Issues in Abdominoplasty

Transcription

1 Editor s note: My thanks to the moderator, Armand A. Lucas, MD (board-certified plastic surgeon and ASAPS member, Cleveland, OH); and to panelists Joseph P. Hunstad, MD (board-certified plastic surgeon and ASAPS member, Charlotte, NC); Renato Saltz, MD (board-certified plastic surgeon and ASAPS member, Salt Lake City, UT); and Luiz S. Toledo, MD (plastic surgeon and ASAPS corresponding member, Sao Paulo, Brazil), for sharing their opinions and clinical experiences. Dr. Lucas: The first case is that of a 42-year-old woman requesting abdominoplasty; she has sustained an 87-lb weight loss (Figure 1). Because obesity at the time of abdominoplasty can adversely affect outcome, is weight loss mandatory prior to body contouring surgery? Dr. Saltz: Certainly not in all cases, because patients are very disappointed when you insist on a weight-loss routine. If they are not morbidly obese, I will treat them. However, for those patients who are more than 25% overweight, I refer them to my nutritionist and prescribe a rigorous exercise program, usually with a personal trainer. Armand A. Lucas, MD Renato Saltz, MD Dr. Lucas: Dr. Toledo, is there an upper limit that would cause you to decline surgery? Dr. Toledo: My upper limit for treating heavy patients is 30% over the ideal weight. We should not remove more than 5% to 8% of total body weight with liposculpture. When I combine abdominoplasty with liposculpture, I will obviously go higher if I have to. Dr. Lucas: Dr. Hunstad, what would your surgical plan be for this patient? Dr. Hunstad: You can clearly see the lateral border of the rectus in the frontal photograph, which shows the muscle laxity. She has lost intra-abdominal as well as extraabdominal fat, and a very aggressive plication of the medial and possibly the lateral borders of the rectus would significantly enhance her waistline. Concurrent lipoplasty, particularly of the hip rolls, would give her a very good result. Joseph P. Hunstad, MD Luiz S. Toledo, MD Dr. Lucas: Does the lipoplasty include the abdominal flap? Dr. Hunstad: Yes. Dr. Lucas: Dr. Toledo, would you perform lipoplasty at the same time? Dr. Toledo: I perform lipoplasty separately from abdominoplasty. If you violate the abdominoplasty flap, it can be very risky. I separate the procedures by 6 months. Dr. Lucas: Dr. Hunstad, in light of reports in the literature warning against concurrent lipoplasty and abdominoplasty because of the risk of devascularizing the distal end of the flap, do you have some guidelines or hints for avoiding this problem? Dr. Hunstad: There were such warnings in the late 1980s and early 1990s, but during the last few years, quite a few articles have reported a low morbidity. Thoroughly infiltrating the subcutaneous tissue with a large volume of dilute adrenaline and lidocaine will hydrate the tissue; this allows smaller diameter cannula passage, causing much less trauma and, I believe, much greater vascular preservation. When we suction, we tend to parallel the vascular supply, particularly that of the intercostal vessels. Dr. Lucas: Why not perform an open lipectomy, rather than lipoplasty? A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER

2 Figure 1. Front and lateral views of a 42-year-old woman requesting an abdominoplasty after an 87-lb weight loss. Dr. Hunstad: Lipoplasty is performed before flap elevation. Once the flap is elevated, it is very difficult to suction because it is mobile. I sharply resect first the inferior tissue, then all of the fat deep to the scarpus fascia. Dr. Lucas: Dr. Saltz, do you combine the procedures? Dr. Saltz: With the patient in a prone position, I perform deep and superficial lipoplasty to her flanks (closing from lateral to medial), hip rolls, and possibly her back. This not only helps to contour the flanks but also decreases the extent of the abdominal scar and helps avoid dog ears. With the patient turned to a supine position, a standard abdominoplasty and rectus muscle plication are done. I perform a sharp lipectomy with the abdominal flap under tension, and then excise the deep fat layer below Scarpa s fascia with the knife to minimize a compromise of blood supply. Next, I apply Reston foam (3M Company, St. Paul, MN) with the girdle over for support. Dr. Hunstad: I agree with Dr. Saltz that the hip roll is not just lateral but always extends posteriorly, so the prone position helps me a great deal to get the very best result. Dr. Toledo: I would treat this patient I perform lipoplasty separately from abdominoplasty. If you violate the abdominoplasty flap, it can be very risky. I separate the procedures by 6 months. Luiz S. Toledo, MD first in the lateral position, to access the flanks and the dorsal region, then in the supine position for the abdominoplasty. Although I use tumescence for lipoplasty, it does not provide enough analgesia for rectus plication or abdominoplasty. Dr. Lucas: The second case illustrates a common problem: a 53-yearold man who underwent standard abdominoplasty, had drainage for 10 days, and then developed a seroma with subsequent pseudo bursa (Figure 2). Dr. Toledo, how do you avoid this problem? Dr. Toledo: I believe that the incidence of seroma is 100% when lipoplasty and abdominoplasty are combined. Pseudo bursa is rare. I don t use suction drains, because they can actually increase the drainage fluid after the seventh or eighth day. I prefer Penrose (Valtex, Sao Paulo, Brazil) drains that I leave in for only 2 or 3 days. I rarely use foam, and I disagree with those who claim they can avoid seromas only with active suturing of the flap to the fascia. Some surgeons use weights on the abdomen or plastic casting of the trunk to prevent seromas, but I do not use these techniques routinely. Dr. Lucas: Dr. Saltz, what is your perioperative care and management for seromas? Dr. Saltz: A seroma followed by a pseudo bursa is a very difficult problem, and I have seen my share of them. When it happens, I find it necessary to completely excise the pseudo bursa and implement a more aggressive treatment. Closed suction drainage has worked well for me; I prefer Blake drains (ETHICON, Inc., Somerville, NJ). On many occasions, I have sprayed tissue adhesives, such as autologous fibrin glue 404 A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER 2000 Volume 20, Number 5

3 or the recently [US Food and Drug Administration-]approved tissue by Baxter Healthcare Corporation (Deerfield, IL). I always use Reston foam and a girdle. I believe this problem indicates a disruption in the lymphatic system, so limiting motion is a key factor. I emphasize to patients that they have to move gingerly on their first 3 or 4 days after surgery while the tissues are adhering, and I insist on no exercise for 4 to 6 weeks. Dr. Lucas: Dr. Hunstad, if you had a patient with a seroma, how would you treat it? Dr. Hunstad: I agree that seromas are more common when abdominoplasty is combined with lipoplasty. Because I normally combine these procedures, my seroma rate is very high; however, my bursa formation rate is almost zero, although I do get them occasionally. I use suction drainage, but in my experience, all the drain types are equivalent. I leave the drains in for 2 to 3 weeks if needed. A seroma can continue even after drain removal but resolves without the residual fullness that is noted here. When I suspect that a bursa is forming early, I disrupt it with a cannula. It is my opinion that if a patient gets a pseudo bursa, immediate surgical extirpation is the only treatment. Dr. Lucas: How do you avoid recurrence? Dr. Hunstad: I use space-obliterating sutures, usually with the #1 chromic, because I believe that chromic sutures will be slightly irritating and enhance adhesion. I also use a suction drain. I think that plaster casts, immobilization, and a sandbag on top of the plaster cast may make a lot of sense. But when I am aggressively thinning Figure 2. Front and lateral views of a 53-year-old man 2 months after undergoing an open abdominoplasty. His drains were removed 10 days after the procedure, and a chronic seroma with pseudo bursa formation developed at 30 days after the procedure. the flap and performing subscarpal resection (the fat deep to Scarpa s fascia), I am so concerned about necrosis that I don t even use a binder anymore until I am positive that vascularity is perfect, which is usually at about the time that I get the drain out, at 7 to 10 days. Dr. Toledo: I agree with Dr. Hunstad; I think we are talking about a patient who has a pseudo bursa resection. At that point, I think that pressure dressings and casting are applicable. I would not use them, however, during the primary abdominoplasty. Dr. Lucas: Dr. Hunstad, do you restrict the patient s activity? Dr. Hunstad: Movement between the abdominal flap and the abdominal wall that prevents any adherence is one of the key causes of seroma formation. I ask my patients to limit mobility, but I do not want them to develop a postoperative deep vein thrombosis (DVT) or other problems, so I like my patients to ambulate to and from the restroom and engage in some minimal mild activity, but no full exercise until 4 to 6 weeks after surgery. I like to put the binder on very tightly after the first postoperative week, although I release it periodically during the day. Dr. Lucas: I understand that Reston foam is not recommended for any Movement between the abdominal flap and the abdominal wall that prevents any adherence is one of the key causes of seroma formation. I ask my patients to limit mobility, but I do not want them to develop a postoperative deep vein thrombosis. Joseph P. Hunstad, MD A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER

4 Figure 3. Front and three-quarter views of a 37-year-old woman requesting an abdominoplasty after a history of abdominal trauma secondary to a motor vehicle accident requiring multiple explorations and ostomies. kind of compression in body-contouring surgery. Dr. Hunstad: The 3M Company, which produces Reston foam, has stated that they never developed it to be in contact with skin, so we should use it with great care. Dr. Saltz: Using it directly on the skin can cause blisters, which we have prevented by coating the skin with a thin layer of petroleum jelly or Neosporin ointment (Pfizer, New York, NY). Dr. Lucas: Topiform (Lysonix Inc., Carpinteria, CA) has been offered as an alternative and it seems to work well. Dr. Toledo, do you have any thoughts on that? Dr. Toledo: I don t use foams in deep lipoplasty, and I have stopped using girdles because they can leave marks on the skin. With superficial lipoplasty, I will use the girdle just to keep the flap immobilized. However, if the girdle starts marking the skin, I will ask the patient to remove it because it is too tight and can provoke depressions, rashes, and even skin necrosis. Dr. Hunstad: Irregularities with garments, elastic waist bands, or panty hose are even more problematic with abdominal lipoplasty, because, I believe, the fat is malleable in that early postoperative period. Because wearing such garments can lead to a permanent crease with perceived fullness above and below, I suggest removing them to keep the skin smooth, wearing loose fitting clothing and, particularly with my male patients, wearing suspenders. Dr. Lucas: The third case is that of a 37-year-old woman who has required exploratory laparatomy and has multiple abdominal scars (Figure 3). Dr. Toledo, what is your approach to this patient? Dr. Toledo: This is an extreme case. The photographs show that she has a huge depression on the epigastric area. I would treat this patient in a closed manner, especially if she has good muscle tone. What you see here are irregularities that can be treated with lipoplasty. It is important to perform a magnetic resonance imaging scan to determine whether she has any hernias at risk. Surgically, I would free those scars from the fascia with the V-tip cannula very close to the skin, and infiltrate the fat for suction. This procedure is much less traumatic for the patient. If a scar is old and nonapparent, but retracted, I will just free it. If the scar is wide or high, I will revise it. Dr. Lucas: Dr. Toledo, how large a surface area would you treat at one time with the V-tip, considering that you are so close to the dermis? Dr. Toledo: I use the cannula in an in-and-out movement only to free the skin depressions. To avoid necrosis, I do not free the whole skin. Dr. Lucas: Dr. Hunstad, what is your approach here? Dr. Hunstad: This woman is very long-waisted, and the location of her umbilicus is at a significant distance from the pubis. The drain scar or the colostomy scar would be the most difficult. A thorough liposuction could give her a good but not great result. If she has lower abdominal muscle diastasis, laxity, and protuberance, then a procedure that combines skin resection and muscle tightening with concurrent lipoplasty would be very helpful. These are old scars; they are white and pale. Many times we are challenged with a patient who has a subcostal scar. I ignore mature scars that have been blessed with few ischemic problems, but fresher scars present a different scenario. Dr. Lucas: Dr. Saltz, what are your thoughts? Dr. Saltz: I would inquire about her pregnancy history to accurately eval- 406 A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER 2000 Volume 20, Number 5

5 uate her rectus muscle. It only takes one pregnancy to get diastasis recti in most patients. My plan would be to revise that midline scar and perform the muscle plication. I would probably not remove too much skin in a vertical direction. I like to finish my abdominoplasty with a very mysterious and vertical umbilicus, so this patient would be a candidate for an umbilicoplasty. I would consider flank suction just to improve the contour and stay away from the undermined areas. Dr. Lucas: Dr. Hunstad, for a patient with a vertical hysterectomy scar, would you routinely try to remove transverse skin, particularly if it goes above the umbilicus? Dr. Hunstad: Unfortunately, when I excise tissue vertically and recreate the scar, it has a tendency to become hypertrophic, particularly when placed under a bit of tension, although it doesn t necessarily widen. I usually do not affix the flap to the abdominal wall, although at one time I was doing that very aggressively. I haven t found that to be a beneficial procedure. Nor do I affix the flap to the abdominal wall to lessen the tension on the flap. Dr. Toledo: Vertical abdominoplasty is difficult because one is unfortunately faced with abnormal highs and lows around the umbilicus that you want to look natural. I would try to do an umbilicoplasty. Dr. Hunstad: For all patients, there are some nuances to achieving a more natural umbilicus, particularly if the patient is a bit heavy. Defatting from 3 to 6 to 9 o clock will preserve the superior or dorsal hooding. Also, the umbilical stalk is tethered inward in this type of aggressive myofascial closure, in which the medial rectus is plicated. The umbilicus scar is virtually internalized and that produces a nice inny appearance, and with proper defatting it could have dorsal hooding, which looks quite nice. A key point is to bring the umbilicus through a minimum skin excision. A major cause for revision of abdominoplasty is a large circular umbilicus, which doesn t look natural in any way. Dr. Saltz: I agree, but the umbilicus cannot be too small. When you look at the abdomen of a woman wearing a bikini, you naturally focus on the belly button. In a study we did at the University of Utah, most men and women preferred a vertical umbilicus. It is very appealing, not only as demonstrated statistically but also in fashion design, where vertical stripes have a very slimming effect. I am now using Dermabond sutures (ETHICON, Somerville, NJ), instead of a running subcuticular suture, and getting nice scars. Dr. Toledo: My preferred umbilicus insetting technique is the Juri technique. A V-type incision is made on the abdominal flap, which is then split into two and taken into the umbilicus; this gives a nice appearance. Another common problem is umbilical malposition off the midline. I emphasize the placement of the suprapubic sutures, and toward the end of the procedure I line them up to re-create the location of the midline. I also use the umbilical locator, which is an instrument for confirming the midline found with suprapubic sutures. Dr. Hunstad: An off-center umbilicus is a risk, particularly with umbilical float procedures, in which you are dividing the stack and doing a very aggressive myofascial plication. It is desirable to replant the umbilicus exactly in the midline; again, I only use a nylon suture from the xiphoid process and hold it down to the pubis area to avoid any possibility of an off-center result. Dr. Lucas: The last case is that of a healthy 36-year-old woman who has moderate muscle laxity and minimal skin excess and who underwent an endoscopic abdominoplasty with rectus plication. Two months postoperatively, she has bogginess, is unhappy with the feel of it, and has many irregularities (Figure 4). Dr. Hunstad, do you perform endoscopic abdominoplasty? If so, how do you select your patients? Dr. Hunstad: Yes, I perform endoscopic abdominoplasty. However, less than 5% of patients are good candidates namely, those with excess adiposity and muscular diastases with no skin redundancy. I like to use a vertical incision concealed The umbilicus cannot be too small. When you look at the abdomen of a woman wearing a bikini, you naturally focus on the belly button. Renato Saltz, MD A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER

6 Figure 4. Front and lateral views of a 36-year-old woman 2 months after an endoscopic abdominoplasty with rectus plication, minimal skin resection, and standard lipoplasty of the upper abdomen with inferior drainage. within the pubic hairline and, of course, the circumumbilical counter incision. The plication is not easy, and I frequently tangle my sutures, but I am pleased with the results in that select group of patients. I also think it is important to undermine sufficiently, so that you don t have tethering and the skin can lay down evenly and uniformly. Dr. Saltz: Endoscopic abdominoplasty is an operation with limited indications. I have almost always found it necessary to completely undermine the anterior abdomen, outside the rectus sheath to minimize the excess skin at the midline, which is what I think we see here. Perhaps in this case, a more extensive undermining, including deep and superficial suction, would help accommodate that skin. Dr. Lucas: Dr. Toledo, would you approach this patient with an endoscope? Dr. Toledo: I don t know why this patient has a bulge after 2 months. Is this a plication that was not done properly, or is she just swollen after the procedure? I tried the endoscopic approach twice and swore that I would never do it again. In Brazil, most patients have a C-section scar, so there is not much reason to use the endoscope. We can plicate the whole midline through that incision. Dr. Lucas: Would this patient have been better served by a miniabdominoplasty? Dr. Saltz: I really don t perform a mini-abdominoplasty, and I think we should eliminate that term. After pregnancy, all women have laxity. It becomes necessary to plicate the full length of the rectus muscle; otherwise, there is a bulge on the upper abdomen. Mini-procedures produce mini-results. Dr. Lucas: Dr. Saltz, what do you do to prevent complications? Do you ask a patient preoperatively about the presence of DVT or thrombophlebitis during pregnancy, and are there absolute or relative contraindications to surgery? Dr. Saltz: With any procedure in which the patient is placed under general anesthesia that lasts for more than 2 hours, there is a higher incidence of DVT, especially in combined abdominoplasty and ob-gyn procedures, and when the patient is obese. We use the compression boot along with enoxaparin (low-molecular-weight heparin) from the time of the induction, which we continue for 5 to 10 days, depending on how early the patient is ambulating and how much surgery she had. That combination has improved the incidence of DVT and pulmonary embolisms in my practice. Dr. Lucas: What are the risks with enoxaparin? Dr. Saltz: Because it is a low-molecular-weight heparin, it almost eliminates the risk of bleeding. Patients usually inject themselves, so it is similar to an insulin injection. The dosage is 30 mg twice a day subcutaneously. Dr. Lucas: Dr. Saltz, if a patient had thrombophlebitis or DVT during pregnancy or in her history, is that a relative or absolute contraindication to full abdominoplasty? Dr. Saltz: Thrombophlebitis is not a contraindication, but DVT represents a very high risk. I would get a duplex scan preoperatively and check not only the lower extremities but also the pelvic veins. If they still have clots, I would be very concerned and probably defer the elective procedure. Dr. Lucas: Dr. Toledo, what is your approach to avoiding DVT? Dr. Toledo: We perform the procedure on the table and use sequential compression boots to massage the patient s legs if the procedure takes longer than 2 hours. Early walking 408 A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER 2000 Volume 20, Number 5

7 is mandatory, especially for obese patients. Dr. Hunstad: I think adequate intravascular volume is important to lessen sludging. Sequential lowerextremity pumping and perioperative steroids probably offer some benefit, although I cannot prove that. Dr. Lucas: The last question for all panelists is this: should abdominoplasty be performed as an inpatient procedure or as an outpatient procedure? Dr. Hunstad: I believe very much in the safety of outpatient abdominoplasty, but in my own facility we now offer overnight stays, and I am starting to keep patients overnight more often. This is particularly useful in treating heavier patients with larger resections and larger volume suctioning. Dr. Toledo: I would agree with that. Dr. Saltz: Most of our procedures are performed on an outpatient basis, but I agree that it is best to individualize treatment for each patient. Reprint orders: Mosby, Inc, Westline Industrial Drive, St Louis, MO ; phone (314) ; reprint no. 70/1/ doi: /maj A ESTHETIC S URGERY J OURNAL ~ SEPTEMBER/OCTOBER