Instant Identification of Redundant Tissue in Abdominoplasty With a Marking Grid

Transcription

1 Body Contouring Instant Identification of Redundant Tissue in Abdominoplasty With a Marking Grid Edward A. Pechter, MD, FACS Standard abdominoplasty traditionally includes a transverse lower abdominal incision, with wide undermining of the skin and subcutaneous tissue to the costal margin. 1 In recognizing that aggressive undermining may compromise circulation and lead to ischemic complications, many surgeons have sought ways to limit undermining while maintaining contour improvement. Lockwood 2,3 showed that wide, direct undermining of the abdominal flap to the costal margins was not essential and that discontinuous undermining allowed effective loosening of the abdominal flap while preserving vascular perforators. Key elements of his technique included direct undermining only in the paramedian area, with discontinuous undermining to the costal margins and flanks as needed. Matarasso 4-6 advised that the abdominoplasty flap should be elevated only to the extent necessary to achieve wound closure with minimal tension, thereby preserving the lateral blood supply (Huger zone III) that predominates in the operated abdomen. He warned of danger zones where extensive liposuction could lead to vascular compromise. Shestak 7 described aggressive superwet liposuction of the abdomen and adjacent anatomic regions to expand the Aesthetic Surgery Journal 30(4) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Abstract Background: It is generally believed that continuous or discontinuous undermining of an abdominoplasty flap is necessary for its advancement, but it is also recognized that such undermining may increase the risk of ischemic complications. Objective: The author describes a grid-marking system to quickly identify the redundant tissue in abdominoplasty, making the procedure simpler, safer, and more consistent. Methods: A standardized grid was preoperatively marked on 35 consecutive female abdominoplasty patients to determine the exact pattern and extent of skin resection at the beginning of the procedure. This allowed resection of redundant tissue while confining proximal flap undermining to the minimum amount necessary for diastasis repair and umbilical repositioning. Results: The 35 patients who underwent abdominoplasty with the author s technique were followed from three months to 2.5 years. Of these, 12 underwent simultaneous liposuction. All procedures were performed on an outpatient basis under general anesthesia in an accredited office operating facility. Overall results were excellent, with no flap ischemia or other complications directly related to wound tension or to limited undermining. Conclusions: A standardized grid system allows identification of redundant abdominoplasty tissue before any incisions are made, which limits undermining to the area over the medial rectus abdominis muscles, the minimum amount necessary for diastasis repair and umbilical repositioning. Simultaneous liposuction can be performed with relative safety, although it is not required for flap advancement. Keywords abdominoplasty, preoperative marking, umbilical repositioning, flap undermining Accepted for publication June 9, miniabdominoplasty concept for the treatment of abdominal wall deformities and reduce the need for traditional full abdominoplasty. Avelar 8 described an abdominoplasty procedure without panniculus undermining but also without panniculus resection, relying instead on skin resection only with subscarpal liposuction to facilitate advancement of the panniculus over the muscular aponeurotic wall. Saldanha 9-11 believed that classic abdominoplasty was associated with a relatively high incidence of complications and so developed a technique relying on liposuction to better conserve perforating vessels and facilitate advancement of the abdominal flap. We present a simple method for identifying the redundant tissue in abdominoplasty at the onset of surgery so as to minimize undermining and maximize safety. From the University of California, Los Angeles. Corresponding Author: Dr. Edward Pechter, Tournament Road Suite 217, Valencia, CA 91355, USA. drpechter@aol.com

2 572 Aesthetic Surgery Journal 30(4) Methods The method presented here arose from this author s previously-described technique utilizing a grid drawn on the abdomen preoperatively, which allowed documentation of the exact amount and pattern of skin resection in each abdominoplasty. 12 When the technique was first developed, surgical staples were placed to demarcate the boundaries of the redundant tissue. At the completion of surgery, the precise pattern of the resected tissue was superimposed on a preoperative photograph of the grid-marked patient, which determined the exact procedure that was performed. Over time, a pattern for the tissue resection emerged and it eventually became possible to identify this redundant tissue in a matter of moments at the start of the procedure. Further experience with this technique led to the development of a standardized design for tissue resection, which eliminated the stapling component of the original procedure while minimizing intraoperative decision-making and providing reliably good aesthetic results. Thirty-five female patients who presented to the author s clinic between January 2007 and June 2009 underwent abdominoplasty with the following technique. Operative Technique Each patient was marked preoperatively in the standing position (Figure 1). A horizontal line was drawn through the umbilicus with a carpenter s level, extending just beyond the mid lateral line of the patient on each side. A vertical midline was drawn from the xiphoid to the pubis, passing through the umbilicus. With these two lines as guides, additional horizontal and vertical lines were drawn with a flexible plastic ruler 5 cm in width (available at most office supply stores), so that grid lines extended 5 to 10 cm above the umbilicus, 10 to 15 cm below the umbilicus, and from side-to-side. One or two horizontal grid lines and corresponding vertical grid lines were drawn in the lower abdomen to help make the markings symmetrical, but it was not necessary to mark the grid on the lower part of an overhanging panniculus or to make the periumbilical and suprapubic grid lines continuous. Aligning the closure was not the primary purpose of the grid. The desired location of the eventual scar was also marked. It was drawn with the patient pulling upward on the lax panniculus with both hands, anticipating the upward migration of the pubis and lateral thighs with wound closure. 13 The midpoint of the distal line of resection was made 5 or 6 cm above the anterior commissure of the labia majora, with the panniculus relaxed. A horizontal line 10 to 12 cm in length was marked through this point, covering the width of the pubis. In the author s experience, this horizontal line was always lower than any existing Pfannenstiel incision scar and led to removal of several centimeters of pubic hair bearing skin, satisfying the author s priority for a low scar that did not excessively elevate the pubic hairline (Figure 2). The distal incision could be planned higher, depending on circumstances or aesthetic preferences. From the ends of the suprapubic horizontal, the distal line of resection was extended upward and outward, parallel to and just above the inguinal creases, where it met the horizontal grid lines at 45-degree angles. This pattern was found to virtually eliminate dog ears, especially when combined with subjacent liposuction. With the patient on the operating table, the hips were flexed in a semi-fowler position. Two forceps were placed to determine the most proximal point on the midline that could comfortably be approximated to the midpoint of the predetermined position of the final scar. This point is most often located at the superior aspect of the umbilicus, but in this series, it varied from 5 cm above to 5 cm below the umbilicus, depending on the degree of skin laxity. Based on the author s experience with the marking grid, the proximal line of resection ideally extends horizontally from this point until it meets the upwardly-curving distal line of resection. These two lines outline the tissue to be resected. Thus, the exact pattern of tissue resection is known within moments of the onset of the procedure. With the patient flat, the umbilicus was circumscribed and the proximal line of resection was incised down to the deep fascia. The proximal flap was undermined to the xiphoid in a narrow inverted V pattern, just wide enough to allow repair of the diastasis recti. Any mild bunching of the remaining tissue resolved spontaneously in the early postoperative period. The curved lower line of resection was then incised and the redundant tissue was removed by any convenient method, leaving a thin layer of fat on the deep fascia to promote lymphatic drainage. The diastasis was repaired from the xiphoid to the pubis with buried, figure-of-eight sutures of #0 Ticron (Syneture/US Surgical, Norwalk, Connecticut). The umbilicus was shortened by securing it to the adjacent fascia at the three, six, and nine-o clock positions with 3-0 Monocryl (Ethicon, Somerville, New Jersey). A bifurcated 10-mm silicone drain (Jac-Cell Medic, Lachine, Quebec, Canada) was brought out through a midline stab incision in the pubis. A pain control catheter (Accufuser, Curlin Medical, Huntington Beach, California) containing 350 ml of 1% lidocaine (Xylocaine, AstraZeneca Pharmaceuticals, Wilmington, Delaware) was inserted through the same opening as the drain and threaded for a portion of its length under the rectus fascia. The surgical table was again adjusted to flex the patient s hips. The umbilicus was brought out at the appropriate location and three or four quilting sutures of 2-0 Vicryl (Ethicon) were placed in the midline, between the deep surface of the flap and the linea alba. The superficial fascial system (SFS) described by Lockwood 2 was closed with inverted 2-0 Vicryl with most stitches, also catching a small bite of the deep fascia to help anchor the flap. The dermis was repaired with multiple inverted 3-0 Monocryl stitches. If the tissue resection did not extend to the level of the umbilicus, the umbilical aperture was closed in layers in the vertical lower midline. (A low scar with a short vertical component is far more aesthetic than a high scar made to avoid a vertical extension.) Liposuction was performed as needed in the

3 Pechter 573 Figure 1. Surgical technique. (A) The standing patient is marked preoperatively with grid lines at 5-cm intervals. (B) The patient is placed in the supine position with hips flexed and two forceps are placed to determine the most proximal point (X) on the midline that can be approximated to the center of the predetermined distal line of resection (Z). The position of point X depends on the degree of tissue redundancy. (C) With the patient flax, the proximal line of resection passes horizontally through X and meets the curved distal line of resection passing through Z, outlining the exact amount and pattern of tissue resection. (D) The proximal line of resection is incised and the midline is undermined to the xiphoid just widely enough to allow diastasis repair and umbilical repositioning. (E) The distal line of resection is incised. (F) The redundant tissue is removed en bloc. (Continued on next page.)

4 574 Aesthetic Surgery Journal 30(4) Figure 1 (continued). (G) With the patient s hips again flexed, the wound is closed in layers. (H) The standing patient is shown one week postoperatively. flanks (zone III) and epigastrium (zone I) prior to final closure, but liposuction was not necessary for advancement of the flap or wound approximation. The skin closure was supported by Suture-strips (Derma Sciences, Inc., Toronto, Ontario, Canada) applied over topical benzoin (Tincture of Benzoin, 3M Healthcare, Neuss, Germany). A pair of light panties was the only dressing. After removal of the Suturestrips, patients were instructed to wear self-adherent silicone strips (Mepiform, Mölnlycke Health Care, Göteborg, Sweden) over the incision for three months. Results All 35 female patients who underwent abdominoplasty with the technique described above between January 2007 and June 2009 were followed up for a period of three months to 2.5 years. All procedures were performed on an outpatient basis under general anesthesia in an accredited office operating facility. The average patient age was 40.7 years (range, years). Body mass index (BMI) of patients ranged from 18.3 to 37.2 kg/m 2, with an average of 25.3 kg/m 2. Only two patients had experienced truly massive weight loss (130 lb and 160 lb), both secondary to gastric bypass surgery. Tissue resection was carried out at the level of the umbilicus in 20 patients, 5 cm or less above the umbilicus in three patients, and 5 cm or less below the umbilicus in 12 patients (Figures 3-5). Ten patients had no liposuction, 13 patients had a nominal amount of liposuction (200 ml or less at the lateral ends of the closure), and 12 patients had simultaneous liposuction of a significant amount in the epigastrium (zone I) and flanks (zone II), averaging 816 ml of aspirate. Liposuction was performed just prior to final wound closure and was not designed to facilitate flap advancement. Three patients underwent additional minor procedures at the time of abdominoplasty (cervical liposuction, upper blepharoplasty, and labiaplasty), and eight underwent simultaneous breast surgery (augmentation, mastopexy, or implant removal and replacement). Seven patients were smokers. All were encouraged to stop smoking in the perioperative period, but it was assumed that they would not. There were three complications in this series, all in smokers. There was one instance of umbilical stenosis, which required secondary correction under local anesthesia. One methicillin-resistant Staphylococcus aureus (MRSA) wound infection (the patient in Figure 4) required wound drainage and a course of oral linezolid (Zyvox, Pfizer, Inc., New York, New York). One patient developed an interstitial hematoma in the areas treated by liposuction; this case was thought to be related to inadvertent aspirin ingestion. No treatment was required other than oral iron supplementation. No seromas were encountered in this series, although aspiration was attempted in three patients to rule out the presence of fluid. There were no ischemic complications or problems directly related to the lack of undermining or to tension on the wound closure. No patients required hospitalization. Discussion Abdominoplasty is traditionally performed by making a long incision across the lower abdomen and elevating a flap up to the costal margins. The flap is then advanced distally to determine the amount of tissue resection. This is a relatively tedious dissection that can compromise circulation to the remaining tissue. 14 Lockwood, Saldanha, and others championed discontinuous undermining via instrument or cannula to minimize disruption of perforating vessels, but it is the author s belief that identifying the redundant tissue at the onset of abdominoplasty minimizes the amount of undermining necessary to complete the procedure. If diastasis repair is not being performed and the umbilicus is being sacrificed, the operation might be possible with no undermining at all. Key to the performance of this technique is the marking of a grid on the preoperative abdominoplasty patient. By serial placement of this grid, the author was able to standardize the pattern of tissue resection in abdominoplasty. This led to the realization that the exact extent and pattern of skin resection could be determined in a matter of moments at the beginning of the procedure by simply determining the most proximal point on the midline that

5 Pechter 575 Figure 2. (A, B) Tissue resection extending below the umbilicus. The preoperative grid markings are shown, with the outline of the resected tissue added postoperatively. (C, D) The woman described in parts A and B is shown preoperatively. (E, F) Four months after abdominoplasty with the author s minimal undermining technique. could be approximated to the midpoint of the desired final scar location. It is not necessarily recommended that other surgeons perform tissue resection in the same pattern as the author, but rather that they adopt the habit of marking a grid preoperatively on their patients. The exact extent and pattern of tissue resection can then be superimposed postoperatively on preoperative photographs of the grid-marked

6 576 Aesthetic Surgery Journal 30(4) Figure 3. (A, B) Tissue resection to the umbilicus. The preoperative grid markings are shown, with the outline of the resected tissue added postoperatively. (C, D) The woman described in parts A and B is shown preoperatively. (E, F) Four months after abdominoplasty with the author s minimal undermining technique. This patient had 700 ml aspirated from the flanks and epigastrium. patient. Over a period of time, this will allow recognition of the pattern of tissue resection that best meets the aesthetic needs of their patients. It should be emphasized that the heavy black lines seen on all photographs in this report were added to the photos postoperatively to document the exact pattern and extent of intraoperative tissue resection. This is in contradistinction to the many preoperative designs proposed for the tissue resection in

7 Pechter 577 Figure 4. (A, B) Tissue resection extending above the umbilicus. The preoperative grid markings are shown, with the outline of the resected tissue added postoperatively. (C, D) The woman described in parts A and B is shown preoperatively. (E, F) Fourteen months after abdominoplasty with the author s minimal undermining technique. The patient also underwent breast implant removal and replacement. abdominoplasty, which do not show how the patterns may have been adjusted intraoperatively In the author s initial description of the technique, stapling was carried out entirely across the redundant tissue, but once it was determined that a horizontal proximal line of resection was ideal, stapling was no longer necessary. Additionally, a two-step procedure was utilized for patients with very large panniculi whose bulk made it difficult to

8 578 Aesthetic Surgery Journal 30(4) determine the ideal point of proximal resection. Although this remains a safe way to learn the procedure, with further experience, the author has been able to gauge the excess tissue accurately with a single step in almost all cases. The grid technique has not been employed in patients with truly massive panniculi or for circumferential bodylifts, although the author believes that the principles of the technique would apply to such cases. Although beginning the operation with a proximal incision is not new, the grid technique allows the site of the proximal incision to be determined by the desired location of the final scar. If the proximal incision is made without prioritizing the final position of the scar, the location of the scar becomes dependent on the amount of redundant tissue, often leaving an unaesthetic high scar with excess elevation of the mons pubis. Conclusions This modified abdominoplasty technique allows the surgeon to determine the exact pattern of tissue resection at the beginning of the case with a grid marked preoperatively on the patient. This technique simplifies and provides consistency to the operation, facilitates placement of the final scar in the desired location, and virtually eliminates dog ears. Perhaps most important, it has led to the realization that a full abdominoplasty can be performed with only the amount of undermining necessary for diastasis repair and umbilical transposition, which in turn minimizes the risks of ischemic complications and of simultaneous liposuction. Acknowledgments The author recognizes Shanell Roberts, ORT; Dennis O Leary, CRNA; Rosanne Valentino, RN; Twila Hancock; and Kathy Meter-Mahler for their contributions to this technique and manuscript. Disclosures The author declared no conflicts of interests with respect to the authorship and/or publication of this article. Funding The author received no financial support for the research and/ or authorship of this article. References 1. Friedland JA, Maffi TR. MOC-PS CME article: abdominoplasty. Plast Reconstr Surg 2008;121: Lockwood T. Lower body lift with superficial fascial suspension. Plast Reconstr Surg 1993;92: Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg 1995;96: Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 1979;45: Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg 1995;95: Matarasso A. Liposuction as an adjunct to a full abdominoplasty revisited. Plast Reconstr Surg 2000;106: Shestak KC. Marriage abdominoplasty expands the miniabdominoplasty concept. Plast Reconstr Surg 1999;103: Avelar JM. Abdominoplasty without panniculus undermining and resection: analysis and 3-year follow-up of 97 consecutive cases. Aesthetic Surg J 2002;22: Saldanha OR, Pinto EB, Matos WN Jr, Lucon RL, Magalhães F, Bello EM. Lipoabdominoplasty without undermining. Aesthetic Surg J 2001;21: Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg 2003;27: Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg 2009;124: Pechter EA. The grid/staple adjunct to abdominoplasty. Plast Reconstr Surg 2006;118: Matarasso A. Geometric incision designing for abdominoplasty (discussion). Plast Reconstr Surg 2002;109: Mayr M, Holm C, Höfter E, Becker A, Pfeiffer U, Mühlbauer W. Effects of aesthetic abdominoplasty on abdominal wall perfusion: a quantitative evaluation. Plast Reconstr Surg 2004;114: Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg 1967;40: Grazer F. Abdominoplasty. Plast Reconstr Surg 1973;51: Regnault P. Abdominoplasty by the W technique. Plast Reconstr Surg 1975;55: Baker TJ, Gordon HL, Mosienko P. A template (pattern) method of abdominal lipectomy. Aesthetic Plast Surg 1977;1: Planas J. The vest over pants abdominoplasty. Plast Reconstr Surg 1978;61: Baroudi R, Moraes M. A bicycle-handlebar type of incision for primary and secondary abdominoplasty. Aesthetic Plast Surg 1995;19: Gerow F, Walker L, Spira M. The French-line abdominoplasty. Ann Plast Surg 1996;36: Grolleau J, Lavigne B, Chavoin J, Costagliola M. A predetermined design for easier aesthetic abdominoplasty. Plast Reconstr Surg 1998;101: Ramirez O. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000;105: Thirumalai A, Varma S. Geometric incision designing for abdominoplasty. Plast Reconstr Surg 2002;109: Teitelbaum S. Demystifying high-lateral-tension abdominoplasty. Aesthetic Surg J 2006;26: