minimized dead space (abdominopexy) plus tension free wound

AAMJ, Vol.8, N. 3, September, 2010 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

268

Minimized dead space (Abdominopexy) plus tension free wound edges Abdominoplasty

Yasser Helmy, Wael Ayad, Abd Al-sttar Al- refai,and ahmad taha

Plastic Surgery, Faculty of Medicine, Al-Azhar University, Cairo

----------------------------------------------------------------------------------------------- ABSTRACT

Background: According to the American Society for Aesthetic Plastic Surgery's 2008 Cosmetic Surgery National Data Bank, the number of abdominoplasty procedures performed has increased approximately333% since 1997 and represent the fifth most frequently performed procedure in 20091,2. Abdominoplasy is one of the most common practiced procedures in Egypt. Large dead spaces is predisposing factor for seroma collection, subsequent infection and wound dehiscence, also wound edges tension is serious predisposing factor for local edges complication. So technique for minimization of dead spaces through certain point’s plication of superficial facial system to abdominal wall musculatures plus closure of tension free edges will be beneficial in minimizing the complication and secondary aesthetic countering of the abdomen. Objective: Use quilting sutures in minimized fashion and certainly defined anatomical points plus tension free wound edges and explain the outcomes. Methods: Twenty two female patient aged from 32 to 49 years old, who was submitted to abdominoplasty with Certain points placation of superficial facial system to abdominal wall musculatures using quilting sutures (abdominopexy) plus closure of tension free wound edges innovated technique. Patient evaluation as regard post operative seroma and local wound complication. Results: Patients submitted for this technique got benefit of minimized dead space and so no post operative hematoma or seroma with early removal of drains and excellent tension free edges wound Healing. Conclusion: Certain anatomical points plication of superficial facial system to abdominal wall musculatures plus closure of tension free edges will be beneficial in minimizing the complication specially seroma and secondary aesthetic countering of the abdomen

Corresponding Author: Yasser Helmy, M.D [email protected]

Yaser Helmy, 2010 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

269

INTRODUCTION

Although abdominoplasty has always been a routine operation, demands for it are constantly increasing for diverse reasons3. The ideal candidate for abdominoplasty should be within normal limits for his or her weight and height (ie, body mass index), has no plans for future pregnancies, has a moderate amount of excess of skin and fat, and has a mild diastasis of the rectus muscles4.

It is very important to achieve early recovery with minimal complications like hematoma, seroma, infection, local wound dehiscence or minor skin edges necrosis. As with all body contouring procedures, complications can occur. In an article from Pitanguy discusses his complication rates over 3 periods, 1955-1960, 1961-1979, and 1980-19985. The most common complications were wound dehiscence, seroma formation, infection, hypertrophic scarring, residual deformity, and wide umbilical scars. As noted from this article, the incidence of complications dropped dramatically with experience.5

According to Pollock, two major factors are responsible for local wound complication, the first is the dead space created by the extensive undermining and mobalization of the abdominal flap, and the second factor is the wound tension which compromise the distal flap and can lead to necrosis 6 .Wound dehiscence may occur when the abdominal wall closure is too tight, with inadequate circulation or stress to the flap or with hematoma formation or development of infection. Tension must be monitored as the abdominal wall is closed. Pain and any postoperative nausea and vomiting must be treated appropriately9.

Seroma is one of the most frequent complications in abdominoplasty7. One theory states that seroma formation is caused by injury to the lymph nodes and lymphatic channels in the inguinal area8,12, whereas others blame it on the use of cautery, too much blood in the wound, or exposed fascia.9

Seroma may cause skin necrosis and subsequent scarring. So careful surgical dissection, reduction in shearing forces, and maintaining some soft tissue over the rectus fascia may decrease the risk of fluid accumulation9.

In the past decades many innovated techniques by many authors have been evolved with great concern to minimize post operative local complications and aiming for improvement of aesthetic outcome.


270

In 1995, Lockwood described the high lateral tension abdominoplasty10. Its key features include limited direct undermining, increased lateral skin resection with high tension wound closure along lateral limbs, and 2-layer superficial fascial system (SFS) repair. Baroudi and Ferreira11 described the attachment of the abdominal flap to the aponeurosis during abdominoplasty to prevent seroma formation. Two years later Pollock6 published progressive tension suture technique to reduce local complication in abdominoplasty by sequential suture technique that involve placing sutures at periodic intervals to advance the abdominal flap and obliterate the dead space between the flap and the underlying musculoaponeurotic facial layer6. In the same year Claude and Pascal described the high superior tension abdominoplasty3. The above techniques were followed by other authors with good clinical results and evaluation of post operative seroma using ultrasonography13.

In this study I used quilting sutures in minimized fashion and certainly defined anatomical points plus tension free wound edges and explain the outcomes.

MATERIAL AND METHODS

Twenty two female patients aged from 32 to 49 years old, who was submitted to abdominoplasty in period from June 2009 to September 2010. They were submitted to abdominoplasty procedure with Certain points plication of superficial facial system to abdominal wall musculatures using quilting sutures (abdominopexy) plus closure of tension free wound edges innovated technique. All patients submitted to general anesthesia and local infiltration with tumescent technique (xylocaine2% and epinephrine 1/200000), only to facilitate surgical plane dissection, and suction of the hips to minimize lateral dog ears. Suction drain was left in every patient. Five patients were submitted to concurrent reduction mamoplasty. Preoperative marking and on table foley’s catheterization after sedation were done. All patients signed an informed consent, for surgery and photography. Patient evaluation as regard post operative surgical drains amount and color, day of drain removal, seroma formation, wound dehiscence, infection, residual deformity, umbilical loss or hypertrophic scarring were done.

Cases were done by the author, who is the same surgeon, 10 cases were done at Al-Azhar university hospitals, and 12 cases at private hospitals, Cairo, Egypt.


271

Surgical technique Transverse lower abdominal suprapubic incision in lazy manner is preformed, flap elevation using surgical knife and cauterization of bleeding points. Leaving thin layer of fat on the muscloapponeurtic layer to preserve lymphatics, without any dissection in Huger’s Zone III. Dissection till the umbilicus then extended circumferential to the umbilicus , with cutting of umbilical skin in heart shaped manner leaving it attached to stalk. A narrow tunnel was dissected over the diastasis from umbilicus stalk till the xiphoid process . Sheath plication in two layers from above downwards and return was done above and below the umbilicus by vicryl 1/0 sutures. Then pannus excision after adjustment when table is flexed. Opening the skin for the new site of umbilicus in heart shaped manner. Five quilting sutures are placed, three of them at 11, 1, and 6 o’clock position peri-umbilical within the umbilical region of the abdomen 2cm away from the umbilical stalk in all directions. Then two quilting suture at 4, and 8 o’clock position at mid-clavicular lines below the level of umbilicus, and above the 6 o’clock one. Quilting suture should anchor the superfacial facial layer with the underlying muscle fascia with moderate traction using vicryl 2/0. Umbilical reorientation and position should be checked before remaining wound closure. Figure 1a, b, and c

Tension free edge closure is carried out from lateral to medial through use of vicryl 2/0, interrupted sutures. Using inverted suture started in upper flap 1-1.5 cm away from the edge including the superfacial fascia and touching the dermis, then entry in the lower flap 1-1.5 cm away from edge by the same technique to carry out closure tension away from the edges so no chance for subdermal plexus injury at the level of woun edges. Surgical drain were left in available spcace, and two layer closure one by vicryl 2/0 in spaces between tension free edge sutures and one layer by prolene or nylone3/0 subcuticular layer Figure 1d.


272

RESULTS Patient were followed for a minimum of 3 months and reporting of post operative local complication as regard post operative surgical drains amount and color, day of drain removal, seroma formation, wound dehiscence, infection, residual deformity, umbilical loss or hypertrophic scarring were done. The average drain removal was by the 3rd to 4th day when output is less than 30cc. No any case developed hematoma or seroma formation at all. Two cases developed wound infection with local cellulitis and fever but controlled with triple parentral antibiotics, fortunately they were not complicated by edge necrosis or dehiscence. No umbilical loss had been reported in the study. Five cases had devolved hypertrophic scars and were managed by intralesional steroid and silicon patches.The dimpling results from quilting or tension free edges suture completely disappeared within 3-4 weeks. All patients healed with good satisfactory aesthetic results as regard symmetry and contour.


273

Figure1. Diagram describing the innovated anatomical 5 quilting suture technique &tension free edge.

Figure2. Intraoperative. periumbilical sutures.

Figure3. Midclavicular 2 sutures below umbilicus.


274

Figure4. Dimpling due to anchoring of SFS.

Figure5 case1: 42 years old female patient presented by abdominal redundancy, weak abdominal musculature with saddle bag deformity. Preoperative front view.

Figure 6. case1: wk postoperative. Note the dimpling around edges.


275

Figure7 .case1: year postoperative, no dimpling with good contour.

Figure8. Case1: preoperative lateral view.

Figure9. case1: postoperative lateral view.


276

Figure10. case 2 : 38 years old female patient presented by abdominal redundancy, and weak abdominal musculature preoperative front view.

Figure11. case 2 : 3months postoperative., front view with active scar.

Figure12. case 3 : 38 years old female patient presented by abdominal redundancy, with good abdominal musculature preoperative front view


277

Figure13. case3: 3weeks postoperative, front view.

Figure14. case3: preoperative. Lateral view.

Figure15. case3: 3weeks post operative lateral view.


278

DESSCUSSION

Abdominoplasty procedure carries the risk of local complications as wound dehiscence, seroma formation, infection, hypertrophic scarring, residual deformity, and wide umbilical scars5. Many techniques had been emerged to overcome this complication specially seroma resulted from dissected dead space with pre muscular lymphatic injury and tension over distal flap edges.6,9,10

When a significant amount of seroma is formed, multiple aspirations are necessary in the postoperative period14. These procedures cause discomfort for the patient and, if not treated, a capsule may develop around the seroma. Eventually, this capsule will contract, leading to a deformity of the anterior region of the abdomen.7

The correction of this deformity requires an operation almost as extensive as the primary procedure. Another possible complication is infection of the fluid collection, leading to thicker scar formation and a secondary deformity, therefore, seroma should be avoided13

Drains do not prevent bleeding or hematomas; but excessive drainage output may alert the nursing staff to a potential bleeding problem3. While the use of drains has traditionally been associated with prevention of seroma, the need for drains may decrease if traditional dissection is limited9. Ninety-eight percent of surgeons performing full abdominoplasty report using drains for prevention of developing seroma, with the drains removed an average of 8 days later16 .In study conducted by Fang, Lin, & Mustoe, 2010 ,one group of patients had standard dissection at the level of the abdominal wall muscular fascia and another group had a more superficial plane of dissection, at or just below Scarpa’s fascia. The standard dissection group developed seven seromas and had drain removal at Day 8 as compared with the modified dissection group with 2 seromas and drain removal at Days 4 and 5. The authors of this study concluded that more superficial flap elevation appeared to decrease the time required for closed-suction drains15.This totally support my study results when drain was removed earlier than group 2 of Fang and Mustoe study, and earlier than Matarasso survey16 when drains removed in this study at average 3rd to 4th day because this technique avoided abdominal muscloapponeurtic layer shaving dissection, and subsequent lymphatic preservation, plus the five plication points had minimized dead space to very little extend


279

Pollock6 published progressive tension suture technique to reduce local complication and criticized in discussion by keneth6 as it is adaptation of the quilting suture technique described by Baroudi11, although pollock mentioned his technique differs from quilting sutures described by Baroudi in that; the progressive tension sutures are placed while advancing the flap, yielding ”progressive tension on each suture”

Quilting sutures play an important role in the prevention of seroma. The immobilization promoted by the sutures may prevent the shearing effect that disrupts the early phase of the healing process between the aponeurosis and the abdominal flap, thus avoiding seroma formation13. Baroudi and Ferreira described using a large number of sutures to attach the abdominal flap to the aponeurosis about 30 to 40 stitches were used. This extensive fixation decreasing dead space and reinforcing immobilization of the flap. Also progressive tension suture technique using about 16 sutures or more and both techniques add approximately 30minutes to the total time and may be more. In this study we used only five quilting suture and this had two advantages; first it is less time consuming so no any risk of lengthy operation, and the second is no extensive traction on the abdominal wall so nearly no risk of vascular impairment to the wound edges specially when combined with the above mentioned free tension wound edge closure, as tension is carried out away from the edge so no subdermal plexus injury and no skin necrosis. This described and illustrated technique is straight forward and the learning curve is low, making it easily mastered.

CONCLUSION

Five anatomical points plication of superficial facial system to abdominal wall musculatures plus closure of tension free edges abdominal wound showed an beneficial effect in early suction drain removal, minimizing the complication specially seroma ,wound dehiscence, edge necrosis, and got better secondary aesthetic countering of the abdomen


280

REFERENCES

1- American Society for Aesthetic Plastic Surgery (ASAPS). 2008 Cosmetic Surgery National Data Bank. ASAPS Web site. Available at http://www.surgery.org/sites/default/files/2008stats.pdf. Accessed January 19, 2010.

2- American Society of Plastic Surgeon(2010) report of 2009 sttistics National clearing house of plastic surgery statistics. Avilable at http://www.plasticsurgery.org/Documents/Media/statistics/2009–US cosmoticreconstructiveplasticsurgeryminimally-invasive-statistics-pdf. Accessed January 19, 2010.

3- Claude Le Louarn, M.D. and Jean Franc¸ois Pascal. High Superior Tension Abdominoplasty. Aesth. Plast. Surg. 24:375–381, 2000

4- Rees TD, ed. Aesthetic Plastic Surgery. Philadelphia, Pa: WB Saunders; 1980.

5 - Pitanguy I. Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg. Apr;105(4):1499-514; discussion 1515-6, 2000

6- Harlon Pollock,and todd Pollock. Progressive tension suture:A technique to reduce local complication in abdominoplasty Plast. Reconst. Surg.:105:2583-2586; discussion by keneth 2587-2588. 2000

7- Hafezi, F., and Nouhi, A. H. Abdominoplasty and seroma (Letter). Ann. Plast. Surg. 48: 109, 2002.

8-khan UD. Risk of seroma with simultaneous liposuction and abdominoplasty and the role of progressive tension suture Aesthetic plast.surg.;32:93-99 discussion 100, 2008

9- Claudette J. Heddens, Al S. Aly, MD What Is New in Abdominoplasty? Plastic Surgical Nursing October-December Volume 30 Number 4, 2010.

10- Lockwood T. High lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg.;96:603-608. 1995

11-Baroudi, R., and Ferreira, C. Seroma: How to avoid it and how to treat it. Aesthetic Surg. 18: 439, 1998.


281

12- Le Louarn C: Partial subfascial abdominoplasty. Aesth Plast Surg 20:123–27, 1996

13- Fabio Xerfan Nahas, Lydia Masako Ferreira, and Charles Ghelfond. Does Quilting Suture Prevent Seroma in Abdominoplasty? Plast Reconstr Surg.;119:1061-1064. 2007

14- Stocchero, I. N. Ultrasound and seromas (Letter). Plast. Reconstr.Surg. 91: 198, 1993.

15-Fang, R. C., Lin, S. J., & Mustoe, T. A. Abdominoplasty flap elevation in a more superficial plane: Decreasing the need for drains. Plastic and Reconstructive Surgery, 125(2), 677–682 ,2010.

16-Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: A national plastic surgery survey. Plast Reconstr Surg.117:1797–1808, 2006


282

تقليل أماكن الفراغ وغلق الجرح بدون ضغط على الحواف في عمليات شد البطن

أحمد طه -عبدالستار الرفاعي-وائل عياد -ياسر حلمي

القاھرة - جامعة األزھر –كلية الطب - جراحة التجميل واإلصالح وعالج الحروق

الملخص العربي

ومن المعروف أن وجود أماكن . ي مصر والعالمتعتبر عمليات شد البطن من أشھر الممارسات الجراحية ففراغ وتحرك بين شريحة البطن وجدار البطن من أھم األسباب التي تؤدي الى زيادة فرص تكون التورم المصلي بعد الجراحة وما قد يترتب على ذلك من التھاب في الجرح وتفزر في الجرح وكذلك فإن الضغط

أثناء غلق الجرح بالغرز الجراحية قد تؤدي الى مضاعفات موت خاليا على التغذية الدموية لحواف الجرح .حواف الجرح

الھدف من البحث

ھو استخدام غرز لحف لتثبيت شريحة البطن مع جدار البطن في أماكن محددة وكذلك غلق حواف الجرح بطريقة مبتكرة ال تضغط على التغذية الدموية وتقييم ذلك من حيث المضاعفات والشكل

النتائج

المرضى الذين خضعوا لھذه التقنية الجراحية قد تم شفائھم بصورة جيدة مع عدم تكون تجمعات دموية او ورم مصلي في اي منھم وقد تم تقليص مدة وجود انبوب االستنزاف بصورة افضل لتصل الى اقل من نصف المدة

.لي أفضلالمتوقعة مع عدم وجود مضاعفات لحواف الجرح والحصول على شكل جما