Ronaldo Pontes block abdominoplasty technique
Técnica Ronaldo Pontes de abdominoplastia em bloco

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.

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

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.

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

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.

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).

DISCUSSION

The methods and approaches differed greatly among the literature reviews^6-12 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 infections^13-15. 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.