Method of contour plastic surgery of anterolateral abdominal wall

Abstract

FIELD: plastic surgery.SUBSTANCE: used for contour plastic surgery of the anterolateral abdominal wall. Preoperative markings are performed first in a standing position, then in a sitting and lying position. Tissue dissection is performed in the supine position with arms abducted at an angle of 30 degrees. An incision is made in the skin and subcutaneous tissue in the suprapubic region up to the aponeurosis of the rectus abdominis muscles. The tissue in the lower section is excised as a single block, and the umbilical ring is separated from the surrounding skin. A vertical dissection is performed within the boundaries of the rectus abdominis muscles; diastasis of the edges of the rectus abdominis muscles is eliminated by creating a duplication with two-row U-shaped sutures. After that the operating table is bent at an angle. The flap in the dissection area is displaced caudally and fixed along the midline. An acceptor bed for the umbilical ring is formed by making a skin incision in the shape of an inverted Latin letter V, the navel is sutured according to the markings, and two active drains by Redon are installed. The surgical access is closed layer by layer.EFFECT: increasing the aesthetic and anatomical effectiveness of abdominoplasty while simultaneously reducing the risk of postoperative complications due to individually verified three-position markings, differentiated tissue excision with preservation of local adipose tissue and Scarpa's fascia, as well as anatomically sound V-shaped repositioning of the umbilical-stem complex.1 cl, 12 dwg

Description

[0001] The invention relates to medicine, namely plastic surgery, and can be used to perform contour plastic surgery of the anterolateral abdominal wall.

[0002] Statistical findings indicate a high incidence of potential complications associated with torso contouring. These include: thromboembolism of major vessels (0.1-1.3%), hematomas (5.2-7.6%), seromas (31.2-51.5%), including encapsulated seromas (3.4-7.3%), secondary infection (6.8-11.1%), delayed wound healing and the formation of long-term non-healing wounds (8.3-11.1%), and the formation of aesthetically unacceptable (hypertrophic and keloid) scars (7.5-12.4%). All of these complications may necessitate additional postoperative treatment, increase the cost of the procedure, and often lead to legal consequences for medical care.In a retrospective analysis of the clinical causes of complications that developed after abdominal contouring in overweight individuals, it became clear that in the overwhelming majority (98% of cases), complications arose when using routine intervention techniques associated with extensive tissue detachments in various planes.

[0003] The closest technique to the claimed method is the Grazer method of anterolateral abdominal wall contouring. Preoperative markings are made in a standing position, with a lower transverse incision being made directly above the pubic symphysis and then along the skin fold to the level of the anterior iliac spines. The marking line is then raised in an arc to the level of the umbilicus. The surgical procedures then begin: incision, dissection to the level of the umbilicus and its removal, wide dissection to the level of the xiphoid process, plication of the rectus abdominis muscles, flap fixation, intraoperative determination of excess tissue and its removal, umbilical fixation, drainage placement, and layered wound closure.

[0004] This technique has its drawbacks. It requires extensive dissection, which increases the aseptic inflammatory cascade and reduces tissue perfusion, leading to the development of the complications described above.

[0005] The technical result of the invention is the preoperative determination of the amount of tissue to be removed, ensuring maximum tissue perfusion, reducing the incidence of complications due to a reduced bell-shaped dissection zone and fixation of the flap to the bottom of the wound; reducing the time of surgery.

[0006] The specified technical result is achieved in the method of contour plastic surgery of the anterolateral abdominal wall, including preoperative marking, tissue dissection and flap fixation, characterized in that the preoperative marking is performed first in a standing position, then sitting and lying down as follows:

[0007] - in a standing position with arms down, mark the midline of the body 1, the midaxillary lines on the right and left, designate the intended incision, which has an arcuate, concave in the caudal direction, bell-shaped shape, the lower point of the incision along the midline of the body 1 in the suprapubic region 4 cm above the pubic symphysis 2, laterally to the right and left the incision is raised to the level of the anterior iliac spines 3 and ends at the level of the midaxillary lines,

[0008] - with the patient in a sitting position with a relaxed back, using a pinch test, the required amount of tissue to be removed is determined along the midclavicular lines 4 on the right and left and the upper border of the incision is marked 1 cm below the points determined by the pinch test,

[0009] - with the patient in a lying position, the lateral boundaries of the rectus abdominis muscles are determined by palpation, marking lines are drawn along these boundaries to the level of the xiphoid process of the sternum 5, at the end of the marking, an area is designated in the suprapubic region in which it is necessary to preserve fatty tissue;

[0010] - tissue dissection is performed in the supine position with arms abducted at an angle of 30 degrees, according to the preliminary marking lines, an incision is made in the skin and subcutaneous tissue in the suprapubic region to the aponeurosis of the rectus abdominis muscles with the preservation of a 3 cm section of tissue and the sheets of Scarpa's fascia in the suprapubic region, the tissues in the lower section of the marking are excised in a single block, the umbilical ring is separated from the surrounding skin with the preservation of the umbilical pedicle, vertical dissection is performed within the boundaries of the rectus abdominis muscles, diastasis of the edges of the rectus abdominis muscles of more than 2.0-2.5 cm is eliminated by creating a duplication with two-row U-shaped sutures? the operating table is bent at an angle of 20 degrees, the flap in the dissection area is moved caudally and fixed with 2 or 3 interrupted sutures along the midline, the new location of the navel is determined 7 cm above the line connecting the anterior iliac spines;an acceptor bed for the umbilical ring is formed by cutting the skin in the shape of an inverted Latin letter V, the navel is sutured according to the markings, two active Redon drains are installed on the right and left, the surgical access is closed layer by layer, interrupted inverted sutures are applied to the subcutaneous tissue, the skin is sutured with an intradermal continuous suture according to Halsted, an aseptic adhesive bandage is applied to the suture area.

[0011] The method is illustrated in Fig. 1-12, where:

[0012] In Fig. 1-5- Preoperative photographing of the patient;

[0013] In Fig. 6, 7 - Diagram of preoperative “bell” marking in the standing and sitting positions, respectively;

[0014] Fig. 8 - The patient's position on the operating table before the start of the redraping stage of the skin-fat flap;

[0015] Fig. 9 - Diagram of fixation of the skin-fat flap to the bottom of the wound;

[0016] Fig. 10 - Average time spent on contour plastic surgery of the anterolateral abdominal wall (p<0.05);

[0017] Fig. 11 - Frequency of development of hematomas after contour plastic surgery of the anterolateral abdominal wall (p<0.05);

[0018] in Fig. 12 - Frequency of development of seroma after contour plastic surgery of the anterolateral abdominal wall (p<0.05);

[0019] The method is carried out, for example, as follows:

[0020] Before the operation, photographic documentation of the patient’s appearance is performed in a standing position at full height in five standard projections: full face, profile on the right, profile on the left, half-turned on the right, half-turned on the left (Fig. 1-5).

[0021] Preoperative marking is performed in a standing position with arms at their sides. The midline of the torso 1 and the midaxillary lines on the right and left are marked. The proposed incision is marked as an arcuate, concave in the caudal direction, with the lower incision point along the midline of the torso 1 in the suprapubic region 4 cm above the pubic symphysis 2. Laterally, to the right and left, the incision ascends to the level of the anterior iliac spines 3 and ends at the level of the midaxillary lines. Then, with the patient seated and relaxed, the required amount of tissue to be removed is determined along the midclavicular lines 4 on the right and left using a pinch test, and the upper border of the incision is marked 1 cm below the points determined by the pinch test. Then, with the patient in a supine position, the lateral boundaries of the rectus abdominis muscles are determined by palpation, and marking lines are drawn along these boundaries to the level of the xiphoid process of the sternum 5.This defines a bell-shaped tissue dissection zone. The markings are completed by identifying a region in the suprapubic area where fat must be preserved to ensure adequate wound margin adaptation and lymphatic drainage (Figs. 6 and 7).

[0022] Surgical stage: in the supine position with the arms abducted at a 30-degree angle, plastic surgery of the anterolateral abdominal wall is performed after three times preparing the surgical field with an antiseptic solution. Along the preliminary marking lines, an incision is made in the skin and subcutaneous tissue in the suprapubic area down to the aponeurosis of the rectus abdominis muscles, preserving a 3-cm area of ​​subcutaneous tissue and the layers of Scarpa's fascia in the suprapubic area. Then, the tissue in the lower area of ​​the marking is excised en bloc. The umbilical ring is separated from the surrounding skin, preserving the umbilical pedicle. Hemostasis is performed as needed. Further dissection is performed vertically exclusively within the boundaries of the rectus abdominis muscles. Diastasis of the edges of the rectus abdominis muscles is assessed intraoperatively. If diastasis of the rectus abdominis muscles is detected, it is eliminated by creating a duplication with two-row U-shaped sutures using 1 / 0 Etibond thread. Hemostasis.Then the surgical table is bent at an angle of 20 degrees and the flap in the dissection zone is moved caudally (Fig. 8, 9).

[0023] The flap is fixed with 2 or 3 interrupted Vicryl 0- sutures along the midline. The new location of the umbilicus is determined in accordance with the individual anatomy of the patient. 3. An acceptor bed for the umbilical ring is formed by making an inverted V-shaped skin incision, and the umbilicus is sutured according to the markings with 5 / 0 Prolene sutures. Two active Redon drains are installed on the right and left. The surgical approach is closed layer by layer, interrupted inverted sutures with 2 / 0 and 3 / 0 Vicryl sutures are applied to the subcutaneous tissue, and the skin is sutured with an intradermal continuous Halsted suture with 4 / 0 Monocryl suture. An aseptic adhesive bandage is applied to the suture area. The surgery is completed by putting on compression garments.

[0024] The method has the following advantages: the average time spent on the intervention is reduced by 60.0±36.3 minutes (Fig. 10), the incidence of hematomas is reduced by 100% (Fig. 11), seromas are observed with a frequency 30 times lower (Fig. 12), compared with abdominoplasty using the generally accepted technique with a wide dissection zone (Graser, 1973).

[0025] The method is confirmed by the following clinical example.

[0026] A 38-year-old female patient with a body mass index of 27 kg / m 2 A patient presented to the clinic with a request to improve the contour of her anterolateral abdominal wall. The patient was examined on an outpatient basis. Upon completion of the outpatient examination, she was examined by a general practitioner to obtain a health assessment and clearance for elective surgical intervention for aesthetic reasons. Admission to the hospital occurred on the day of surgery. All liquids and food were withheld for 10 hours prior to admission.

[0027] Preoperative preparation included the administration of low molecular weight heparin (Clexane) 12 hours before surgery in dosages according to body weight.

[0028] To prevent thromboembolic complications, compression stockings were individually selected.

[0029] On the day of surgery, the patient was re-examined by the physician and anesthesiologist. Forty minutes before surgery, antibiotic prophylaxis with a broad-spectrum antibiotic (ceftriaxone) was administered at the required daily dose.

[0030] A contour plastic surgery of the anterolateral abdominal wall was performed using the method described above. Following the surgery, the patient spent two hours in the recovery room and was then transferred to the inpatient ward, where she remained for two days until discharge. The drains were removed 24 hours after the procedure. The surgical time was 120 minutes. The hospital stay was 48 hours.

[0031] The patient's condition was monitored clinically at days 1, 2, 5, 7, and 14 after abdominoplasty, then at 1.5 months, 6 months, and 12 months. The rate of skin integrity restoration, the presence or absence of seromas, hematomas, impaired wound perfusion, and ligature fistulas, as well as the severity of pain, were assessed. No hematomas were detected in patients undergoing anterolateral abdominal wall contouring during the entire observation period.

[0032] The claimed method allows for preoperative determination of the amount of tissue to be removed, ensuring maximum tissue perfusion, reducing the incidence of complications due to a reduced bell-shaped dissection zone and fixation of the flap to the bottom of the wound, and reducing the time of surgery.

Claims

A method of contour plastic surgery of the anterolateral abdominal wall, including preoperative marking, tissue dissection and flap fixation, characterized in that the preoperative marking is performed first in a standing position, then in a sitting and lying position as follows: - in a standing position with arms down, mark the midline of the body, the midaxillary lines on the right and left, designate the intended incision, which has an arcuate, concave in the caudal direction, bell-shaped form, the lower point of the incision along the midline in the suprapubic region 4 cm above the pubic symphysis, laterally to the right and left the incision is raised to the level of the anterior iliac axes and ends at the level of the midaxillary lines, - with the patient in a sitting position with a relaxed back, using a pinch test, the required amount of tissue to be removed is determined along the midclavicular lines on the right and left and the upper border of the incision is marked 1 cm below the points determined by the pinch test, - with the patient in a supine position, the lateral boundaries of the rectus abdominis muscles are determined by palpation, marking lines are drawn along these boundaries to the level of the xiphoid process of the sternum, and the last step is to mark the area in the suprapubic region in which it is necessary to preserve the fatty tissue; - tissue dissection is performed in the supine position with arms abducted at an angle of 30 degrees, according to the preliminary marking lines, an incision is made in the skin and subcutaneous tissue in the suprapubic region up to the aponeurosis of the rectus abdominis muscles with preservation of a 3 cm section of tissue and layers of Scarpa's fascia in the suprapubic region, tissues in the lower marking area are excised as a single block, the umbilical ring is separated from the surrounding skin with preservation of the umbilical pedicle, vertical dissection is performed within the boundaries of the rectus abdominis muscles, diastasis of the edges of the rectus abdominis muscles is eliminated by creating a duplication with two-row U-shaped sutures, the operating table is bent at an angle of 20 degrees, the flap in the dissection zone is shifted caudally and fixed with 2 or 3 interrupted sutures along the midline, a new location of the umbilicus is determined 7 cm upward from the line connecting the anterior iliac spines;an acceptor bed for the umbilical ring is formed by cutting the skin in the shape of an inverted Latin letter V, the navel is sutured according to the markings, two active Redon drains are installed on the right and left, the surgical access is closed layer by layer, interrupted inverted sutures are applied to the subcutaneous tissue, the skin is sutured with an intradermal continuous suture according to Halsted, an aseptic adhesive bandage is applied to the suture area.

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