9 Personal Approach to Aesthetic Abdominal Deformities

Transcription

1 Chpter 9 9 Personl Approch to Aesthetic Adominl Deformities Ivo Pitnguy, Henrique N. Rdwnski 9.1 Introduction The domen plys leding role in the esthetic imge of the upright humn ody, nd is of prime importnce in defining the overll contour of the individul. Slimmer forms hve sustituted the voluptuous figures tht were idelized y rtists in the pst. Tody s fshion trends nd outdoor ctivities promote ody-reveling ttire s never efore, nd this is especilly true in countries with wrmer climte nd n estheticlly wre society [1]. Plstic esthetic surgeons must strive to understnd the motivtion of ptients who present themselves wnting contour ltertions of the domen. Opposing fctorssuchssedentrylifestyle,weightgin,pregnncy nd the inevitle ging process contrst with the len nd thletic model, nd this ecomes the source of personl frustrtion nd lower self-esteem. The domen is usully seen s centrl to defining the younger nd more vitl physique. The desire for surgicl tretment of these deformities should e evluted within the context of wht surgery my chieve to estow physicl form tht pproximtes the individul with his or her idel self-imge [2]. Theformofthedomenisdefinedytheskeletl structure, s well s the quntity nd distriution of ft, the ppernce nd condition of the skin, the tonus of the poneurotic nd musculr system, nd the protrusion of the intr-dominl orgns. Ech of these components constitutes n independent vrile within the dignosis of deformity of the dominl wll, nd will determine the type of tretment indicted for the ptient. Three lrge muscles (the externl olique, the internl olique nd the trnsversus dominis) re found on ech side of the dominl wll, which is reinforced t the mid-line y the rectus nd pyrmidlis muscles. This musculr shield is vitl for mintining posture, locomotion nd intestinl functions, constituting the primry elements in estlishing the tone of the dominl wll. Adominl ltertions my e summrized s: cutneous (redundncies, stretch mrks, scrs, flccidity nd retrctions); ccumultion of sucutneous tissue (lipodystrophy); nd those ffecting the musculr-poneurotic system (distsis, herni, eventrtion nd convexity). Procedures hve, therefore, een descried to correct the integument (skin nd loose sucutneouscellulrtissue),theponeurosisndthemuscle structure. The ultimte gol of surgery is to chieve n esthetic contour, with cceptle scrs, nd the return of full function of the dominl girdle [3, 4]. A personl pproch to dominl deformities ws descried in 1967, where ttention to oth function nd esthetics ws emphsized [5]. The functionl spect of dominoplsties ws deemed to e especilly pertinent in the older, overweight, multiprous womn. The reinforcement of the dominl wll, s proposed, ws done y the pliction of the poneurosis from top to ottom, without opening of the fsci. A plesing curvture ws given to the wist, not y pulling on the skin, ut y tension on the poneurosis nd the muscles. 9.2 Clssifiction In generl terms, the humn form my e clssified into different somtotypes: mesomorphic, ectomorphic nd endomorphic, representing the vrious ody shpes. Mesomorphic individuls hve more solid, stronger ppernce. Ectomorphs re chrcterized y their lengthndfrgility,withminimldevelopmentofmusculr nd ftty tissue. Endomorphs feture excessive ft, protuernt domen nd short lims. There is nturlly high level of vriility mong the three types. On the other hnd, the ptient tht presents with n esthetic complint regrding the domen my hve his or her domen descried s either pendulous, gloous or flccid. The pendulous type presents n ccumultion of ft in the inferior domen nd round the umilicus, with the skin folding ck over the puis duetoexcessweight.thegloousdomenisrounded with generlized distention nd vrile quntity of ft, with or without flccidity of the poneurosis nd muscle system. The flccid domen fetures skin tht is loose, often with stretch mrks or strie.

2 9.3 Preopertive Plnning 103 Tle 9.1. Pitnguy s clssifiction of esthetic dominl deformities Type Clinicl presenttion I II III IV O Adominl lipodystrophy without skin flccidity; sence of distsis or herni Moderte dominl lipodystrophy with distsis Accentuted dominl lipodystrophy with cutneous flccidity nd excess; presence of distsis; with or without ssocited scr Skin flccidity nd/or lipodystrophy, with distsis or eventrtion; ssocited scr Mrked generlized dominl lipodystrophy with sence of excess skin Suggested technique Liposuction Mini-dominoplsty or endoscopic dominoplsty Stndrd dominoplsty Atypicl pproch These ptients re not idel cndidtes fordominoplsty,ndshoulde prepred for surgery y strict clinicl tretment to lose weight The uthor hs proposed clssifiction of esthetic dominl deformities [6 8]. Aesthetic defects re those tht modify the outline of the ody, due minly to the flccidity of the dominl wll, ccumultion of ft, nd wekening of the poneurosis nd muscle system. This clssifiction hs proven useful in selecting the most pproprite surgicl procedure for ech cse, ensuring tretment with consistently stisfctory results, oth esthetic nd functionl (Tle 9.1). 9.3 Preopertive Plnning The domen should e evluted in itself nd lso in reltion to the rests nd the trochnteric region, llowing the surgeon to decide whether or not n ssocited surgicl procedure is indicted, in order chieve more hrmonious overll result [9]. The ptient is exmined stnding up, sitting, nd lying down. Creful plption should inspect for hidden hernis nd musclewekness.thesurgeonshouldgrsptheinfrumilicl flp nd pull downwrds, so s to estimte the finl tension tht will e plced on the flp. The ptient s overll helth nd psychologicl sttus should e evluted s for ny esthetic procedure. Approprite lortory exmintions re routine, nd specific ssessments re requested cse y cse. Weight loss isprtofthepreopertivepreprtionforconsiderle numer of ptients presenting with contour ltertions of the domen, nd the collortion of multidisciplinry tem should e considered, which my include the endocrinologist nd nutritionist. Mcertion, intertrigo nd dermtitis re found in some ptients, secondry to constnt moisture nd ruing of skin folds cused y skin redundncy, prticulrly in ptients with pron-like dominl flps. Any dermtologicl condition must e treted ccordingly. Aesthetic ody contour deformities my e restricted to the domen; yet frequently these ltertions ffect two or more distinct res, demnding more complex surgicl plnning. Multiple or severe ltertions re seen especilly in ptients who hve undergone drmtic weight loss, nd who thus will require multistge progrm [10]. Not infrequently, these ptients present with vriety of complints, nd the surgeon must decide nd pln for two or more procedures ccordingly. There re, of course, mny enefits for the ptientifssocitedprocedurescneperformedduring one single opertion nd hospitliztion [11 13]. Thepprochtomultiplecontourdeformitiesinthe ptient who hs suffered gret loss of weight is personl. Procedures such s mmmplsty, dominoplsty, dermolipectomy nd liposuction cn e indicted, in vrious comintions [14 21]. More importnt thn the technicl procedure, however, is correct dignosis nd creful surgicl plnning. In ssociting procedures, the extent of the opertion nd surgicl trum, s well s the length of nesthesi, must not e gretly incresed. Blood loss should e nticipted, nd whenever indicted, utologous lood trnsfusion is plnned eforehnd. Comining procedures lso demnds tht the surgicl tem e ppropritely trined. The surgeon is seen s the leder of n orchestrted group, nd the memers re well prepred for ech stge. The sequence of the opertion should e logicl nd plnned in such mnner tht prtofthetemisclosingoneregionwhilethesurgeon undertkes the second or third procedure, leving mple room for ech memer to work comfortly. One should not ttempt newer pproches when ssociting techniques,sthismyetime-consuming.welso prefer not to crry out comined plstic surgery procedures in conjunction with other specilties. Finlly, the surgeon who grees to operte on the ptient s dominl deformity should openly enquire into the ptient s expecttions nd motivtions, nd the limittions of the surgicl procedure should e explined, especilly regrding the plcement of finl scrs. Cution should e tken when the ptient de-

3 104 9 Personl Approch to Aesthetic Adominl Deformities mnds n incision tht will e covered only y certin type of thing suit, ecuse fshion trends will pss, while the scr is permnent. 9.4 Surgicl Technique Adominoplsty The principles of the uthor s technique in dominoplsty hve een dhered to since the first pulictions. It is true tht the plcement of scrs hs chnged ccording to the model of ech ttires, nd currently the incision is plced immeditely ove the puic re with horizontl lterl extension, curving upwrds. There my e certin vriility, dictted y the ptient s preference for thing suits. A long suture is useful to check for symmetry (Fig. 9.1). Following the lower incision, the ftty lyer ove the puis is eveled, ssuring certin mount of dipose tissue, preventing the displesing depression over the midline tht sometimes occurs. Knife dissection proceeds over the muscle fsci until the umilicus is reched. A circulr incision is done round the umilicus, nd the lower dominl flp is divided. Shrp undermining reches the costl mrgins, ut the dissection should e limited lterlly. Muscle distses re repired through pliction of the rectus dominis poneurosis, without opening the muscle fsci, s hd een previously done. This reinforcement of the dominl wll, which ws first proposed y the uthors [5], egins t the xyphoid process to correct epigstric protrusion nd extends down to thepuis.strongnon-sorlesuturesreplcedin n X fshion, inverting the knot, tightening the poneurosis of the rectus dominis muscle (Fig. 9.2). Fig Drwing shows the vrious incisions tht my e used, s long s they re kept hidden y thing trunks. Alongsuture, plced t the midline, is useful to check for symmetry Fig Pliction of the rectus dominis muscle, s descried initilly y the senior uthor, extends from the xyphoid to the puis, without opening of the poneurosis. Detil of inverted sutures

4 9.4 Surgicl Technique 105 Fig. 9.3., The ptient is flexed prior to demrction of excess tissue. A temporry suture is plced in the midline to eqully distriute nd fix the flps, nd long Pitnguy flp demrctorisusedtoestimtemountofexcesstissue Fig After demrction ech flp is incised, eveling the dipose tissue When the pedicle of the umilicus is very long, it my e shortened with sutures, nchoring it firmly to the dominl wll. This should e done without exggertion, especilly in ptients with thick pnniculus, so s to void excessive trction. The tle is now elevted, rising the ptient s trunk to n ngle of 15, nd temporry suture t the midline fixes the flp. The ssistnt pulls ech flp downwrds nd towrds the midline. A long Pitnguy flp demrctor is useful to estimte the precise mount of excess tissue, nd this is mrked (Fig. 9.3). The sme procedure is done to the opposite side, nd oth flps re checked for symmetry, efore finl dermolipectomy (Fig. 9.4). The umilicus should e exteriorized t level corresponding to its nturl position, without trction to void displcement. The sme demrctor checks for thecorrectpositionoftheumilicusontheexterior surfce of the dominl wll (Fig. 9.5). Our preferred Fig The flp demrctor is helpful in the demrction of the new position of the umilicus. The incision is trnsverse, in stright line without removl of tissue, which ecomes tringulr y the trction of the flps method of creting the neo-umilicus hs een through trnsverse, or semicirculr, incision mesuringpproximtely2cm,whichisdonetthedemrcted point. There is thus no resection of skin. It will e noticedthtthisstrightlineecomesnturltringle when the flp is positioned. A resection of sucutneous tissue is removed elow this incision in corklike fshion,sostocusesmoothperiumilicusdepression (Fig. 9.6). The umilicus is then rought to the surfce of the flp, using long sutures (Fig. 9.7). Before finl sutures, suction-ssisted lipectomy is performed, in res not undermined. Closure is done y plnes, ringing the flps inwrds, so s to void dog-ers nd not elongte the finl scr (Fig. 9.8). Atypicl pproches to the domen re dictted minly y preexisting scrs. Verticl incisions elow the umilicus llow the surgeon to compenste the flps medilly, reducing the lterl extension of the lower horizontl scr. On the other hnd, verticl scr

5 106 9 Personl Approch to Aesthetic Adominl Deformities Fig. 9.6., Aconeofsucutneous tissue is resected, llowing for the exterioriztion of the umilicus nd its pedicle Fig The umilicus is pulled out nd then is sutured in its plce tht extends from the upper to the lower domen my llow the surgeon to forego horizontl incision ltogether, permitting the correction of redundnt skin y ringing the undermined flps towrds the midline (Cses 1 5: Figs ). Hernisoreventrtionsmyprecludeprimryclosure of the poneurosis, nd n loplstic mesh will ecomeessentiltopermitclosureofthedefectndssure equl tonus of the entire dominl wll [22] (Cses6 9:Figs ). Serosnguineous collections re one of the most frequent complictions following dominoplsties, yet in our experience the rte of collections hs een low. A few mneuvers hve een dopted nd hve proven useful in preventing collections. These include the covering of ll tissues with moist sterile towels to void desicction during surgery, nd rigorous hemostsis with the routine plcement of drins. A plster shield, molded over thick, soft dressing, hs een dopted s prt of our routine [23]. This ecomes, s it were, custom-designed nterior dominl plte, covering ll undermined tissues, nd is mintined for the first two postopertive dys. A 2-kg weight is plced to ssure n even nd firm pressure, gurnteeing dhesion of the dissected flp (Fig. 9.18). This diminishes the risk of hemtom nd serom, nd hs een noted to decrese ptient discomfort during thefirst48postopertivehours. Fig Finlsuturesredoneyplnes,withthessistnt pulling the flp inwrds so s to decrese lterl extension of the finl scrs

6 9.4 Surgicl Technique 107 Fig. 9.9,. Cse 1. Preopertive 31-yer-old womn with lower dominl flccidity nd distsis (type II deformity). Two yers postopertively following mini-dominoplsty Fig. 9.10,. Cse 2. Preopertive 45-yer-old womn with dominl flccidity, lipodystrophy, nd rectus distsis (type III deformity). Two yers postopertively following stndrd dominoplsty

7 108 9 Personl Approch to Aesthetic Adominl Deformities Fig. 9.11,. Cse 3. Preopertive 46-yer-old womn with dominl flccidity, lipodystrophy, nd rectus distsis (type III deformity). Two yers postopertively following stndrd dominoplsty Fig d. Cse 4.,Preopertive 36-yer-old womn with dominl flccidity (type III deformity) nd rest ptosis.

8 9.4 Surgicl Technique 109 Fig. 9.12c, d. Two yers postopertively following stndrd dominoplsty, plcing the incision so s to respect the lower type of thing trunks nd mstopexy procedure c d Fig d. Cse 5., Preopertive 51-yer-old mn with dominl deformity type III following weight loss of 45 kg.

9 110 9 Personl Approch to Aesthetic Adominl Deformities c d Fig. 9.13c, d. Two yers postopertively fter stndrd dominoplsty with suction-ssisted lipectomy of the nterior chest for correction of pseudogynecomsti Fig. 9.14,. Cse 6. Preopertive 29-yer-old womn with n unsightly longitudinlscrduetoprevious explortory lprotomy (type IV deformity). One yer postopertively fter verticl dominoplsty with muscle reinforcement

10 9.4 Surgicl Technique 111 Fig. 9.15,. Cse 7. Preopertive 35-yer-old womn presented with n incisionl herni in the lower domen (type IV deformity) nd rest ptosis. Four yers postopertively following stndrd dominoplsty without mesh reinforcement, together with mstopexy c Fig c. Cse 8. Preopertive 35-yer-old mn with n incisionl herni fter n explortory lprotomy (type IV deformity). Reconstruction of the dominl wll ws performed fter tissue expnsion with two croissnt shpe expnders through n typicl dominoplsty with mesh reinforcement. c Two yers postopertively

11 112 9 Personl Approch to Aesthetic Adominl Deformities Fig c. Cse 9. Preopertive 46-yer-old womn with n incisionl herni in the lower domen (type IV deformity) nd rest ptosis. Atypicl dominoplsty with mesh reinforcement ws performed fter tissue expnsion in the upper domen nd superior thighs. c Two yers postopertively c Fig A plster shield covers ll the dissected flp, plced over soft dressing

12 9.5 Liposuction Liposuction (Cses 10, 11: Figs. 9.19, 9.20) proved, either s single procedure or ssocited with dominoplsty, llowing the surgeon to complement dermolipectomy with liposuction to enhnce the wistline. Suction-ssisted lipectomy hs lso decresed the necessity for extensive undermining, thus contriuting to lessening the rte of complictions, such s serosnguineous collection nd flp ischemi. Liposuction is Fig. 9.19,. Cse 10. Preopertive 26-yer-old ptient with lower dominl lipodystrophy (type I deformity). Two yers postopertively fter liposuction An importnt contriution to contouring of the trunk ws the introduction of suction-ssisted lipectomy (SAL) in the lte 1970s, which hs permitted the removlofftdepositsymensofminimlincisions. Modeling of the domen hs een considerly im Fig. 9.20,. Cse 11. Preopertive 22-yer-old ptient presented with lower dominl lipodystrophy (type I deformity). Two yers postopertively following liposuction

13 114 9 Personl Approch to Aesthetic Adominl Deformities frequently done to other ntomicl res in ssocition with dominoplsty. It should e emphsized tht liposuction should e restricted to non-undermined res. Two primry rteril plexi re responsile for the irrigtion of the dominl wll: sudermic superficil system nd deeper, more profound musculoponeurotic system. Mny lood vessels form nstmotic connections etween the two levels, prticulrly in the periumilicl region. This vsculr ntomy must e respected so s not to risk cusing decrese in vsculriztion of the dominl flp. Acknowledgements. Theuthorsregrtefulforthe collortion of Frncisco Slgdo, MD, nd Aln Lndecker, MD. References 1. Sheldon WH (1963) The vriety of humn physique. Hfner, New York 2. Lewis JR (1989) The rt of esthetic surgery. Little, Brown, Boston, pp Jimovich CA, Mzzrone F, Prr JFN, Pitnguy I (1999) Semiology of the dominl wll: Its vlue in plnning dominoplsty. Rev Brs Cir Plst 14: Pitnguy I (1987) Body contour. Am J Cosm Surg 4: Pitnguy I (1967) Adominl lipectomy: An pproch to it through n nlysis of 300 consecutive cses. Plst Reconstr Surg 40: Pitnguy I (1995) Adominoplsty: clssifiction nd surgicl techniques. Rev Brs Cir 85: Pitnguy I (2000) Evlution of ody contouring surgery tody: A 30-yer perspective. Plst Reconstr Surg 105: Pitnguy I (2000) Fcil cosmetic surgery: A 30-yer perspective. Plst Reconstr Surg 105: Pitnguy I (1984) The domen. In: Aesthetic surgery of hedndody.springer-verlg,berlin,pp PitnguyI,AmorimNFG,RdwnskiHN(2000)Contour surgery in the ptient with gret weight loss. Aesth Plst Surg 24: Pitnguy I, Cvlcnti MA (1978) Methodology in comined esthetic surgeries. Aesth Plst Surg 2: Pitnguy I (1981) Comined esthetic procedures. In: Aesthetic plstic surgery of hed nd ody. Springer-Verlg, Berlin, pp Pitnguy I, Cervolo M (1983) Our experience with comined procedures in esthetic plstic surgery. Plst Reconstr Surg 71: Pitnguy I (1964) Trochnteric lipodystrophy. Plst Reconstr Surg 34: Pitnguy I (1972) Thigh lift nd dominl lipectomy. In: Goldwyn RM (ed) Unfvorle results in plstic surgery. Little Brown, Boston, p Pitnguy I (1973) Lipectomy dominoplsty nd lipodystrophyoftheinnersideoftherm.in:grw,smithj (eds) Plstic surgery: concise guide to clinicl prctice, 2nd edn. Little Brown, Boston, pp Pitnguy I (1975) Adominl lipectomy. Clin Plst Surg 2: Pitnguy I (1975) Correction of lipodystrophy of the lterl thorcic spect nd inner side of the rm nd elow dermosenescence. Clin Plst Surg 2: Pitnguy I (1977) Dermolipectomy of the dominl wll, thighs, uttocks nd upper extremity. In: Converse JM (ed) Reconstructive plstic surgery, vol 7, 2nd edn. Sunders, Phildelphi, pp Pitnguy I (1984) Upper extremity: Dermolipectomy. In: Aesthetic surgery of hed nd ody. Springer-Verlg, Berlin, pp Pitnguy I (1989) Thigh nd uttock lift. In: Lewis JR (ed) The rt of esthetic surgery, vol 2. Little Brown, Boston, pp Pitnguy I (1984) Tretment of dominl wll eventrtions ssocited with dominoplsty techniques. Aesth Plst Surg 8: Pitnguy I (1967) Vntggi dell impiego di contenzione gesst nelle plstiche dominli. Minerv Chirurgic 22:

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