INTRODUCTION
The aesthetic demand for a perfect abdomen compels the plastic surgeon to
constantly develop innovative surgical techniques. By contrast, it is imperative
that the patient understand that not all variables that involve abdominal
protrusion are susceptible to surgical correction. Bad posture, sedentary
lifestyle, and obesity should, preferably, be corrected prior to surgery. Excess
visceral fat, variation in collagen type with stronger or more fragile
aponeuroses1,2, and the associated bone structure in the
abdominal polygon3 can also change the
outcome.
The crossbow technique was conceived by the present author from his experience in
abdominal wall plication. Before developing this technique, the author used
horizontal shortening of the rectus abdominis muscles3-6 and
sometimes the rectus and oblique abdominis muscles4,5. The results
showed large variations in the lower abdominal region, from excellent
rectifications to residual bulging that required a second intervention to
correct the bulging.
In an attempt to fix the residual bulging of the lower abdomen, from observations
over time, the author moved the vectors of these plicatures until a vertical
position was attained, which provided better retrusion of the region between the
iliac fossa and the hypogastrium.
When migrating from secondary correction to primary indication, the conventional
plicature (correction of the diastasis of the rectus abdominis and oblique
abdominis muscles in the semilunar line) must be incorporated to the transverse
arc plicature in the lower floor of the abdomen. This fusion gave rise to the
crossbow technique with its variations, which appeared in all the samples. The
types were defined as follows: type I, xiphopubic plication of the rectus
abdominis (Figure 1, 2A); type II, mini-abdominoplasties and restriction of the
detachment to the umbilical scar (Figure 2B); and type III, plication of the semilunar line concomitant with
plication of the diastasis of the rectus abdominis muscles (Figure 2C).
Figure 1 - Marking in Crossbow type I, reference points in red. Acquired and
modified from: iStock-160085304..
Figure 1 - Marking in Crossbow type I, reference points in red. Acquired and
modified from: iStock-160085304..
Figure 2 - Variations of marking in Crossbow. A: type I;
B: Type II and C: Type III. Acquired
and modified from: iStock-160085304.
Figure 2 - Variations of marking in Crossbow. A: type I;
B: Type II and C: Type III. Acquired
and modified from: iStock-160085304.
The crossbow technique is indicated for patients who exhibit diastase of the
linea alba, a semilunar line, and multidirectional enlargement, mainly in the
lower floor of the abdomen, where we observed bulging containing only by the
inguinal ligament and upper edge of the pubis, demonstrating esthetic failure in
the containment of abdominal volume.
Studies using vertical or mixed abdominal wall traction vectors (Figure 3) were initially conducted by
Jackson and Downie7 in 1978. Their
cruciform plication technique foresaw plication of the diastasis of the rectus
abdominis muscles and, at the same time, another plication with a transverse
spindle, with the umbilical scar as the center of the intersection.
Figure 3 - Techniques that compose horizontal plications. 1 - Jacson I,
1967; 2 - Abramo AC, 1999; 3 - Ferreira LM, 2001; 4 - Cardenas R,
2002; 5 - Cardenas, 2004; 6 - Villegas F, 2011; 7 - Bozola AR, 2013;
8 - Gonzales HO, 2016.
Figure 3 - Techniques that compose horizontal plications. 1 - Jacson I,
1967; 2 - Abramo AC, 1999; 3 - Ferreira LM, 2001; 4 - Cardenas R,
2002; 5 - Cardenas, 2004; 6 - Villegas F, 2011; 7 - Bozola AR, 2013;
8 - Gonzales HO, 2016.
In 1999, Abramo et al.8 proposed a
plication in the form of a horizontal “H” involving a small arciforme plication
in the epigastrium, another arciforme plication in the lower region of the
abdomen, and plication of the rectus abdominis muscles. In 2001, Ferreira et al.
used a triangular suture in the aponeurosis of the rectus abdominis, in the
epigastric region, promoting vertical and horizontal shortening that prevented
residual epigastric bulging1. For mini
abdominoplasties, Cárdenas Restrepo and Munoz Ahmed, in 20029, indicated a detachment limited to the
umbilicus and preparation of a horizontal semilunar plication in the aponeurosis
of the lower abdomen.
Cárdenas Restrepo and García Gutiérrez, in 200410, published a new technique with plicature in the anchor with the
closing spindle of the diastasis of the rectus abdominis muscles and plication
in a recurved horizontal arc in the lower floor of the abdomen, without the
intersection of the 2 drawings. Villegas, in 201111, demonstrated his TULUA technique at the Vancouver Ipras World
Congress, where he more broadly defended the systematic amputation of the
umbilical stump and the confection of a large horizontal spindle in the
aponeurosis throughout the lower abdomen, this being the only plication,
promoting remarkable vertical shortening of the abdominal wall.
In 2013, Dr. Pamella Verissimo, at the Federal University of São Paulo, guided by
Dr. Fabio Nahas, presented the study entitled, “Plication of the anterior lamina
of the rectus abdominis sheath with the triangular suture technique”12. This work proved the maintenance of
vertical shortening by imaging tests accompanied by metallic clips inserted in
the abdominal wall. In 2013, Antônio Roberto Bozola, in his publication
entitled, “27 years of observation by the author”4, exposed the need for a complementary horizontal spindle plication
between the iliac fossae in cases of bulging in the hypogastrium.
More recently, in 2016, Gonzalez published his technique called smile
plication13, which provides for the
plication of the diastasis of the rectus abdominis muscles, concomitant to
horizontal plication in the tendinous intersections of the rectus abdominis,
aiming at an abdomen with more muscular appearance.
OBJECTIVE
The objective of this study was to demonstrate the plication using the crossbow
technique and its variations, identify complications and conduct a double-blind
comparative assessment, and observe the lower abdomen of these patients and
other patients who received only plication of the rectus abdominis muscles.
METHODS
From January 2016 to February 2018, the author performed surgery with type I, II,
or III crossbowplication in 22 patients (Table 1). In the preoperative period, the patients were evaluated with
clinical and laboratory examinations, and an assessment of their cardiac
surgical risk was performed by the anesthetic team. The patients’ ages ranged
from 29 to 59 years; of the 22 patients, 21 were female and 1 was male.
Table 1 - Correlation between the types of surgery and crossbow
plication.
| |
Plication type |
Type I |
Type II |
Type III |
Total no of Patients |
| Surgery type |
|
| Abdominoplasty |
3 |
|
1 |
4 |
| Mini lipoabdominoplasty |
|
2 |
|
2 |
| Lipoabdominoplasty |
11 |
|
1 |
12 |
| Anchor dermolipectomy |
4 |
|
|
4 |
| Total |
18 |
2 |
2 |
22 |
Table 1 - Correlation between the types of surgery and crossbow
plication.
The patients were chosen according to the following criteria: underwent bariatric
surgery with a body mass index (BMI) of <30 kg/m2, had an
indication for anchor dermolipectomy, esthetic cases with a BMI of <28
kg/m2, had a history of multiparity,
had no desire to conceive again, and had bulging of the lower abdomen. The
exclusion criteria were relative and cover primiparous patients, patients who
still had doubts about conceiving, and patients with clinical contraindication.
In these cases, the plication were restricted conventionally to the rectus
abdominis diastasis.
The study followed the principles of the Declaration of Helsinki.
As rigid anthropometric measurements would be complex in relation to the abdomen
owing to the number of variables, the author opted for an empirical evaluation
and a double-blind study to compare 10 lipoabdominoplasty patients who underwent
plication using the crossbow technique (group A) and 10 lipoabdominoplasties
patients by the author, with an isolated plication of the diastase of the rectus
abdominis muscles (group B).
The assessment took into account the observation of the horizontal distance of
the anterosuperior iliac spine from the edge of the abdominal silhouette in the
lateral view of the patient in the orthostatic position, with arms outstretched
to the front at a 90° angle. Results were considered excellent when this
distance was almost tangential, good when this distance did not exceed a
harmonic silhouette (abdominal lyre), and poor when there was greater and
inadequate distance and residual bulging of the hypogastrium.
By assigning 1 point for each vote of the 21 observers, we arrived at 210 points,
and the following graphs were constructed (Graphics 1, 2 and Table 1):
Graph 1 - Patients with crossbow plication.
Graph 1 - Patients with crossbow plication.
Graph 2 - Patients with plication of the rectus abdominis only.
Graph 2 - Patients with plication of the rectus abdominis only.
Surgical procedure
At the surgical center, the patients received antibiotic prophylaxis and care
to prevent venous thrombosis according to the modified Sandri protocol. All
the patients underwent operation under routine epidural anesthesia with a
catheter.
Type I crossbow plication was most frequently used (Figure 1, 2A).
This technique begins with the patient in the dorsal decubitus position, and
when indicated, liposuction is performed before abdominoplasty in the same
procedure. After the due suprafascial detachment in the tunnel, similar to
that recommended by Saldanha6, the
following reference points are identified: the xiphoid appendix, upper edge
of the pubis bone, right and left anterior superior iliac spines, and
umbilical scar (Figura 1).
The marking begins by tracing the conventional zone for the treatment of the
diastasis of the rectus abdominis muscles and, most often, the xiphoid
appendix to the upper edge of the pubis (Figura 4). Then, a straight line is drawn that connects the
anterosuperior right iliac spine to the left anterosuperior iliac spine,
which we call the cord.
Figure 4 - Marking of the xiphobic rubric for plication of the rectus
abdominis muscles and identification of the anterior superior
iliac spines.
Figure 4 - Marking of the xiphobic rubric for plication of the rectus
abdominis muscles and identification of the anterior superior
iliac spines.
At this time, the space between the cord and the upper edge of the pubis is
divided into three equal parts, within the marking of the plication of the
rectus abdominis muscles. A second line, in the form of an arc, connects the
anterior superior iliac spines, with the lowest point of this arc tangent to
the second pubic cord space (Figure 5). The importance of this marking is the protection of the critical
structures that border the inguinal region (Figure 6), avoiding their sequestration with the plicature
(Figure 7).
Figure 5 - Marking the rope and the bow.
Figure 5 - Marking the rope and the bow.
Figure 6 - Complete type I plication.
Figure 6 - Complete type I plication.
Figure 7 - Delimited in green - area below the marking arch that should
not be included in the plicature. modified from: C Anatomy
'application image 18.
Figure 7 - Delimited in green - area below the marking arch that should
not be included in the plicature. modified from: C Anatomy
'application image 18.
With the patient in the supine position, we begin plication of the rectus
abdominis muscles from the xiphoid appendix to near the points of
intersection of the drawing, just below the umbilical scar. A more vigorous
figure-8 polypropylene suture
(Prolene 0 or similar suture) is applied in a figure-8 pattern, joining the four intersection sutures of the
drawing, which facilitates the observation of the level of tension of this
suture, the main suture of the technique. We then continue in the lower
direction to plicate the pyramidal muscles with 2 or more sutures.
Figure 8 - Pre and post-operative of 6 months; lipoabdominoplasty with
type I plication.
Figure 8 - Pre and post-operative of 6 months; lipoabdominoplasty with
type I plication.
The next step is the horizontal plication of the aponeurosis of the external
oblique muscle, from the center of the drawing outward until the
anterosuperior iliac spines are reached. Sutures are all performed in shaped
8 pattern with the knot inverted, using Prolene 0 or a similar suture.
Additional interrupted running sutures with Vicryl 0 (polyglactin) are also
used as reinforcement on top of the Prolene sutures. The surgery continues
with the resection of skin and subcutaneous tissue flaps, introduction of a
suction drain, fixation of the umbilicus with Vicryl 0, closure of thefascia
of Scarpa with Monocryl 3-0, subdermal sutures also with Monocryl 3-0, and
micropore dressing.
Most cases will be solved with this technique, in Crossbow type 1 (Figure 8).
Special attention must be paid to patients with naturally low implantation of
the umbilicus because vertical shortening of the abdomen causes the
umbilical stump to be too low. In these cases, one must amputate the
umbilical stump and prepare a new umbilicus in a higher position (Figure 9).
Figure 9 - Pre-and post-operative of three months. Lipoabdominoplasty,
Type I Plication, amputation of the umbilical stump and creation
of neo-navel in the highest position.
Figure 9 - Pre-and post-operative of three months. Lipoabdominoplasty,
Type I Plication, amputation of the umbilical stump and creation
of neo-navel in the highest position.
The technique can adapt to the need of a mini abdomen, with the detachment
restricted to the umbilicus, only a small vertical spindle that connects the
umbilicus to the pubis, and the conventional marking of the cord and arc
(Figure 10).
Figure 10 - Pre and post-operative 6 months. Minilipoabdominoplasty with
scar extended by great skin flaccidity and detachment restricted
to umbilical scar. Plicature type II.
Figure 10 - Pre and post-operative 6 months. Minilipoabdominoplasty with
scar extended by great skin flaccidity and detachment restricted
to umbilical scar. Plicature type II.
In cases that need plication of the diastase of the semilunar line
concomitant to plication of the rectus abdominis, we select the vertical
spindle of the closure of the rectus abdominis, arc, and cord. However, the
2 ends of the arc should bend and follow the semilunar line, and no longer
the anterosuperior iliac spines (Figure 11).
Figure 11 - Pre-and postoperative of 6 months; abdominoplasty plicature
type III.
Figure 11 - Pre-and postoperative of 6 months; abdominoplasty plicature
type III.
RESULTS
With regard to complications, one case of slight hematoma occurred in a patient
with dermolipectomy in anchor, which was drained in the postoperative period. In
a patient who underwent lipoabdominoplasty, persistent pain occurred in the
right inguinal region but was resolved in 3 months. Two small sacral seromas
(liposuction) and one seroma occurred in the lower abdomen but was resolved with
puncture and compression. Another patient had a keloid after abdominoplasty. So
far, reintervention to correct residual convexities in the lower abdominal
region has never been required with this technique.
According to the comparative double-blind assessment, 5 observers classified the
concept as poor in only three patients from group B (conventional plication) and
in none of the patients in group A (crossbow). Group A attained a higher number
of points for excellent concept than group B, whose major concept was classified
as poor.
DISCUSSION
We know from previous studies that decreased waist and abdominal protrusions hold
a direct relationship with the diastasis of the rectus14 and oblique abdominis muscles. Factors such as
volumetric increase, type of collagen1,2
, and distension of the musculoaponeurotic fibers also induce this
protrusion. Thus, in some patients who underwent lipoabdominoplasties, a
residual bulging was observed in the lower abdomen in the postoperative period,
despite the plication of the rectus and oblique abdominis muscles4. The hypothesis is that the increase in
the musculoaponeurotic wall area was caused not only by the diastases of the
linea alba and semilunar line but also by the multidirectional distention of its
fibers9,12-14.
Below the arcuate line, only the transversalis fascia is observed, next to the
inner surface of the rectus abdominis muscles15. These areas are susceptible to pressure and the weight of the
abdominal contents, and to the effects of pregnancy, predisposing the patients
toward greater flaccidity and protrusion. The use of vertical and horizontal
traction vectors is assumed to attain both shortening and reinforcement of this
region, thereby preventing or minimizing residual bulging7,8,10-13.
As the transversalis fasciadoes not offer as much resistance as the posterior
aponeurosis of the rectus abdominis muscles, below the arcuate line, the rectus
abdominis muscles can adapt without risk of compartmental syndrome. In this
context, in the subcutaneous level, it is important to approximate the
superficial fascia at the time of occlusion of the flaps before subdermal
closure to prevent its retraction and subsequent division, which would increase
the suprapubic bulging4-6,16.
The crossbow technique was initially developed for secondary abdomens and,
subsequently, introduced in primary abdomens to prevent myofascial bulging in
the hypogastrium.
Multiparous, post-bariatric patients, or those with a large distension on the
lower floor of the abdomen are ideal indications for this technique.
The consequences of gestation in the patients who underwent crossbow plicature
were not evaluated; thus, it is recommended that patients undergo this procedure
only after they have given birth and if they do not wish to conceive
further.
CONCLUSION
The crossbow technique is simple, standardized, and reproducible. Possible
complications are the same as those of the conventional techniques. According to
the author’s preliminary assessment, in principle, the technique contributes to
the shortening and strengthening of the abdominal wall, improving the contour of
the iliac fossa and hypogastric region. According to the observers, none of the
10 patients with crossbow plication had a residual bulging in the hypogastrium.
The expectation is that with the increase in the sample size, a conclusion can
be reached about the possible advantages of the method and its
applicability.
COLLABORATIONS
|
ISF
|
Analysis and/or data interpretation, conception and design study,
conceptualization, data curation, final manuscript approval, formal
analysis, investigation, methodology, project administration,
realization of operations and/or trials, resources, supervision,
validation, visualization, writing - original draft preparation,
writing - review & editing.
|
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1. Hospital Policlínica São Vicente de Paula,
Francisco Beltrão, PR, Brazil
2. Hospital São Francisco de Assis, Francisco
Beltrão, PR, Brazil.
Corresponding author: Israel Soares
Filho Av. Julio Assis Cavalheiro, nº 605, Apt. 162 - Centro,
Francisco Beltrão, PR, Brazil Zip Code 85601-000 E-mail:
israpoint@gmail.com
Article received: March 20, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.
