Abdominoplasty with corset plication

Introduction: Abdominoplasty is one of the most common plastic surgery procedures used worldwide. It covers the esthetic appearance and reconstruction of the abdominal wall. Many variations of the incisions, musculofascial repair, and remodeling of the navel have been described. In 1965, Callia performed an incision on the pubis with lateral extensions. In 1967, Pitanguy performed a low horizontal incision with the extremities out and down, and promoted the plication of the rectus abdominis muscles without opening the aponeurosis. Besides demonstrating the ease of implementation and safety of the procedure, the objective of this study was to perform classical abdominoplasty in combination with median and external pararectal plications, also referred to as a corset technique, to recover abdominal wall tension and then liposuction at the end of the procedure to improve abdominal body contour. Methods: Sixty-two women with a mean age of 37 years underwent operation between 2011 and 2013. Results: None of the women in the present study had hematoma, infection, necrosis, or epidermolysis. Late encapsulated seroma was observed in one patient. Five patients had a “dog ear,” and eight had unsightly scars but no keloid. All the patients were satisfied with the surgical outcome. Conclusion: The technique described in this study adds two more plications to the classic abdominoplasty, which lead to higher tension in the abdominal wall and more satisfactory esthetic results. Besides being easy to implement, the technique enables lower positioning of the suprapubic transverse incision, which can be easily hidden even with short clothing. ■ ABSTRACT


INTRODUCTION
Abdominoplasty is one of the most frequently performed plastic surgery procedures worldwide.It covers not only the esthetic aspect but also reconstruction of the abdominal wall.Esthetic aspects include abdominal body contour, natural appearance of the navel, and proper location of the scars.The reconstructive component includes recreating the anatomical position of the fascia and musculature, and restoring other deformities that may be present 1 .
In addition to umbilical repositioning, the surgery consists of low abdominal dermolipectomy, associated with repair or musculofascial plastic surgery, which is achieved with the plication of the aponeuroses of the rectus abdominis muscles.Many variations of the incisions, musculofascial repair, and navel remodeling have been described 2,3 .
Since 1899, several authors have described abdominoplasty techniques, with tactical variants that require collaboration with specialists.In 1965, Callia 4,5 performed an incision of the pubis with lateral extensions; this procedure was then used by other surgeons.Pitanguy 6,7 performed a low horizontal incision with the ends out and down.In addition, he promoted the plication of the rectus abdominis muscles without opening the aponeurosis, contributing to the improvement of the result of abdominoplasty.
Franco and Rebello 8,9 performed dermolipectomy in combination with a submammary incision called an inverted abdomen.Sinder 10,11 reported anterior marking of the abdomen with a triangle, only removing the inferior flap after the detachment of the upper flap and positioning the scar thereafter.Planas 12 described a technique similar to that of Sinder 10,11 , called "vest over pants." Psillakis 13 described the treatment of muscleaponeurotic flaccidity where the oblique muscle is sutured to the fascia of the rectus abdominis muscle.Illouz 14,15 presented for the first time in Brazil, at the Brazilian Congress of Plastic Surgery, in Fortaleza, a liposuction technique that then became part of abdominal dermolipectomy in order to obtain a more satisfactory esthetic result.Hakme 16 performed liposuction with partial abdominoplasty, denominating it as mini lipoabdominoplasty and abdominoplasty.Avelar [17][18][19] described liposuction with abdominoplasty for patients with a protruding abdomen, supraumbilical and infraumbilical localized fat, and muscle flaccidity.Baroudi et al. 20,21 proposed the use of quilting sutures by attaching the flap to the abdominal wall, from the xiphoid process to the inferior border of the pubis incision, to prevent seroma.
Matarasso 22 described liposuction with abdominoplasty performed to preserve the blood supply of the abdominal flap.Avelar 17,18 published his work on liposuction with abdominoplasty without detachment.Nahas 23,24 presented a plication of the external oblique muscles in the region of the semilunar line and later presented a study to determine effective techniques for correction of abdominal wall defects and deformities.
Saldanha et al. and Avelar 17,18,25,26 in parallel studies presented abdominoplasty techniques without detachment, introducing lipoabdominoplasty techniques in the clinical setting.Bozola and Psillakis, in 1988, 27 and Rosa and Bozola, in 2010, 28 emphasized the classification of esthetic changes attained with their specific treatments for the abdomen.Nahas and Ferreira 29 showed the long-term efficacy of correction of diastasis of the rectus abdominis muscles.In 2010, the same authors 30 called attention to factors related to flaccidity of the abdominal wall.
In this study, we performed classic abdominoplasty in combination with medial and external pararectal plications, a technique we call "corset abdominoplasty," to recover the abdominal wall tension and then liposuction at the end of the procedure to improve abdominal body contour 13 .In addition, we demonstrate the ease of execution and safety of the procedure.The name of the technique arose from the similarity of the plications to a corset, a female fashion piece used to highlight the abdominal contour (Figure 1).
The main vascularization of the abdominal flap occurs through the perforating arteries of the rectus abdominis muscles 17,25,31 .The tunnels required for lateral plications are performed at the confluence of the aponeuroses of the external, internal, and transverse oblique muscles, lateral to the fibers of the rectus abdominis muscle and its perforating arteries, avoiding impairment of the vascularization of the flap.This area is also called the semilunar line or Spigelian line 32 (Figure 2).

OBJECTIVE
The objectives of this study were to present a technique of classic abdominoplasty with medial

METHODS
Between February 2011 and December 2013, 62 cases of abdominolipoplasty with corset plication were performed either in combination with other surgeries or as a single procedure.All the patients were female, aged between 21 and 53 years (mean, 37 years).The procedures were performed by the same surgical team.All the patients were referred for preoperative clinical evaluation of surgical-cardiac risk and preanesthetic evaluation.Their weights were measured, and photographic documentation was accomplished.
All the patients provided written informed consent after resolving all doubts in relation to the procedure, being deemed suitable for surgery.The study followed the principles of the Declaration of Helsinki.
Surgical markings were made with the patient in the supine position, and the surgeries were performed under neuraxial block (spinal or epidural) and sedation and/or general anesthesia, with prophylactic antibiotic therapy during anesthetic induction and every 3 h during the procedure.
Compression stockings (¾) and a venous compression device at 60 mm Hg were routinely used.Antithrombotic prophylaxis therapy (enoxaparin 40 mg) was administered in accordance with the modified protocol of Sandri [33][34][35] (Annex 1 33 ) and maintained daily until normal ambulation of the patient.
With the patient in the lateral decubitus position, infiltration of a vasoconstrictor solution (saline solution at 0.9% with epinephrine 1:500,000 IU) was initiated.Then, liposuction of the flanks or back, depending on the need, was performed.
In the dorsal decubitus position, the patient underwent incision of the marked area (periumbilical and low abdominal) with a no.15 scalpel blade.With electrocautery, pre-aponeurotic detachment was attained in a semicircle up to approximately 2 cm above the navel.Selective detachment of the supraumbilical flap was started in a tunnel with a width necessary to correct diastasis (Figure 3).Medial plication of the rectus abdominis muscles in the upper and lower limbs was initiated by using 0 polypropylene wires (Prolene -).After the medial plication, the lateral tunnels were detached from the edges of the rectus abdominis muscles (Spigelian line).This maneuver keeps intact the perforating vessels of the rectus abdominis muscles that supply the flap.
Next, lateral plications were started with 0 polypropylene wires, which originate at the costal borders and terminate approximately at the height of an imaginary line joining the anterior superior iliac spines (Figure 4).A dermal fat flap resection was performed with lower traction of the flap.
Next, the new position of the navel on the flap was marked.Closure was performed on four planes, the first two with Vicryl -2.0 covering the fascia of Scarpa, lamellar fat, and areolar fat.Subdermal suture was accomplished with Monocryl -3.0; and intradermal suture, with Monocryl -4.0.
A diamond-shaped incision was made for the new positioning of the navel and pubic incision in the midline between the commissure and the newly formed horizontal scar.Subsequently, infiltration with 0.9% saline solution with adrenaline 1:500,000 IU and liposuction of the flap and pubis were performed by using the two incisions (umbilical and pubic) for the entry of the 4-and/or 5-mm cannulas (Figure 5).A suction drain was placed with a closed system through the pubic incision, which remained with the patient for approximately 7 days (Figure 6).
Still in the surgical block, a dressing was laced on the scars and the modeling corset was placed.Surgeries lasted approximately 4 h.The patients were encouraged to walk on the same day of surgery and discharged the next morning.

RESULTS
Among the 62 patients who underwent operation, none had hematoma, infection, necrosis, or epidermolysis.Despite the use of the drain for approximately 7 days after surgery, the presence of late encapsulated seroma (Morel-Lavallée cyst) was observed in one patient, requiring a new surgical procedure for its removal.Five cases of "dog ear" were observed in the side edges of the scar, and eight cases of unsightly scars were observed by the physician and/or patient.For these cases, surgical revisions were performed under local anesthesia.None of the patients developed a keloid scar (Figure 7).In the subsequent consultations, the patients were greatly satisfied with the results obtained, although this satisfaction was not reported in response to individual and confidential questionnaires but only through an interview between the physician and the patient during the postoperative follow-up.Even in the cases where unsightly scars were corrected, the level of satisfaction was high, considering the final results (Figures 8-13).
The technique reported in this study added two more muscle plications to the classic abdominoplasty, which leads to a higher tension in the abdominal wall and a more satisfactory esthetic result.With the technique, the suprapubic transverse incision could be positioned lower, allowing the coverage of the scar even with small garments (Figures 8-13).

DISCUSSION
In this study, the following two good indications for the application of lateral plications to the median plicature were reinforced: 1. Multiparous patients with great flaccidity of the abdominal wall showing residual sagging even after performing medial plication, and 2. Patients with great flaccidity of the abdominal wall without excess of adipose tissue, who when only medial plication is performed,      abdominoplasty.Psillakis 13 described the treatment of muscle-aponeurotic flaccidity where the oblique muscle is sutured to the fascia of the rectus abdominis muscle.Performing liposuction at the same surgical time provided better results in abdominal contour 15,17 .Liposuction at the end of abdominoplasty promotes uniformization of the upper flap with the pubis.In addition, it probably allows preservation of several musculocutaneous perforating vessels, maintaining sufficient blood supply, and venous and lymphatic drainage of the detachment flap to avoid impairment to the final vascularization 28 .
The removal of a large number of adipose cells via liposuction can contribute to decreased tension and the metabolic need of the flap, and allows the relaxation of vascular plexuses in the flap, improving blood flow and venous return 28 , which can be evidenced by the absence of complications such as epidermolysis and necrosis of the abdominal flap in the cases studied.On the contrary, it seems to increase postoperative drainage, requiring aspiration drainage.
To better validate our observations, a larger sample size with a longer follow-up (>3 years) is needed.

CONCLUSION
The technique described herein is effective in the esthetic treatment of the abdominal region.Candidate patients for classic abdominoplasty who have excess adipose tissue in the upper abdomen and/ or large muscle-aponeurotic flaccidity may benefit from the technique.Liposuction performed at the end of abdominoplasty maintains the natural results, as it promotes a uniformity of adipose tissue throughout the abdominal and pubic regions.It also facilitates lower positioning of the suprapubic transverse incision, which allows covering of the scar even with short garments.It is easy, safe, and fast to execute, with low complication rates.

COLLABORATIONS
show a projection of the skin and adipose tissue above the navel (epigastrium and mesogastrium), which alters the harmony and esthetics of the abdominal relief pad, being a frequent complaint of patients in the postoperative period 27,28 .Medial plication performed in combination with external pararectal plications results in better skin and fat distributions, in addition to achieving greater abdominal wall tension with optimal esthetic results (Figures 14 and 15).In addition to plications, liposuction of the flap is performed at the end of the procedure, which decreases the tension with probable improvement of circulation 28 .Another issue raised is that possible hernias can be visualized and corrected during abdominoplasty, before liposuction, without the risk of cannula entry through the hernia.
As the plication area lies laterally to the perforating vessels of the rectus abdominis muscles, the vascularization of the flap is not impaired, which makes the technique quite safe 17,25,31 .
Recall that classic abdominoplasty is a technique widely used by plastic surgeons for a long time.The technique proposed by Callia 4,5 marked a new era of abdominoplasties, placing the incision over the pubis and its lateral extensions parallel to the inguinal folds, positioning the scar in a hidden area.
Pitanguy 6,7 suggested a plication of the rectus abdominis muscles without opening the aponeurosis, contributing to the improvement of the result of RFPG Analysis and/or interpretation of data; statistical analysis; final approval of the manuscript; conception and design of the study; completion of operations and/or experiments; and drafting of the manuscript or critical review of its contents.

IRG
Analysis and/or interpretation, and drafting of the manuscript or critical review of its contents.

JGT
Analysis and/or interpretation of data, and drafting of the manuscript or critical review of its contents.

Figure 2 .
Figure 2. Confluence of the external, internal, and transverse oblique muscles, lateral to the fibers of the rectus abdominis muscles.

Figure 3 .
Figure 3. Area of detachment and the median tunnel usually performed in abdominoplasty.

Figure 4 .
Figure 4. Complete plications (corset appearance).Note the preservation of the area on the rectus abdominis muscles where the perforating vessels exit to supply the flap.

Figure 5 .
Figure 5. Pubic orifice for liposuction where the continuous suction drain will be placed.

Figure 6 .
Figure 6.Positioning of the drain through the pubic incision and final aspect of the surgery.

Figure 13 .
Figure 13.Three-month postoperative period: front, profile, and side views.Purposely showing the low position of the scar, which can be naturally hidden with a short garment.

Figure 14 .
Figure 14.Before and after the plications.Improvement of the bulging of the abdominal wall can be observed.

Figure 15 .
Figure 15.Application of force on the abdominal wall, demonstrating improvement in tension.