INTRODUCTION
In 1889, Kelly was the first to use the expression "abdominal lipectomy"1 when he performed a transverse dermal adipose excision that included the navel. Abdominoplasty
is among the most commonly performed aesthetic procedures that encompass both aesthetic
features and abdominal wall structural reconstruction2. Due to the number of variations and modifications of abdominoplasty procedures,
it is essential that surgeons select the appropriate technique based on the patient's
characteristics to minimize postoperative morbidity and disability while achieving
a desirable and predictable result3.
Abdominoplasties were initially performed using a low incision, cranial flap separation,
treatment of the aponeurosis muscle, caudal traction, resection, navel transposition,
and wound closure. This type of procedure often results in asymmetrical healing due
to flap traction irregularities. In the adipose abdomen, this problem was aggravated
by difficulty supporting an extremely heavy flap during the dissection4. For this reason, in the early 1960s, the previously marked flap was resected in
block using lateral dissection to facilitate the surgical procedure, provide better
bleeding control, and reduce the operative time. With technical improvements and experience
with different cases, in 1971, four types of horizontal resections and their application
were idealized in several cases by following the same principle5.
OBJECTIVE
This study aimed to demonstrate our experience with abdominoplasty focusing on the
scar aesthetic results and the evolution of these patients with application of the
block resection technique developed by Professor Ronaldo Pontes (RP).
METHODS
This retrospective observational series consisted of data collection from medical
records comprising a total of 124 patients (122 women, 2 men) who underwent block
abdominoplasty surgery (Figure 1) using the RP block resection technique between March 2014 and March 2017 with respect
of the individualization of all four of its variants (Chart 1).
Figure 1 - In block abdominoplasty technique.
Figure 1 - In block abdominoplasty technique.
Chart 1 - Surgical technique of block abdominoplasty.
1. |
Marking of the block abdominal incision (RP technique) with the patient in the standing
and lying positions;
|
2. |
Pneumatic boot placement; |
3. |
Patient in horizontal dorsal decubitus position with asepsis and antisepsis and placement
of sterile fields under general anesthesia;
|
4. |
Local infiltration with anesthetic solution*; |
5. |
Incision of excess tissue according to previous and circumferential navel marking; |
6. |
Resection of excess tissue previously marked, keeping the navel inserted in the aponeurosis**; |
7. |
Tunnel flap detachment up to the xiphoid process with plicature marking of the muscle-aponeurotic
system of the abdominal rectum;
|
8. |
Plicature according to the marking, with number 0 Prolene thread and navel fixation in the aponeurosis with four cardinal points;
|
9. |
Flap caudal traction to mark the onphaloplasty on the skin as a Y (3-point star); |
10. |
Review of hemostasis and introduction of a closed suction drain system (exiting in
the pubic region);
|
11. |
Confection of Baroudi adhesion points;
|
12. |
Onphaloplasty, resulting in an equilateral triangle (directed to the pubis); |
13. |
Flap synthesis in three planes; and |
14. |
Local dressing. |
Chart 1 - Surgical technique of block abdominoplasty.
Type I (RP1) - Indicated in patients with supra- or infraumbilical flaccidity. The cranial tracing
of the ellipse passes just above the umbilical scar, descending gently on both sides
to the middle of the lateral part of the bikini demarcation. The lower tracing has
three segments: two lateral cranial concavity segments and the suprapubic arch, which
has a slight caudal concavity and a diameter inferior to that of the pubis. The two
lower lateral arches must also be curved, with opposite curvature to the upper ones,
to create a slightly curved scar with superior concavity.
Type II (RP2) - Also called the mini abdomen, the ellipse occupies the lower third between the
navel and the pubis. This variant is indicated for patients with only infraumbilical
flaccidity without the need for plicature of the rectus abdominis muscles. The indication
of Type II should be extremely careful and should be denied when there is significant
flaccidity in the epigastric region.
Type III (RP3) - Indicated exclusively for patients with a high umbilicus and infraumbilical flaccidity.
The design is identical to that of Type II, with the difference being that the umbilical
scar is sectioned at its base; after cranial dissection and plicature of the abdominal
rectus muscles, it is reinserted below its original point, resulting in navel lowering
of about 2 cm.
Type IV (RP4) - Indicated in patients with supra- or infraumbilical flaccidity with no indication
of other variants. The marking is similar to Type I, but the cranial tracing of the
ellipse passes just below the umbilical scar, where it subsequently has an original
point closed longitudinally since it is not included in the area to be resected. The
flap descends normally and the navel is transposed, similar to a typical abdominoplasty,
resulting in an inverted T-incision.
Vertical - For cases in which there is a previous vertical supraumbilical scar or in cases
with skin redundancy in which the cost-benefit favors the vertical scar.
Professor Baroudi's adhesion points were used in these abdominoplasty techniques.
The exclusion criteria in the study were: patients younger than 18 years or older
than 65 years, body mass index (BMI) less than 20, previous cavitary gynecological
surgery, abdominal deformities after abdominal or bariatric surgery, positive screening
for breast cancer, and intentions of pregnancy.
The inclusion criteria in the study were: patients between 18 and 65 years if age,
patients with supraumbilical and infraumbilical skin flaccidity, presence of abdominal
rectus muscle diastasis, patients with satisfied progeny and body mass index above
20 (Table 1).
Table 1 - Body mass index values of the study population
Body mass index (kg/m2) |
Frequency |
% |
20-22 |
13 |
10.40 |
23-25 |
48 |
38.80 |
26-28 |
35 |
28.20 |
29-31 |
15 |
12.10 |
32-34 |
8 |
6.50 |
≥35 |
5 |
4.00 |
Table 1 - Body mass index values of the study population
A detailed physical examination was performed of all patients and the implications
of an abdominal plastic surgery were thoroughly discussed with the patients, as was
guidance on fertility, time required for recovery, walking with some flexion of the
abdomen, length of stay, and the use of suction drains (Table 2). Routine laboratory tests, total abdominal and abdominal wall ultrasonography, and
venous Doppler of the lower limbs were requested.
Table 2 - Frequency of comorbidities.
Comorbidity |
Frequency |
% |
None (healthy patient) |
84 |
67.74 |
Diabetes |
4 |
3.22 |
Hypertension |
15 |
12.09 |
Hypothyroidism |
8 |
6.45 |
Other |
15 |
12.09 |
Table 2 - Frequency of comorbidities.
In the postoperative period, all patients underwent prophylactic treatment for deep
vein thrombosis using pneumatic boots in the preoperative and postoperative periods
and clexane in the postoperative period. A written statement of clarification was provided, and
photographic documentation was routinely performed.
The patients were followed up daily for the first two postoperative days and weekly
during the first month, followed by once a month. The aesthetic result was evaluated
at 6 months postoperative.
RESULTS
The mean patient age was 44.5 (range, 18-63) years (Table 3). The mean surgical time was 154 (range, 100-250) minutes. The mean indwelling drain
time was 7 days to chart 2. The surgeries associated to abdominoplasties are presented in chart 2 and 3.
Table 3 - Age frequencies
Age (years) |
Frequency |
% |
18-30 |
20 |
16.12 |
31-45 |
67 |
54 |
46-60 |
33 |
27 |
61-65 |
4 |
3 |
Table 3 - Age frequencies
Chart 2 - Frequency of Ronaldo Pontes (RP) technique variations used over 3 years
Chart 2 - Frequency of Ronaldo Pontes (RP) technique variations used over 3 years
Chart 3 - List of combined surgeries used
Chart 3 - List of combined surgeries used
In our study, there was a decreased incidence of complications noted with the RP block
abdominoplasty technique compared to those in the literature (Table 4). We observed a small number of cases of healing changes (Table 5). Patients who underwent surgery had a high degree of morphological and functional
satisfaction.
Table 4 - Frequency of complications.
Complication |
Frequency (%) |
Literature (range, %)
|
Seroma |
1.61 (2 cases) |
1.0-4.2 |
Hematoma |
0.80 (1 cases) |
5.0-6.1 |
Surgical site infection |
0.00 (0 cases) |
2.2-7.3 |
Flap necrosis or loss |
0.80 (1 cases) |
4.8-6.0 |
Deep vein thrombosis |
0.00 (0 cases) |
1.0-1.1 |
Pulmonary embolism |
0.00 (0 cases) |
0.5-0.8 |
Table 4 - Frequency of complications.
Table 5 - Healing changes
Complication |
Frequency (N = 124) |
% |
Without complications |
118 |
95.18 |
Wound dehiscence |
0 |
0.00 |
Hypertrophic scar |
2 |
1.61 |
Keloid scars |
1 |
0.80 |
Table 5 - Healing changes
Case 1
Figure 2 - A. Preoperative view; B. Six months postoperative view.
Figure 2 - A. Preoperative view; B. Six months postoperative view.
Case 2
Figure 3 - A. Preoperative view; B. Six months postoperative view.
Figure 3 - A. Preoperative view; B. Six months postoperative view.
Case 3
Figure 4 - A. Preoperative view; B. Six months postoperative view.
Figure 4 - A. Preoperative view; B. Six months postoperative view.
Case 4
Figure 5 - A. Preoperative (frontal view); B. Six months postoperative (frontal view); C. Preoperative (profile view); D. Six months postoperative (profile view).
Figure 5 - A. Preoperative (frontal view); B. Six months postoperative (frontal view); C. Preoperative (profile view); D. Six months postoperative (profile view).
Procedure To Guarantee Ethical Aspects
The study was conducted with data obtained from the surgeon's personal files. There
was no direct contact with the patients; therefore, no informed consent was required.
The identity of the patients who participated in the study remained anonymous since
their identities were not necessary for the study.
We agreed to abide by the ethical and moral principles that should govern all research
involving human beings, including the Declaration of Helsinki, Belmont Report, Good
Clinical Practice, and the Ethical Standards and Criteria set forth in codes of ethical
confidentiality and/or current laws. We also respected the data confidentiality obtained
from clinical records and any other data collection methods to prevent disclosing
any information that would allow us to identify the subjects.
Authorization was requested from the authorities of the Niterói D'Or Hospital, as
was approval from the Institutional Ethics Committee.
DISCUSSION
The methods and approaches differed greatly among the literature reviews6-12 and using comparisons with retrospective studies as a discussion point. Thus, we
tried to bypass the discrepancies by defining the facts with a simple objective and
comparing the most common complications with our evidence.
The practice of combined surgeries increases the risk of morbidity, consequently increasing
length of hospital stay, blood transfusion index in the intra- and postoperative periods,
and the incidence of thromboembolism and severe infections13-15. We believe that common sense is essential to evaluating a procedure's cost-effectiveness
to enable understanding of the safety of performing surgeries combined with abdominoplasty.
The advantages of the RP technique are to simplify resection, dispense the need to
hold a very long and heavy flap during dissection, facilitate bleeding control, ensure
better symmetry of the resulting scar, drastically reduce procedure time, and stimulate
the best preoperative planning. The flap marking to be resected is usually made the
day before or in the ward, as it reduces operating room use time and patient anesthesia
time5, thus minimizing complications and scar defects.
We emphasize that, among all complications, deep vein thrombosis (DVT) and pulmonary
embolism are the most dramatic. The incidence of DVT in patients undergoing general
surgery is reportedly 6-12%9, while the incidence of pulmonary embolism is 1.5%9. These events were avoided in our cases due to knowledge of their pathophysiology,
use of preventive measures, and short surgical time.
CONCLUSION
The RP technique and its variants meet the need for several types of cases, ensure
safe and effective surgeries, and are reproducible.
The prevention of hematomas and seromas occurs through rigorous hemostasis, the use
of adhesion points and suction drains to prevent prolonged active drainage, and thus
minimizing rates of these complications associated with adequate postoperative guidance.
Therefore, knowledge of the pathophysiology, use of prophylactic measures, and the
use of a technique with shorter surgical time reduced the risk of thromboembolic events
and consequently the occurrence of pulmonary embolism. Hence, we provided excellent
patient care and achieved a high degree of morphological and functional satisfaction.
COLLABORATIONS
LXB
|
Conceptualization, Final manuscript approval, Investigation, Realization of operations
and/or trials, Resources, Supervision, Writing - Original Draft Preparation
|
ACAMD
|
Resources, Supervision
|
RAK
|
Analysis and/or data interpretation, Data Curation, Formal Analysis, Investigation,
Methodology, Writing - Original Draft Preparation, Writing - Review & Editing
|
ROL
|
Analysis and/or data interpretation, Conceptualization, Data Curation, Formal Analysis,
Writing - Original Draft Preparation, Writing - Review & Editing
|
GHP
|
Final manuscript approval, Supervision, Validation, Writing - Original Draft Preparation
|
REFERENCES
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1. Hospital Niterói D'Or, Serviço de Pós-Graduação em Cirurgia Plástica Prof. Ronaldo
Pontes Niterói, RJ, Brazil.
Corresponding author: Leonardo Xavier Braga Rua Otávio Carneiro, 143, Sala 401, Icaraí, Niterói , RJ, Brazil. Zip code: 24220-000.
E-mail: leonardoxbraga@yahoo.com
Article received: June 4, 2018.
Article accepted: October 21, 2019.
Conflicts of interest: none.