Chapter 80.

Abdominoplasty

HISTORY

EQUIPMENT

PATIENT SELECTION AND PREOPERATIVE PLANNING

PREVENTION OF COMPLICAITONS

Volume Loading

Pulmonary Thrombosis, Pulmonary Fat Embolism Syndorme

TECHNIQUE FOR SUCTIONING OF ABDOMEN ONLY

FULL ABDOMINOPLASTY

FULL-ABDOMINOPLASTY

MINI-ABDOMINOPLASTY

REVERSE ABDOMINOPLASTY

COMBINED PROCEDURES

POSTOPERATIVE MANAGEMENT

SECONDARY/REVISION PROCEDURE

□ advocated 3 methods(fig 80-1)

① vertical midline resection

② transverse resection

③ combination of vertical & transverse

EQUIPMENT(LIPOSUCTION)

1. pump : 743mmHg

2. silicone tubing : noncollapsible

3. cannulas

① abdomen : 5mm 이하

② most versatile : 3.7mm(annula) with multiple aperture(3 hole)

PATIENT SELECTION & PREOP PLANNING

1. parameter of abdominoplasty

① good health

② integrity of skin & sc tissue

③ skin turgor & contractibility

④ completely normal preop history & physical exam

⑤ drugs : aspirin & anti-inflammatory agent(naproxen) : 2주전에 discontinue

⑥ detailed dietary history & fish oil concentrate(PLT영향)

⑦ preoperative sunburn & any open skin defect

⑧ smoking: 2 주전에 stop

2. typical candidate in each category

① SAL alone으로 좋은 결과

ⓐ localized deformity

ⓑ satisfactory skin turgor

ⓒ potential for skin to contract after suctioning

② candidate for mini-abdominoplasty

: deformity located primarily below umbilicus with loss of elasticity while upper abdomen is firm & flat

③ candidate for abdominoplasty : deformity existing both above & below umbilicus

ⓐ generalized abdominal wall weakness

ⓑ diastasis recti

ⓒ striae gravidarum

3. autologous blood

① suction volume > 2500 ml

② 수술 1-2개월 전에 2 units 이상 donated & oral iron therapy

PREVENTION OF COMPLICATIONS

□ major potential complications

① infection

② wound seperation

③ hematioma, seroma : meticulous hemostasis

④ skin & sc tissue necrosis

⑤ hypovolemic shock

⑥ deep venous thrombosis

⑦ pulmonary problems

(atelectasis, pul embolism, fat embolism synd.)

□ volume loading

① fluid restriction

ⓐ fluid deficit volume of at least 1500-2000ml

ⓑ sudden blood loss & tissue trauma due to surgery

ⓒ fluid shift out of the tissue into major circulation

② to prevent fluid shift

ⓐ crystalloid (Ringer's lactate)

ⓑ 10-12 ml/kg

ⓒ 마취시작 전 투여

□ pulmonary thrombosis, pulmonary fat embolism syndrome

① abdominoplasty, SAL시의 pulmonary embolism

ⓐ 원인 : surgical fat disruption

ⓑ pathophysiology of pulmonary destruction(fig 80-8)

phase I : mechanical obstruction

phase II : hydrolysis of neutral fat

--> increased in local free fat acid concentration

phase III : vasoconstriction, fibrin thrombi, occlusion, DIC

② 방지방법

ⓐ abdominoplasty 시작 시 standard 5% dextrose & 5% alcohol을 IV

: solution contents

ⓑ total 50gm of alcohol을 30분-3시간동안 주입

--> 혈중농도 80mg% 유지(below intoxication level)

(마취효과가 있으므로 마취용량 감소)

ⓒ alcohol의 기전

□ lipase activity inhibit

--> free fat에서 fatty acid로의 breakdown방지

□ tissue plasminogen activator, prostacyclin 형성자극

□ both

a. anti-PLT activity & anti-thromboembolic activity

b. vasodilator action

TECHNIQUE FOR SUCTIONING OF ABDOMEN ONLY

1. SAL indication : satisfactony skin turgor with deformity localized 1o in lower abdomen

2. anesthesia

① 750ml 이하의 suction : local anesthesia(0.3 % lido with 1:320,000 E)

□ 장점

ⓐ blood loss ↓

ⓑ immediate postop period에 pain relief

② > 750 ml : epidural or general

3. blood loss estimation

① lipocrit

ⓐ by determining amount of blood in aspirate following centrifugation of 10ml aliquot

ⓑ 10 % packed cells / 1,000mL aspirate

= 100 mL packed cells / 1000 mL aspirate

② total blood loss = lipocrit x aspiration amount / Hct

③ 5mm 이하의 3 hole cannula : mc used

FULL ABDOMINOPLASTY

□ 9 main steps of full abdominoplasty

① selection of incision

② elevation of panniculus와 SAL의 indication되는가 된다면 elevation전 or 후에 할 것인지를 결정

③ plication of diastasis recti, if indicated

④ closure

⑤ tailoring of umbilicus

⑥ suctioning of upper abdomen, if indicated

⑦ suctioning of adjacent deformities

: hips, flanks, trochanteric areas, if indicated

⑧ trimming of flap & suctioning of dog-ears if present

⑨ drains & dressing

1. selection of incision(fig 80-14)

① depend on

ⓐ patient body type

ⓑ choice of bathing apparel

② 방법

ⓐ modified W-plasty for high French cut bathing suit

ⓑ skin line incision for overweight pt & male

ⓒ gull-wing incision for standard bikini

ⓓ inverted T incision for long waisted pt

2. elevation of panniculus

① panniculus elevation시 electrodissection 유용

ⓐ blood loss↓

ⓑ fascia에 남겨두는 fat↓

② fascia에 subcutaneous fat를 남기는 이유

ⓐ lymphatic vessel의 injury 감소 : seroma 감소

ⓑ perforating vessel의 injury 감소 : bleeding 감소

ⓒ fascia injury감소 : seroma, hematoma흡수 촉진

3. plication of diastasis recti

□ lower abdominal fullness 교정방법

: plication of rectus sheath로 ant. abdominal wall contour deformity가 correction되지 않을 때

① waistline suture of Jackson

ⓑ transposition of EOF flap(Psillakis)

4. closure : flexed position에서

5. tailoring the umbilicus

① umbilicus tailoring시 incsion 범위 : 1-1.5cm in length 이하

② abdominal skin & umbilical stalk base의 rectus fascia suture point

: 3, 6, 9 o'clock position

③ 12시에 안하는 이유 : small hooding으로

ⓐ very youthful appearance. normal appearing umbilicus

ⓑ places small scar in less conspicuous site

6. suctioning of upper abdomen

① controversial → compromized circulation to flap

: small cannula 사용으로 줄일 수 있다

② light suctioning of upper abdomen : more pleasing contour & result

7. suctioning of adjacent deformity

8. trimming of flaps & suctioning of dog-ears

9. drains & dressings

□ supportive garment

① Velcro abdo binder

② girdle of Caromed or foundation type : hip & thigh에 excessive suction

MINI-ABDOMINOPLASTY

1. indication : deformity is limited primarily below umbilicus

2. incision choice : full abdominoplasity와 비슷하나, lat. extent가 not as long

REVERSE ABDOMINOPLASTY

□ indications

① surgical scar 등의 deformity가 upper abdo국한 : inframmary fold incision

② reduction mamoplasty와 흔히 병용, but augmentation은 병행 않음

COMBINED PROCEDURES

□ breast augmentation, reduction, mastopexy

POSTOP MANAGEMENT

1. maintained in flexed position on day of surgery --> 24 시간 후 ambulation

□ OPD : 24hr동안 semiflexed position유지

□ suction patient : no required position

2. drain : 1-2일후 remove

3. velcro binder : 2-3주 동안

4. ultrasound : twice a week for 2-3 weeks

① resolve ecchymosis, edema

② small irregularities교정(lump등)

5. normal activity

① SAL alone : ecchymosis & edema subside직후(2-3주)

② abdominoplasty : 3-4주후

③ strenuous activity : 4-6주

SECONDARY/REVISION PROCEDURE

1. 시기

① SAL alone : 4개월후

② abdominoplasty : 6-12개월후

2. 종류

① scar revision

② suctioning of irregular area

③ deepening of abdominal median raphe