Abdominoplasty Marking Instrument

Introduction: Data from the International Society of Aesthetic Plastic Surgery indicate that abdominoplasty is the fourth most common plastic surgery performed worldwide. Several surgical techniques aim to restore the abdominal contour. The indication for the technique used should aim to improve any individual deformity present in the abdomen. Abdominoplasty marking is done using a ruler, protractor, compass, nylon thread, toothpick, pen, and/or methylene blue, according to the surgeon’s preference. Here we aimed to produce a surgical instrument that optimizes the abdominoplasty marking procedure. Methods: The study was approved by the ethics research committee. Graphic designs were developed to identify each part of the instrument, a precedence search was performed, and a patent application was requested. Results: We developed an abdominoplasty marking instrument consisting of a horizontal ruler that receives a vertical ruler at its midpoint, two pivotal rulers with a basal protractor, all marked in millimeters, and a central area that allows marking in this region with methylene blue or a pen. Moreover, it acts as a compass and features side pivotal rulers derived from a basal grade protractor. Conclusion: The instrument developed in this study was designed to minimize the amount of material used and optimize abdominoplasty marking time.

In 1899, Kelly described a dermofat excision technique, elliptical and transversal at the level of the umbilicus, in which skin and fat were resected together, initiating a challenge for surgeons in the treatment of abdominal deformities 6 .
In 1957, extensive dissection of the dermofat graft was standardized to facilitate transposition of the navel, initiating this important phase in abdominoplasty 7 .
In 1965, Callia positioned the horizontal incision in the suprapubic region, extending it laterally toward the iliac crests and leaving the scar less apparent.This type of incision has had large acceptance and is used today with slight design variations.Pitanguy described rectus abdominis muscle plication at the midline 7,8 .
The introduction of liposuction by Illouz in 1980 enabled the reduction of fat volume of the body contour in patients with excessive adipose tissue without excess or sagging skin.Between liposuction and plastic surgery of the abdomen are intermediate modality interventions called partial abdominoplasties 9 .

INTRODUCTION
Abdominoplasty is one of the most common plastic surgeries performed in Brazil.In 2015, data from the International Society of Aesthetic Plastic Surgery (ISAPS) indicated that abdominoplasty was the fourth most common plastic surgery performed worldwide 1 .
Functional changes, genetics, life habits, inadequate diet, lack of physical exercise, pregnancy, weight loss, aesthetic alterations of the abdominal wall, and other factors contribute to decreasing patient selfesteem and well-being 2,3 .
For more than a century, plastic surgery has sought solutions to correct the abdomen, initially by abdominoplasty and later with liposuction, which are the two cosmetic surgeries most commonly performed in this anatomical area 4 .
The first descriptions of the surgical treatment of abdominal wall deformities were associated with the correction of umbilical hernias, which required the concomitant removal of fat and skin 4,5 .

OBJECTIVE
To develop a surgical instrument that optimizes abdominoplasty marking time.

Ethical Approval
The study was approved by the Ethics Research Committee (Comitê de Ética em Pesquisa) of the Federal University of São Paulo (Universidade Federal de São Paulo -Unifesp, no.2355210116).

Precedence Search
A precedence search was performed in national and international patent databases of the National Institute of Industrial Property (Instituto Nacional da Propriedade Industrial) 13 .
A list of all patents concerning abdominoplasty marking was obtained with a description of each patent and drawing.

Technological Innovation Nucleus
The invention report, drawings of the instrument, and documents needed to request a filing application for the abdominoplasty marking instrument were forwarded to the village consultancy.

Description and characteristics
A description of the features and functions of the abdominoplasty marking instrument was created.

Illustration of use
Graphics were developed to identify each part of the instrument.

Description of the instrument components and characteristics
The instrument shown in Figures 1-5 that consists of a horizontal ruler (1), which receives a vertical ruler (2) at its midpoint, and two pivotal rulers (3) with a basal protractor (4), all marked in millimeters, and a central void (5) that allows marking in this region with methylene blue or pen and, consequently, the marking of the abdominoplasty procedure.It also functions as a compass with laterally derived pivotal rulers (4) with a basal-type protractor ( 5), all rulers (1, 3, 4) marked in millimeters on both sides and a void in the central axis; a mechanism (9) formed by a screw (10) attached to the blade of the slats (3 and 4) allows movement between the parts.In one example of the invention, the joint between the rulers is achieved using a mechanism (9) formed by a screw (10) fastened to the blade of the slats (3 and 4) in which the tightening and loosening is affected by an acrylic screw (11), but such a grip may be provided by another movable/rotary mechanism.

Illustration of use
As shown in Figure 5, the methodology of the abdominoplasty marking procedure involves positioning the instrument on the patient's abdomen, where a horizontal line is drawn in the suprapubic region with extensions of approximately 12-14 cm, 7 cm from the vulvar commissure and laterally toward the iliac crests by 6-7 cm on each side.Areas in which liposuction can be performed are also demarcated using this method.The measurements may vary according to the abdominal lipodystrophy of each patient and the marking preferences of each surgeon.

Patents found in the precedence search
Chart 1 contains information of three patents found in the precedence search.

Description of patent PI 9702889-4
The PLASTIC SURGERY SIMULATOR KIT (Figure 6) provides the resident a practical learning opportunity for various surgical techniques as well as periodic self-assessments.The kit contains breasts (1)  or a trunk replica including breasts and an abdomen (2) and is made of suitable materials that simulate skin, glands, and muscles of different colors to indicate the different layers of these regions of the human body and that can constructively limit the "prohibited" areas of access in certain surgical techniques so that, when sensitized (e.g. by the touch of the scalpel), they trigger a visual or audible alarm in addition to counting errors in an electronic panel.

Description of patent PI 0106759-1
The surgical marking pen (Figure 7) is used in superficial surgeries to demarcate the area to be operated.It is composed of a rod (1) and a marker tip (2).This tip has an inner orifice (2.1) into which appropriate graphite can be inserted (3), whose main characteristic is to produce an accurate and fixed marking on human skin to perfectly demarcate the area that will undergo incision, or even marker tip; in this case, there is a cone needle (4) that, when pressed against the skin, will release microquantities of ink, filling the space previously occupied by the graphite and marking the area with the same efficiency.

Description of patent PI 9702889-4
The pincers used for navel marking in abdominal surgery (Figure 8) is composed of a scissors body.An extension with a slot in the middle is present on one of its faces with the aim of precisely and definitely locating the navel beneath the skin.On the other side is an extension at which a navel marking device of various forms is positioned on the skin.

Public domain instruments used for abdominoplasty marking
The marking of abdominoplasty surgeries is performed according to the lipodystrophy of each patient and the surgeon's marking preferences.
Chart 2 contains public domain tools used for abdominoplasty marking.

Description of the ruler
The origin of the word ruler is French and means "law or rule."Rulers were found in excavations in Mohenjo-Daro in 1500 B.C.This is an instrument used to draw straight lines made in wood, plastic, or metal with measurements marked in millimeters or

Description of the protractor
A protractor is an instrument that is used to measure angles.It is composed of a circular scale, or circle sections, divided and marked at angles spaced regularly as those on a ruler.Its use is diversified in education, mathematics, engineering, surveying, construction, and various other activities that require the precise measurement of angles.There are fixed 360°, 180°, and 90° protractors.Protractors can measure angles not only in degrees but also in thousandths of a degree, such as those used by the military for shooting applications 16 .

Description of suture wire
Suturing is a very important step in the surgical procedure.From ancient times, a large number of suturing materials have been tested and used, such as vegetable fibers, resins, tendons, intestines of various centimeters (http://www.reguaonline.com/sobre-aregua.html) 14.

Description of the compass
The compass is a drawing instrument that makes circumferential arcs.It is also used to mark a segment on a line of equal length to that of another given segment and solve some types of geometric problems, such as constructing a hexagon or finding the center of a circle 15 .the material used for suturing but also about antisepsis.Thus, the trend of using a variety of sterilized suture threads with pre-installed needles that are supplied ready to use began 17 .

Description of the pen
The pen is an instrument used for writing with ink.Even today, students use it worldwide for schoolwork.Ballpoint pens, which are mainly used today, were invented in 1937 by the Hungarian Ladislao Biro, based on a pen that did not erase and the ink did not dry in the deposit, unlike old fountain pens.
The pens vary from simple to sophisticated and elegant, such as those commonly used by professionals, and of various colors.Even today they are used worldwide 18 .

Description of methylene blue
In 1876, Caro synthesized methylene blue; it has subsequently had various uses in medical research.Methylene blue is an aromatic heterocyclic compound that is solid dark green, soluble in water, and produces an odorless blue solution.Methylene blue dye is used as a bacteriological dye and indicator.It has many applications in various fields, such as biology and chemistry 19 .

Description of the toothpick
Toothpicks are small rods usually made of wood or plastic that are frequently used to remove detritus from the teeth, especially after meals, that have existed for hundreds of years.The toothpick usually has one or two sharply tapered ends to ensure better insertion between the teeth 20 .
A chart was prepared with the patent data found in the precedence search with International Patent Classification identification number and code, inventor name(s), date of publication, and place of registration.
Given the patents mentioned previously, comparisons were made with the design of the marking instrument presented in this thesis.

Comparison between the study instrument and patent PI 9702889-4
The Plastic Surgery Simulator Kit (Figure 6) is used to train students and residents to perform surgical techniques.The differences between the abdominoplasty marking instrument and patent PI 9702889-4 are described in Chart 3.

DISCUSSION
In 2015, Brazil registered 1,224,300 plastic surgeries, including 758,590 abdominoplasties.A survey of these data has been performed by the ISAPS among the total number of plastic surgeries performed by all plastic surgeons in each of the participating countries 15 .
The search for improvements in body contour and quality of life has led to an increase in demand for plastic surgery 2,21,22 .Professionals should be able to accurately diagnose these deformities and know the alternatives to provide adequate treatment 2,21,23 .
When choosing abdominoplasty, in accordance with the diagnosed deformity, the marking can be made by the surgeon using a ruler, protractor, compass, nylon thread, toothpick, pens, and methylene blue.
Preoperative surgical marking has been reported since the early days of plastic surgery with Sushruta Samhita's description of the use of vegetable leaves to demarcate the nasal flaps and has progressed over centuries to the use of leather and wax and then the more widespread use of incision drawings done with paints and dyes starting in the 19 th century 8 .
According to the pertinent literature, intraoperative surgical marking has received less attention.Weiss's study (1947) can be highlighted since it advocated the use of technical pens and precision compasses made of aluminum and steel and sterilized in germicidal solutions for use during surgeries.
The use of this study instrument is performed in the following way: the instrument is placed on the abdomen of the patient in the supine position during the pre-or intraoperative period; and it defines the extension of the horizontal trajectory of the suprapubic region, the extension of the vertical trajectory of the vulvar commissure, and the tracing of the extension and the angles of the lateral region toward the iliac crests.Using a pen or methylene blue, the abdominoplasty

Comparison of study instrument and patent PI 0106759-1
The surgical marking pen (Figure 7) is used to delineate markings.The differences between the abdominoplasty marking instrument and patent PI 0106759-1 are described in Chart 4.

Comparison of study instrument and patent PI 0106759-1
The pincers used for navel marking in abdominal surgeries (Figure 8) is an instrument used in abdominal surgeries; however, its use is limited to marking the navel, unlike the study instrument, which demarcates the entire surgical area with the exception of the navel (Chart 5).

Comparison of study instrument and the ruler
The instrument of study comprises a horizontal ruler that articulates with a vertical ruler at its midpoint and two pivoting rulers.Unlike the public domain ruler, the study ruler features a central empty space that allows marking in this region with methylene blue or a pen to delineate the abdominoplasty procedure.The instrument also has a mechanism formed by a bolt fastened to the blade of the rulers that allows movement between the parts, thus enabling the pivotal slides to also be used as a compass (Chart 6).
After the precedence search, the study of the presented results, and the development of the study marking is performed in the empty space of the overlapping articulating and millimeter rulers in an easy, practical, and fast manner.In abdominoplasties performed after major weight loss, the utility of the abdominoplasty marking instrument is reduced to the anchor technique, but the use of its vertical and horizontal components to ensure symmetry and alignment is of great value.
Since the scar's final position results from the traction force of the abdominal flap upward versus the traction suprapubic tissue resistance (pubic region) versus marking precision, this study is important.

Details of the present invention
The conventional technique used to mark the abdominoplasty involves the use of a ruler, protractor, compass, nylon thread, toothpick, pens, and methylene blue.
The instrument developed in this study can be used in the pre-and intraoperative periods, has an integrated ruler and compass, is articulated, is easy to handle and transport, and features an empty space in the central region of the rulers to reduce the incidence of misaligned markings and blurring of methylene blue or ink of the chosen pen used for the marking.

Target audience
The target audience for abdominoplasty marking instrument use includes plastic surgery trainees and residents and plastic surgeons.

Perspectives
The perspective is that many surgeons and plastic surgery residency services use the instrument developed in this study in their surgeries and teaching practices.

CONCLUSION
Here we developed an abdominoplasty marking instrument that minimizes the amount of material used and optimizes the marking time.

Figure 1 .
Figure 1.Diagram of the abdominoplasty marking instrument.

Figure 2 .
Figure 2. Exploded diagram of the abdominoplasty marking instrument.

Figure 3 .
Figure 3. Side view of the abdominoplasty marking instrument.

Figure 4 .
Figure 4. Enlarged lateral detail of the inter-ruler joint of the abdominoplasty marking instrument.Perspective view of the abdominoplasty marking instrument in transport position.

Figure 5 .
Figure 5. Perspective view of the abdominoplasty marking instrument in a demonstration of its use.
Applicability and social impacta) Prevention of marking corrections; b) Fewer instruments used; and c) Facilitation of the surgical teaching of abdominoplasties in accredited medical residency programs.

Chart 1 .
Precedence search of abdominoplasty marking patents.

Chart 5 .
Comparison between study instrument and the pincers used for navel marking in abdominal surgeries.Comparison of study instrument and the ruler.