Indications for abdominoplasty

The main characteristics of the "ideal" belly:

• dense, taut lateral surface of the body and groin area with a deeply defined, tucked-in waist;
• the centrally located tissues are not tense and have a soft convexity in the hypogastric region and a soft concavity in the epigastric region;
• In the epigastric region between the edges of the rectus abdominis muscles there is a median groove.

The main components of postpartum deformation of the anterior abdominal wall are:

• excess subcutaneous fat and/or skin;
• relaxation (overstretching) of the muscular-fascial system;
• skin stretches and/or post-operative scars.

A significant increase in the volume of abdominal contents during pregnancy leads to vertical and horizontal overstretching of the muscular-fascial layer, the development of diastasis of the rectus muscles and stretching of the skin. Subsequently, all these changes undergo reverse development, but not to the full extent. To a large extent, the severity of the final tissue changes depends on the size of the fetal sac and the individual tissue extensibility (contractility).

The main indicators of anatomical and functional insufficiency of the anterior abdominal wall are:

• presence and degree of soft tissue ptosis;
• thickness of the subcutaneous fat layer;
• degree of divergence of the rectus abdominis muscles;
• skin condition (flabbiness, presence of skin stretch marks and postoperative scars);
• the presence of an umbilical hernia.

The presence and degree of ptosis of the tissues of the anterior abdominal wall are the most important indicator and in many cases are characterized by the presence of a sagging skin-fat fold ("apron"). The latter most often determines the indications for surgery.

The presence of soft tissue ptosis is assessed with the patient's body in a vertical position. A. Matarasso identifies four degrees of soft tissue ptosis of the anterior abdominal wall, which allows formulating indications for one or another type of abdominoplasty.

Since the main complaint of patients with ptosis of the anterior abdominal wall tissues is the presence of an "apron", this clinical symptom is the most important. Taking this circumstance into account, it is advisable to distinguish four groups of patients with different degrees of expression of ptosis of the soft tissues of the anterior abdominal wall.

Group 1: patients with moderate stretching of the skin of the anterior abdominal wall, primarily in the hypogastric region without the formation of an "apron". In this case, indications for surgery arise mainly in the presence of skin stretch bands (striae gravidarum).

2nd group: the presence of a small and not yet sagging skin-fat fold (almost an "apron") in the lower abdomen in combination with flabbiness of the skin in the epigastric and hypogastric zones. In this situation, abdominoplasty can be performed, but the relatively small degree of possible displacement of the skin-fat layer of the abdominal wall in the caudal direction often does not allow the surgeon to limit himself to only horizontal access, and the postoperative scar may also have a vertical component.

Group 3: patients have an “apron” up to 10 cm wide, which is located within the anterior abdominal wall with a transition to the lateral surfaces of the body.

Group 4: the width of the "apron" exceeds 10 cm, the skin-fat fold extends to the lumbar region and is combined with folds on the postero-outer surfaces of the chest.

In the 3rd and 4th groups of patients, the indications for abdominoplasty are obvious, and the type of surgery is determined taking into account the entire set of circumstances.

The thickness of the subcutaneous fat layer of the anterior abdominal wall is an important indicator, largely determining the risk of developing seromas and other complications due to the fact that subcutaneous fat is very sensitive to any trauma, including surgical trauma. The most common variants of the location of fat tissue on the anterior abdominal wall are:

• relatively uniform;
• with a predominance of fat deposits in the lateral parts of the body, moving to the flanks;
• with concentration in the central zone along the rectus abdominis muscles.

With a minimal thickness of subcutaneous fat (less than 2 cm), the risk of developing seroma is minimal. With a moderate thickness (2-5 cm), the likelihood of developing seroma increases. With a significant thickness of the subcutaneous fat layer (more than 5 cm), the risk of developing seroma is significant, and the aesthetic results of the operation are worsened. In this situation, there are indications for preliminary liposuction of the anterior abdominal wall.

The degree of divergence of the rectus abdominis muscles determines the size of the duplication of the aponeurosis of the anterior abdominal wall created during abdominoplasty. In turn, this determines the degree of correction of the waist circumference, the amount of displacement of the navel into the depth of the wound when creating a duplication of the aponeurosis, as well as the risk of developing a syndrome of hypercompression of the abdominal wall organs with the possibility of developing pulmonary edema.

Several degrees of divergence of the rectus abdominis muscles can be distinguished. With an insignificant degree, duplication of the aponeurosis is not needed or can be formed on a section up to 5 cm wide. With moderate divergence of the rectus muscles, duplication of the aponeurosis section 5-10 cm wide is formed, and with significant divergence - on a section more than 10 cm wide. In the latter case, with a combination of significant divergence of the rectus abdominis muscles with a significant thickness of subcutaneous fat and a deep location of the navel, there may be indications for removal of the latter.

Skin condition. This indicator may be the basis for performing surgery in the presence of stretch marks. If the latter are located predominantly in the hypogastric area, their main part can be removed during abdominoplasty. However, this is not always possible, since stretch marks often form with a minimal thickness of the subcutaneous fat layer. In this case, significant displacement of the skin-fat flap in the caudal direction is often impossible, so the stretch marks are removed only partially, and the postoperative scar may have an additional vertical component.

The presence of an umbilical hernia is possible with any degree of anatomical and functional insufficiency of the anterior abdominal wall and can significantly complicate the operation.

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