Evaluation of Tension Reduction on Abdominoplasty Scar Using Baroudi Adhesion Sutures

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n 1988, Baroudi et al. published a paper describing the use of adhesion points between the dermoadipose flap and the anterior rectus abdominis sheath to reduce dead space and consequent seroma formation, a frequent complication previously observed due to extensive detachment in the classic abdominoplasty 2 .In 1999, Avelar et al. 3 described the technique of minitummy tuck without flap detachment in the lower abdominal portion.In 2001, Saldanha 4 introduced the lipoabdominoplasty technique with preservation of the perforating vessels, showing a significant reduction in flap necrosis rates and introducing a new direction in abdominal plastic surgery.Lipoabdominoplasty with liposuction reduces supraumbilical dermoadipose flap detachment and preserves blood circulation in the flap 3 .
Abdominoplasty is based on the variable length of detachment of the fasciocutaneous layer of the abdomen encompassing the xipho-pubic region, flank region, and costal arches, with subsequent resection of the dermoadipose panicle excess and lowering of

INTRODUCTION
Abdominal dermolipectomy, also known as abdominoplasty, has been performed for decades, and it has gradually evolved to the more elaborate techniques currently in use.
From the surgical point of view, there has been a considerable evolution with respect to scar extension and dermoadipose flap detachment.
In the late 1970s, reduced incision abdominoplasty was introduced, which provided good results in selected cases.However, changes in the supraumbilical region could not be properly corrected with this technique, and this limitation with excess skin was evident when the patient sat, leading to patient and doctor dissatisfaction in most cases.
In the 1980s, the introduction of liposuction associated with abdominal plastic surgery yielded better results.However, there were considerable complication rates, especially with seromas 1 .
■ RESUMO Descritores: Dermolipectomia; Pontos de Baroudi; Tensão cicatricial; Cicatriz abdominal; Medidas do abdome.the flap.The tension generated by the flap approach towards the lower incision seems to be responsible for scar enlargement, tendency of more cranial scar positioning, suture dehiscence, and necrosis of the lower flap portions 4 .
Since 2005, lipoabdominoplasty has been the preferred technique for treatment of abdominal deformities at the Santa Casa de Misericórdia Plastic Surgery Service of Porto Alegre/Federal University of Health Sciences of Porto Alegre.This consists of performing epigastrium and flank liposuction with reduced dermoadipose flap detachment.During the synthesis, Baroudi adhesion points are made to reducing the dead space and facilitate the flap descent associated with better positioning.The number of points executed does not follow any predetermined rigid standard and are performed as needed 5 .
Although several studies have been conducted on the use of Baroudi points for seroma reduction, limited data are available on the use of Baroudi adhesion points for scar tension reduction and subsequent improvement in its appearance.
Therefore, the present study proposed to demonstrate a probable correlation between Baroudi adhesion points and flap tension force, verifying the positioning, maintenance, and scar quality after abdominoplasty by using these points 6 .

OBJECTIVE
The main objective of the present study was to quantify the reduction of scar tension after abdominoplasty using Baroudi adhesion points.
Additionally, the transoperatory measurements of the distance from the sternal xiphoid appendix to the umbilical scar before and after the execution of Baroudi adhesion points was compared to correlate these measurements with the healing quality.

METHODS Inclusion criteria
Female non-smoking patients aged 18-60 years and with a body mass index (BMI) of <28 kg/m 2 who underwent lipoabdominoplasty at the Santa Casa de Misericórdia Plastic Service of Porto Alegre from January to April 2019 were included.

Exclusion Criteria
Patients who did not agree to participate in the study were excluded.

Design
This was a prospective observational study.

METHODS
All included patients underwent standardized pre-, trans-, and postoperative care.
The transoperatory measurements of distance from the sternal xiphoid appendix to the umbilical scar and from the pre-xiphoid to the post-xiphoid scar before and after execution of Baroudi's adhesion points were measured.The difference between these two measurements was evaluated in the results.
Consecutive prospective statistical analysis of the data was performed using Excel software ® .
The present study was not interventional.The surgical procedure for abdominal dermolipectomy was performed in each patient as indicated by the case after the consent form and authorization for surgery were obtained.Lipoabdominoplasty was used as the surgical technique, and the study included patients who met the inclusion criteria.All standards issued by the National Health Agency were strictly followed.Patients and/or guardians received proper guidance on the procedures performed.
The Santa Casa de Misericórdia Plastic Surgery Service of Porto Alegre/Federal University of Health Sciences of Porto Alegre is committed to maintain confidentiality of data contained in the medical records, ensuring that patients are not identified during the course of the research.

RESULTS
Eighteen patients were included in the study, and their transoperatory measurements are listed in Table 1.
A decreased in the distance of the xiphoidumbilical scar appendix and the xiphoid-surgical scar appendix (Figures 1, 2 and 3) was observed after the use of Baroudi adhesion points (Figures 4 and 5).

DISCUSSION
There have been complications associated with the evolution of abdominoplasty, especially for seroma and flap necrosis, which vary according to the case.The main cause of complications is the large displacement in classical surgery that sliced lymphatic and perforating vessels.To minimize such complications, various techniques were proposed to reduce dissections.Baroudi's adhesion points were undoubtedly a simple and efficient solution to a frequent and sometimes complex problem.In abdominoplasty, the adhesion technique initially   Based on our study results, it was possible to refute the null hypothesis that there is no significant difference in distances with and without the use of Baroudi adhesion points.
The reduction in the distance of the xiphoidumbilical scar appendix and xiphoid-surgical scar appendix was verified after the execution of Baroudi suture (mean 1.5 cm), assuming a reduction in scar tension and a reduction in the surgical scar distance of the xiphoid appendix at the expense of narrowing the distance between it and the umbilical scar.