الفهرس 
Anatomy of the abdominal wallOnly 14 pages are availabe for public view
 |  | from | 146 |  |  |
| | | from | 146 | | |
Abstract
We all know that the anterior abdominal wall is one of the body areas most affected by aging, body weight variations, non disciplined life style, adipose tissue anomalous accumulations, celiotomies and pregnancies. For decades, these dysmorphisms have led many men and women to pursue exercise, physiotherapy, sports, dietary regimens and all sorts of non invasive treatments to solve their physical problems, of which the anterior abdominal wall is one of the most important. And in face of the very limited and unsatisfactory results achieved, the best solution turned out to be cosmetic abdominoplasty.
Surgical correction of abdominal wall laxity, tissue redundancy, and increased lipodystrophy through an open abdominoplasty procedure has been an accepted practice since the mid-twentieth century. The procedure has been revised and updated countless times, whereas the principal belief of reduction of the redundant panniculus and correction of rectus fascia diastasis has remained.
Abdominoplasty, one of the most commonly performed aesthetic procedures, has undergone a significant evolution over the past several decades. It is targeted at addressing abdominal deformities characterized by excess skin and subcutaneous tissue and laxity of the abdominal wall musculature.
Abdominoplasty has been performed for more than 110 years. During this time, many significant advancements of this procedure have been developed. This operation is no longer simply an excision and closure removing unwanted redundant lower abdominal skin. It is now a family of procedures that addresses each individual patient’s body habitus, personal desires and health status to provide for maximal benefit in shape and contour.
When performing abdominal contouring procedures, it is necessary to understand the anatomy of the abdominal region and how it relates to the specific surgical operation being performed. The anatomy of the abdominal wall is both straightforward and elegant. A thorough knowledge of the vascular source, the innervation, the lymphatics, as well as the deep and superficial structures of the abdominal wall is important for performing abdominoplasty and abdominal contouring procedures. Most importantly, knowledge of the vascular supply to the abdominal soft tissue as well as the superficial soft-tissue structures, specifically Scarpa’s fascia, is critical to safely achieve an optimum aesthetic result.
Understanding the superficial fascia (SFS) or Scarpa’s fascia is important in achieving safe and aesthetically pleasing results in abdominoplasty procedures. The vascularity of the abdominal soft tissue is particularly important, considering the large area that is often undermined during abdominoplasty, the common use of concurrent liposuction, and the fact that the tissue is often closed under tension. A clear understanding of the blood supply and soft tissue layers is critical when planning incisions, determining the amount of tissue to be resected, and deciding whether concomitant liposuction or lipectomy is indicated. It is also important when managing the umbilicus and calculating the degree of flap elevation, especially in patients who have had prior abdominal procedures.
Understanding the muscular and fascial components of the abdominal wall is important for myofascial plication and hernia repair. The sensory distribution is also important when considering incision placement for abdominal body contouring procedures.
The form of the abdomen is defined by the skeletal structure, as well as the quantity and distribution of fat, the appearance and condition of the skin, the tonus of the aponeurotic and muscular system, and the protrusion of the intra-abdominal organs. Each of these components constitutes an independent variable within the diagnosis of deformity of the abdominal wall, and will determine the type of treatment indicated for the patient. Abdominal alterations may be summarized as: cutaneous (redundancies, stretch marks, scars, flaccidity and retractions); accumulation of subcutaneous tissue (lipodystrophy); and those affecting the muscular-aponeurotic system (diastasis, hernia, eventration and convexity). The ultimate goal of surgery is to achieve an aesthetic contour, with acceptable scars, and the return of full function of the abdominal girdle.
Proper patient selection and education are paramount factors to ensure long-term success of the procedure. Selection of the ideal abdominoplasty procedure depends on the grade of excess skin and stretch marks, lipodystrophy, and musculoaponeurotic laxity. Patients opting for abdominoplasty must have realistic expectations and should be committed to implementing some healthy lifestyle changes that include eating, a well-balanced diet and exercising regularly. Several authors created useful classifications mostly on the basis of subcutaneous excess fat, skin deformity, and rectus diastasis secondary to pregnancy.
Many surgical techniques are currently available for abdominal contouring. Based on the individual characteristic of the patient’s anatomy and their goals, these abdominal contouring procedures include liposuction alone and different techniques of abdominoplasty procedures with or without liposuction.
An important contribution to contouring of the trunk was the introduction of suction-assisted lipectomy (SAL) in the late 1970s, which has permitted the removal of fat deposits by means of minimal incisions. Modeling of the abdomen has been considerably improved, either as a single procedure or associated with abdominoplasty, allowing the surgeon to complement a dermolipectomy with liposuction to enhance the waistline. It is no longer conceivable to aesthetically improve an abdomen without it. Suction-assisted lipectomy has also decreased the necessity for extensive undermining, thus contributing to lessening the rate of complications, such as serosanguineous collection and flap ischemia.
Traditional abdominal contouring surgery has been limited to the standard abdominoplasty performed through a variety of surgical incisions and with minimal variations in technique for long period. Standard abdominoplasty is a surgical procedure in which excess skin and subcutaneous fat in the abdominal area is removed and the abdominal muscles are tightened. It is usually associated with a relatively high complication rate because of the large scale undermining required. It also involves the rupturing of the lymphatic and neurovascular supply to the abdominal flap.
The traditional abdominoplasty has been used for many years with several modifications intending to achieve better aesthetic contouring and to reduce complications. However, each modification solves problems only partially.
Despite advancements in abdominoplasty techniques, however, a significant complication rate still is associated with abdominoplasty including flap necrosis, seroma, hematoma, infections, and fat necrosis, wound dehiscence, and delayed healing. Because this procedure involves extensive undermining, denervation occurs, and the skin flap loses vascularity. The flap, with its reduced blood flow and innervations, then is stretched maximally and sutured under tension, which results in ischemia and lack of sensation in the lower abdominal skin. Moreover, even with adequate drainage, there still is a high rate of postoperative seroma.
The advent of minimally invasive surgery has led surgeons to seek a method that would provide cosmetic improvement of the abdominal wall laxity and rectus diastasis and would minimize the resultant scar. Endoscopically assisted techniques of abdominoplasty such as plication of the rectus fascia through an umbilical incision by using an endoscopic retractor were described. These approaches have been labeled “prefascial endoscopic abdominoplasties”.
The Lipoabdominoplasty technique is not simply using liposuction while performing abdominoplasty. It represents a much wider concept, respecting the complete abdominal anatomy. Lipoabdominoplasty is based on the selective undermining of the abdominal flap in the superior midline between the medial edges of the rectus abdominus for muscle plication, resulting in the preservation of arteries, veins, lymphatic vessels, and nerves. The classic undermining was replaced with cannula undermining and liposuction of the subcutaneous fat of the entire abdomen with resection of the infraumbilical skin and remaining subcutaneous fat. As a result, we preserve most of the peri- and supraumbilical perforator vessels to the abdominal skin, the neural chain and lymphatic vessels, thereby reducing the incidence of complications associated with traditional abdominoplasty due to large-scale of undermining required such as seroma, hematoma, skin slough, and skin necrosis, and preserving the suprapubic sensibility.
The keys to successful lipoabdominoplasty, first developed as the high-superior-tension technique, are extensive liposuction, preservation of lymphatic trunks, preaponeurotic epigastric dissection, major muscle fascia plication, two high-tension paraumbilical sutures, hypogastric tension sutures, and closure of the dead spaces.
Abdominoplasty has become one of the most frequently performed procedures for improving body contour. Abdominoplasty is among the most popular procedures in esthetic surgery generating high levels of patient satisfaction. It is, nevertheless, associated with a significant incidence of complications (32e37.4%). These, however, do not seem to negatively affect patient satisfaction. The most commonly reported being seroma formation and wound complications/skin flap necrosis. There are numerous reports that focus on the preoperative risk factors and postoperative complications, with studies further suggesting technical modifications in order to decrease their occurrence. In particular, obese patients, smoking and those with no previous history of abdominal surgery seem to be at risk for complications.
Reducing the incidence of complications is an important focus for all surgical procedures. This is especially the case with cosmetic procedures, where relatively healthy and functionally normal patients undergo elective surgery to improve their appearance. Patient selection, preoperative screening, selection of the appropriate surgical procedure, and good surgical technique are all important in avoiding or reducing the incidence of complications. Equally important for overall patient satisfaction, safety, and the final aesthetic result is the proper diagnosis and management of complications when they do occur. As with all problem-solving situations, identifying the existence of the problem, correct diagnosis, and appropriate treatment are all necessary to accomplish this.