Endoscopic plication techniques for the treatment of abdominal contour

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Chapter 24 Endoscopic plication techniques for the treatment of abdominal contour

Ana Z.D. Badin, Lea M. Moraes

Introduction

The treatment of the abdominal contour, in general, is managed by procedures at two extremes, liposuction and classic abdominoplasty. Patients with excess abdominal adiposity without flaccidity undergo liposuction, and those with accentuated abdominal laxity have traditionally been treated with the classic abdominoplasty, which corrects the excess skin and fat in the abdominal wall, and is usually performed in association with the correction of abdominal diastasis recti. In most patients the outcome of the latter procedure is favorable, but at the expense of extensive scarring, which is not always well accepted by patients. However, a range of intermediary cases exist which are not a perfect match for either simple liposuction or classic abdominoplasty.

Basic Science

Diastasis of the rectus abdominis muscles requires correction, regardless of whether there is enough excess skin for classic abdominoplasty. Many cases requiring correction of diastasis are contraindicated for classic abdominoplasty.

In cases where the navel is high, leaving little skin expanse above the umbilicus, or even in cases where the supraumbilical skin has little flaccidity, a classic abdominoplasty is difficult. Patients with post-pregnancy diastasis but with plans for further pregnancies are also a relative contraindication for the classic tummy tuck.

The correction of the diastasis can be accomplished via a small video-assisted suprapubic incision, without skin resection, or by a mini-abdominoplasty in a technique described since 1971 by Callia, with a small infraumbilical skin resection. Other authors have already described, with variations, an infraumbilical plication only and no detachment of the umbilicus.¹^–⁷ There are also descriptions of a small incision in the umbilicus to facilitate the supraumbilical detachment² and another approach that detached the umbilicus from the m. rectus.^8,⁹ Since the introduction of video-endoscopy, indications for the correction of diastasis without skin resection can be extended to include, primarily, congenital diastasis and diastasis in men.¹⁰

Indications for video-assisted mini-abdominoplasty are limited. This option must be precisely discussed with the patient because, on the one hand, there is the advantage of less scarring, but on the other hand, resection of skin is limited and there may be mild residual laxity both above and below the umbilicus. Another factor that should be considered in female patients is the possibility of pregnancy after surgery. In nulliparous patients who have abdominal flaccidity following weight loss (Figs 24.1 and 24.2), or in patients who have post-pregnancy abdominal flaccidity but are planning another pregnancy, this technique would be well indicated, because it doesn’t present the same limitations as classical abdominoplasty for postoperative pregnancy.

FIG. 24.1 Pre- and postoperative young patient, post weight loss, frontal view.

FIG 24.2 Appears ONLINE ONLY

FIG. 24.2 Pre- and postoperative young patient, post weight loss, half profile view.

Diagnosis/Patient Presentation

It is essential that candidates for this procedure have a high navel; this allows correction of the flaccidity that occurs right above the umbilicus, by reinserting the navel a few centimeters lower (1.5 to 2 cm), while still maintaining an adequate distance between the umbilical scar and pubic region.

Proper physical examination of the patient is of paramount importance, both in the seated position, to measure if the supraumbilical fold is correctable with mini-abdominoplasty, as well as lying down with effort, to assess the degree of diastasis. In patients with thick adipose tissue, moderate liposuction can also be performed, being sure to maintain a sufficient thickness of the panniculus to avoid surface irregularities and increased skin flaccidity above the umbilicus.

Patient Selection

The selection of patients is subject to strict criteria:

• Patients with mild supra- and/or infraumbilical skin laxity, with diastasis of the rectus abdominis.

• High navel position, more than 14 cm above the pubis.

• Firm or minimally flaccid supraumbilical skin that will not allow the descent of the supraumbilical region to the suprapubic region.

• The possibility of post-abdominoplasty pregnancy, provided that the flaccidity is not excessive. These patients fall into Types III and IV of the Bozola and Psillakis classifications,¹ and Type I in the Nahas classification system.⁴

• Diastasis of the rectus abdominis muscle, which can either be acquired (post-pregnancy or following weight loss), or congenital, which can occur in both women and men (Figs 24.1–24.7).

FIG. 24.3 Correction of congenital diastasis – male patient, frontal view.

FIG. 24.5 Correction of congenital diastasis – male patient, profile view.

FIG. 24.6 Correction of diastasis of the rectus abdominis, half profile view.

FIG. 24.7 Correction of diastasis of the rectus abdominis, profile view.

FIG 24.4 Appears ONLINE ONLY

• Abdominal hernias (especially umbilical hernia) associated with lipodystrophy and skin flaccidity (Figs 24.8 and 24.9).

• Lipodystrophy and moderate skin flaccidity, where liposuction would offer limited results (Figs 24.10 and 24.11). Younger patients who have undergone massive weight loss resulting in abdominal flaccidity fall into this category, and also those with post-pregnancy flaccidity but who may become pregnant in the future (Figs 24.12 and 24.13).

FIG. 24.8 Abdominal hernias (especially supraumbilical hernia) associated with lipodystrophy and sagging skin, frontal view.

FIG. 24.9 Abdominal hernias (especially supraumbilical hernia) associated with lipodystrophy and sagging skin, profile view.

FIG. 24.12 Patient with post-pregnancy flaccidity and umbilical hernia who may have a future pregnancy, frontal view.

FIG. 24.13 Patient with post-pregnancy flaccidity and umbilical hernia who may have a future pregnancy, profile view.

FIG 24.10, 24.11 Appears ONLINE ONLY

FIG. 24.4 Correction of congenital diastasis – male patient, half profile view.

FIG. 24.10 Pre- and postoperative patient who underwent mini-abdominoplasty with repair of diastasis associated with liposuction scapular regions, waist and flanks, frontal view.

FIG. 24.11 Pre- and postoperative patient who underwent mini-abdominoplasty with repair of diastasis associated with liposuction of scapular regions, waist and flanks, half profile view.

Surgical Technique

Materials for Video-endoscopy

Video endoscopic-assisted surgical procedures offer image amplification and visualization, and the ability to both reduce scars and position them remotely, away from the surgical field. However, they also require a greater complexity in instrumentation and in organizing the surgical suite, as well as familiarization with new technologies and a flat learning curve.

Basic components for performing the procedures are:

FIG. 24.15 Video imaging system.

Monitor, light source, micro camera.

In plastic surgery we use 30° or 45° endoscopes, 4 or 10 mm at 0° for larger optical cavities in need of better lighting, such as in surgery for the breast and torso. The retractor compensates for the angle of the endoscope and allows maintained visualization of the pocket being dissected. The xenon light source is fundamental to the 4 mm endoscope, to provide more illumination, because the field with the upper abdominal muscles is a deep, dark hollow. The 10 mm endoscopes can be used effectively with a 250 W halogen light source.

Video Imaging System

Video-endoscopic systems include a video camera, light source, video monitors and recording devices. These elements comprise the most costly part of the instrumentation. They are available in most surgery centers and are commonly in use in all surgical specialties that employ video-surgery.

Methods for Creating and Maintaining the Optical Cavity

In plastic surgery, where there are no natural optical cavities that provide visualization of the structures, they must be created within the target tissue area.

By separating the tissues in a cranial direction, the retractors serve a dual purpose: to expose the structures and to facilitate the dissection, using the tension exerted by the tissues not yet dissected. For this reason, the lens is 30° or 45°, to compensate for the rise of the optical tip, focusing the image in the margin of the optical cavity, where most of the dissection takes place. The 10 mm endoscopes may have a 0° angle, because they offer the greatest amplitude of image (Fig. 24.16).

FIG. 24.16 Endoscope and retractors – the retractor is coupled to the endoscope.

Dissectors

In endoscopic mini-abdominoplasty, we use various instruments for dissection, suction and cautery, and endoscopic tweezers and scissors. These instruments come in several configurations, depending on the manufacturer. They need to be long, to accommodate the distance from the incision to the work area. The tweezers and scissors should engage with the cautery, to be able to cut and cauterize in a single motion.

Video-Assisted Technique

Access to the upper abdomen without an extensive incision is quite difficult, and fiber optic endoscopy has contributed greatly to this approach by offering excellent access, with reduced scarring.

The video-assisted mini-abdominoplasty consists of a suprapubic incision, followed by detachment up to the xiphoid process, with detachment of the umbilicus.

In patients with thick adipose tissue, liposuction using cannulas of 3.0 to 3.5 mm is done first, above and below the umbilicus, as well as in the waist and flank regions, if necessary.

The detachment is performed under direct visualization up to the umbilicus, and after this detachment, a retractor connected to the video camera is used to complete the detachment, for hemostasis, and for plication of the aponeurosis of the rectus abdominis muscles.

The plication repair is initially done with separate 2-0 nylon sutures, followed by continuous #1 Vicryl sutures up to a point on the linea alba, about 1.5 to 2 cm from the original position of the umbilicus before plication. Then we continue with interrupted sutures for 1 to 1.5 cm below this point and return to the running stitch, to complete the plication caudally.

The diastasis of the rectus abdominis muscles has a strong impact on the body contour, especially in the upper abdomen. A swordtail-pubic plication promotes better abdominal contouring, with better definition of the anterior abdominal wall and improvement of volume in the epigastric region.

After completion of the plication, the navel is reinserted through the suture that was left in the midline, and plunged into the navel plication. This maneuver, described by Correa,¹¹ gives a natural depth to the navel. It is important to fix the umbilicus in its new insertion point before resection of the skin, to achieve a precise result.

Another way of fixing the navel is to make three internal sutures with Vicryl 3-0 in the umbilicus, two above and one below, forming an inverted triangle. Mark the new position of the umbilicus, observing for symmetry, and fix these sutures in the aponeurosis of the rectus abdominis. With this method, the navel tends to be shallower.

A 4.2 mm suction drain is placed, leaving a counter incision in the pubic region.

Then the resection of excess skin and subcutaneous tissue that has been estimated previously is carried out. Do not remove too much skin when doing a very minimal incision (Caesarean type). A medium-length scar (not as extensive as the classic), is a better option with a good esthetic result.

A few Baroudi stitches are made between the flap and aponeurosis, to reduce dead space, and the suturing of skin and subcutaneous tissue is performed in multiple planes.

Postoperative Care

A pressure dressing is applied, and the drain is removed only when the drainage volume over 24 hours is less than 30 ml. After the drain removal, the patient uses a contention plate and abdominal compression garment for 30 to 60 days.

Smoking should be stopped at least 15 days pre-and postoperatively.

Regarding the recovery period, we see no great difference from classical abdominoplasty, contrary to those authors who advocate only an infraumbilical plication.⁷ Because of the dissection and muscle plication, the patient remains hospitalized for 24 hours, and should relax for 10 to 14 days, which is also important for prevention of seromas.

Outcomes, Prognosis, and Complications

Plication of the rectus abdominal with a minimal incision involves a central swordtail-pubic detachment, and may involve liposuction to accommodate the abdominal flap while preserving the lateral perforations, or even the Dílson Luz ¹² retractors, to release the flap from the lateral area without compromising the perforators, and avoiding excess skin above the navel.

As any detachment seroma and hematoma may occur, Baroudi sutures and vacuum drainage contribute greatly to reduce the incidence of these complications.

A flat navel, without depth, occurs particularly in thin patients. The use of the maneuver described by Correa has contributed to a more esthetic umbilicus. Dog-ears can be corrected with minimal skin resection or liposuction.

Secondary Procedures

In one case, the patient experienced an epigastric hernia, which was corrected via a new mini-abdominoplasty.

The most undesirable result is patient dissatisfaction with the surgical result, due to unrealistic expectations. Therefore, we should take enough time preoperatively, trying to understand the expectations of the patient, to avoid having to turn a mini-abdominoplasty into a classic abdominoplasty, due to patient dissatisfaction (Figs 24.17 and 24.18). Video-endoscopy has made a major contribution to the correction of diastasis of the rectus abdominis muscles, umbilical and supraumbilical hernias. It enables hemostasis and plication of the aponeurosis of the rectus abdominis muscle, avoiding a new incision at the umbilicus. This technical refinement facilitates surgery, reduces scarring and results in better outcomes.

FIG. 24.17 Correction of diastasis with mini-abdominoplasty.

(A) Preoperative view; (B) post mini-abdominoplasty.

FIG. 24.18 Patient dissatisfied with mini-abdominoplasty and underwent subsequent classic abdominoplasty.

(A) Preoperative view (post mini-abdominoplasty); (B) Post classic abdominoplasty.

Another great advantage of this technique is the improved vascularization of the abdominal flap, because the detachment is more central, avoiding the costal margin, which preserves the upper pedicles (superior epigastric and intercostal arteries).¹³ This, coupled with less tension on the scar, due to limited resection of skin, reduces complications. Beyond that, the flap procedure in combination with abdominal liposuction does not increase risks, if performed carefully, and allows better accommodation of the flap over the plicated abdominal wall, especially above the navel. The applicability of this technique is related to precise indications and strict evaluation, to avoid patient dissatisfaction related not to the abdominal wall fixation, which is always satisfactory, but to skin excess, which is not tolerated by patients. When the indication, treatment of diastasis without excess skin, is correct, the result will always be pleasing for women or men.

Bonus images for this chapter can be found online at http://www.expertconsult.com