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Abdominoplasty: Too many tools, not enough time?

Article-Abdominoplasty: Too many tools, not enough time?

New Orleans — The tools used for abdominal recontouring have evolved vastly from what was offered just a decade ago, and these technological innovations have caused both surgeon and patient to place much more emphasis on the esthetic end result.

When charged with how to best accomplish an artistic abdominoplasty, the importance is placed on the armory of tools and when these should or should not be used to accomplish the best result. As the fourth most popular procedure among American women with over 145,000 abdominoplasties performed in 2004, the tools and their uses can either aid the surgeon or deluge his decisions.

"Anytime you want a good result you have to first know what result it is you're trying to reach," said Felmont F. Eaves, III, M.D., as a panel presenter here at the Aesthetic Meeting 2005, the Annual Meeting of the American Society for Aesthetic Plastic Surgery. "There are a number of different tools and all give good results, but it's important to determine which is best for each patient."

Determine directive

Although the procedures for today's abdominoplasty may range from liposuction to an endoscopic approach, the modern key to esthetic success lies with an established thought process: know your patient.

"Look at the patient with a thought process that focuses first on the quality and amount of skin. Next, determine the amount of fatty tissue and, finally, be cognizant of the muscle layer underneath," Dr. Eaves says, who is attending physician, Charlotte Plastic Surgery, Charlotte, N.C. "If there has been a hernia or diastasis, you will have to repair this area to tighten the muscle layer."

Focusing on the musculoaponeurotic layer is an approach Dr. Eaves' panel co-presenter, Fabio X. Nahas, M.D., Ph.D., stresses.

"Most of my studies were done based on this layer — abdominal deformities occur because of the excess skin, excessive subcutaneous tissue and deformities of the muscles and fascias of the abdominal wall," Dr. Nahas says, who is plastic surgeon, practicing in São Paulo, Brazil.

In a recent case report of two patients, Dr. Nahas addressed recurrent rectus diastasis secondary to abdominoplasty. The main reason for recurrence of this deformity in these patients was lateral insertion of the rectus muscles on the costal margins. According to the findings, advancement of the recti muscles seems to be a reliable method for correcting recurrent rectus diastasis in patients with later insertion of the recti muscles (Aesthetic Plast Surg. 2004 Jul-Aug;28(4):189-196).

"Rectus diastasis is a deformity of the musculoaponeurotic structure of the abdomen that usually occurs secondary to pregnancy. However, I described a special congenital condition (the lateral insertion of the recti muscles in the costal margin) on which the traditional method of correction of this deformity may fail, leading to recurrence," Dr. Nahas says. "Therefore, these two patients described were corrected by the traditional method and presented recurrence of this deformity. This paper stresses the point that a proper diagnosis of deformity of rectus diastasis and other deformities of this layer should be carefully diagnosed and treated using a specific technique."

Being aware of adjacent areas outside of the abdomen, like the flanks and mons, as well as emphasizing the esthetic appearance of the umbilicus further aids the plastic surgeon in optimizing overall results, according to Dr. Eaves.

"The umbilicus can be very challenging, especially if there is a circular hole and the scar contracts," Dr. Eaves says. "There are two ways to solve this problem: place a small flap to break up the scar pattern or make a new umbilicus. One way to inset a flap is to mature the umbilicus through an inverted 'U' or 'V' incision combined with an adjacent splitting incision in the umbilicus. The small resulting abdominal skin flap is sutured into the split of the umbilicus. If a neoumbilical reconstruction is undertaken, a modification of the Baroudi technique is utilized."

While not used by many, neoumbilical reconstruction is a procedure Dr. Eaves uses most often in conjunction with tram-flap breast reconstruction, massive weight loss patients, those who have had a prior umbilical hernia repair or in patients whose blood supply to their umbilical is not intact due to a prior mini-abdominoplasty.

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