cir. 1965;52: R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; BioEstat versão 5.0. Available at: blogspot.com.br/2010/12/bioestat-50.html. 15. Pitanguy I. Surgical reduction of the abdomen, thigh, and buttocks. Surg Clin North Am. 1971;51: Pitanguy I. Aesthetic Plastic Surgery of Head and Body. Berlin: Springer-Verlag; 1981: Sinder R. Cirurgia Plástica do Abdomen. Rio de Janeiro: Editado pelo Autor; Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekkel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240: ; discussion Nahas FX, Augusto SM, Ghelfond C. Nylon versus polydioxanone in the correction of rectus diastasis. Plast Reconstr Surg. 2001;107: Nahas FX, Augusto SM, Ghelfond C. Long-term followup of correction of rectus diastasis. Plast Reconstr Surg. 2005;115: Nahas FX, Ferreira LM, Ely PB, Ghelfond C. Rectus diastasis corrected with absorbable suture: A long-term evaluation. Aesthetic Plast Surg. 2011;35: Nahas FX. Pregnancy after abdominoplasty. Aesthetic Plast Surg. 2002;26: Van Uchelen JH, Kon M, Werker PM. The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography. Plast Reconstr Surg. 2001;107: Nahas FX, Barbosa MV, Ferreira LM. Factors that may influence failure of the correction of the musculoaponeurotic deformities of the abdomen. Plast Reconstr Surg. 2009;124: Nahas FX, Ferreira LM, Mendes Jde A. An efficient way to correct recurrent rectus diastasis. Aesthetic Plast Surg. 2004;28: Submit your manuscript today through PRS Enkwell. The Enkwell submission and review Web site helps make the submission process easier, more efficient, and less expensive for authors, and makes the review process quicker, more accessible, and less expensive for reviewers. If you are a first-time user, be sure to register on the system. 338