Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis.

INTRODUCTION: Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy. METHODS: A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed. RESULTS: Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores. CONCLUSIONS: Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

Siguiendo la trayectoria de la abdominoplastia TULUA ­ Revelación de su evolución e impacto global / Tracing the Trajectory of TULUA Abdominoplasty ­ Unveiling its Evolution and Global Impact

La técnica de abdominoplastia TULUA, fue concebida por el Dr. Francisco Villegas en Colombia, su acrónimo en inglés refleja sus principios fundamentales: plicatura Transversal, Sin despegamiento, Liposucción sin restricción que incluye la línea media y flancos, Neo umbilicoplastia, ubicación baja de cicatriz y libre posición del ombligo. A lo largo de los últimos 12 años, la técnica TULUA ha ganado espacio en América Latina, Norteamérica, la zona árabe e India. Destacando su relevancia, se ha propuesto la publicación de un libro monográfico, programado para 2024, que abarcará desde los principios fundamentales hasta las experiencias internacionales con la técnica. Las indicaciones de la abdominoplastia TULUA han evolucionado, incluyendo casos estéticos, secundarios, hernias, cicatrices previas, pérdida masiva de peso, alta definición, aumento muscular y combinaciones con otras plicaturas. Ha sido aplicada con éxito en cierre del abdomen donante de reconstrucción mamaria. A través de investigaciones especializadas y revisiones de pares, la TULUA ha sido reconocida por su aplicabilidad y beneficios, especialmente en la realización segura de liposucción en abdominoplastias. Se sugieren estudios adicionales para evaluar los resultados y posibles complicaciones, abriendo oportunidades para una mayor comprensión y refinamiento. El futuro de la abdominoplastia TULUA parece prometedor, anticipando trabajos prospectivos, indicaciones adicionales y un enfoque gradual para cirujanos en formación. En última instancia, la técnica se presenta como una adición al repertorio de procedimientos estéticos abdominales, contribuyendo al avance de la cirugía abdominal estética.

The TULUA abdominoplasty technique, conceived by Dr. Francisco Villegas in Colombia, its acronym in English reflects its fundamental principles: Transverse plication, no Undermined flap above the umbilicus, Liposuction without restrictions including midline and flanks, Neo umbilicoplasty, low scar placement, and free umbilical positioning. Over the past 12 years, the TULUA technique has gained acceptance in Latin America, North America, the Arab region, and India. Highlighting its relevance, the publication of a monographic book has been proposed, its launch is scheduled for 2024, covering from fundamental principles to international experiences with the technique. Indications for TULUA abdominoplasty have evolved, including aesthetic cases, secondary cases, hernias, previous scars, massive weight loss, high definition, muscle augmentation, and combinations with other plications. It has been successfully applied in closing the donor abdomen for breast reconstruction. Through specialized research and peer reviews, TULUA has been recognized for its applicability and benefits, especially in safely performing liposuction during abdominoplasties. Additional studies are suggested to evaluate results and potential complications, opening opportunities for greater understanding and refinement. The future of TULUA abdominoplasty appears promising, anticipating prospective works, additional indications, and a gradual approach for surgeons in training. Ultimately, the technique presents itself as an addition to the repertoire of abdominal aesthetic procedures, contributing to the advancement of aesthetic abdominal surgery.

Indications, outcomes, and complications of neoumbilical reconstruction: A systematic review.

BACKGROUND AND OBJECTIVES: Neoumbilicoplasty aims to reconstruct an aesthetically pleasing new umbilicus following agenesis, malignancy, anatomical distortion, or umbilicus loss. Despite the wide variety of surgical techniques described, literature is scarce when it comes to standardized categorization of these as well as the clear definition of patients' selections, specific indications, final outcomes, and possible complications. According to available literature, this work aims to evaluate different surgical approaches, and correlate them to specific surgical needs, to simplify the surgical choice and patient management. METHODS: A systematic review was performed in December 2020 in PubMed, Web of Science, and MedLine Ovid databases according to the PRISMA guidelines. RESULTS: A total of 41 studies and 588 patients were finally included. On the basis of the evidence of the literature collected, we divided the studies into four groups according to the neoumbilicoplasty techniques: single suture or purse-string suture, single flap, multiple flap, and skin graft. Patients' surgical comorbidities, neoumbilicoplasty indications, and aesthetic and surgical outcomes were investigated. Direct suture and single and multiple flap techniques assured overall, satisfactory cosmetic outcomes with a low rate of surgical complications. Whereas suture-only techniques were chosen mostly by general surgeons/urologists in laparoscopic surgery, the single flap was the preferred method to reconstruct the umbilicus in open abdominal surgery or combined abdominoplasty with herniorrhaphy. Multiple flap and skin grafts were adopted in abdominoplasty-related umbilicus reconstruction, although the latter option showed impactful aesthetic and surgical complications. CONCLUSIONS: Umbilicoplasty can assure generally pleasant aesthetic outcomes with relatively low complication rates. Indications for specific techniques correspond to different patient populations and surgical scenarios.

Standardization of the Extent and Timing of Rectus Diastasis Repair in Abdominoplasty Cases with TOF Neuromuscular Monitoring: A Clinical Study.

Despite the close focus on the anterior abdominal wall and the classification, maneuvers and materials related to the rectus abdominis and its fascia, there is no established standard concerning the extent of plication. The anterior abdominal wall is a musculoaponeurotic structure and a dynamic motor system with innervation and tonus. Therefore, the timing of the plication is as important as the suture technique and material, since the muscle relaxant will lose its effect in varying time periods. The aims of our study were to determine the change in the amount of plication between groups with and without muscle relaxants before plication and whether the amount of this change can be standardized using train-of-four (TOF) monitoring. In 2022 and 2023, 12 women aged between 25 and 48 years with a body mass index between 24 and 38 years were included in the study. Neuromuscular blockade was monitored by train-of-four (TOF) monitoring in all patients. Maximum plication areas at above-zero TOF value and zero TOF value were calculated and compared with each other. The reduction in the area of group 1, which represents the phase without muscle relaxant, and group 2, which represents the phase with neuromuscular blockade, were compared using the t-test. When assessed for above-zero TOF, the area between plication lines (a, a') was always smaller than the area between the plication lines (b, b') when the TOF value was zero. The t test comparison of group 1, which includes (a, a') values, and group 2, which includes (b, b') values, resulted in a value of p = 0.000. All cases, the plication value obtained with above-zero TOF value was lower than the plication value when the TOF value was zero. This difference was also confirmed statistically on a group basis. This suggests that neuromuscular measurements should be taken during the plication phase in the routine flow of surgery. Muscle relaxants are not routinely administered to patients undergoing abdominoplasty or rectus diastasis repair who are already under sufficient analgesia, unless there is a pressure alert on the anesthesia device. The surgeon cannot always determine the degree of muscle laxity accurately by palpation. TOF monitoring is a cost-effective quantitative method that can be easily and quickly performed, accurately determining the timing of muscle-fascia plication of the rectus abdominis. Through this approach, the anterior abdominal wall can be plicated with maximum tightness and maximum aesthetic gain can be obtained.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Abdominoplasty in Tumescent Local Anesthesia Combined with Subdural Anesthesia.

BACKGROUND: Abdominoplasty is a common surgical procedure performed under general anesthesia, and although the use of TLA combined with subdural anesthesia has never been reported in abdominoplasty, it offers several benefits such as safe and effective local anesthesia and vasoconstriction. We outline our experience with the TLA technique for primary abdominoplasty over the last 7 years. METHODS: From 2014 to 2021, TLA and subdural anesthesia have been used in primary abdominoplasty surgeries for 106 patients. The TLA solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) diluted in 1000 mL of 0.9% saline solution. The solution was then injected with a 2-mm cannula into the subcutaneous adipose tissue in the suprafascial plane. The subdural anesthesia was performed at intervertebral level L1-L2 using Ropivacaine 15/18 mg in 4 ml. RESULTS: Patients aged from 32 to 75 years. The amount of tumescent solution infiltrated ranged between 500 and 1000 mL. Mean surgery time was 70 minutes, and recovery room time averaged at 240 minutes. Major complications related to the surgery were observed in 12.26% of patients, including eight hematomas and five seromas. Two patients experienced wound dehiscence, and no dystrophic scar formation was observed. Eventually, there was no need for a conversion to general anesthesia. CONCLUSIONS: Tumescent local anesthesia combined with subdural anesthesia is a highly effective and safe method for performing abdominoplasty. This technique has proven to be an excellent choice for primary abdominoplasty, providing significant benefits to patients and surgeons alike due to its safe administration, precise pain management during and after surgery, and minimal postoperative side effects. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparative analysis of the efficacy and functionality of abdominoplasty versus minimally invasive techniques in the surgical treatment of diastasis rectus abdominis in postpartum women.

INTRODUCTION: This review aims to describe the surgical options available for treatment of diastasis recti in postpartum women, as well as compare the effectiveness of these treatment options. Historically, diastasis recti has been repaired through open procedures, such as abdominoplasty. More recently, studies have explored other methods for the treatment of diastasis recti, including various minimally invasive surgical options. METHODS: Twelve studies ranging from 2015 to 2022 were included in this analysis. Studies were identified using PubMed, EMBASE, and Cochrane Library. Studies that met the inclusion criteria were analyzed descriptively. Statistical comparison of surgical outcomes between studies was performed using Fisher's Exact Test in SPSS. RESULTS: Minimally invasive approaches were categorized as laparoscopic preaponeurotic approaches, robotic approaches, and enhanced-view/extended totally extraperitoneal (eTEP) approaches. These techniques were compared to two open approaches: abdominoplasty and miniabdominoplasty. There were no significant differences in the rate of seromas, surgical site infections/complications, or hematomas between abdominoplasty and minimally invasive surgical techniques (p > 0.05). Among the minimally invasive techniques, no significant differences in readmission rates were reported (p > 0.05). Additionally, no significant differences in recurrence rates were seen following minimally invasive or abdominoplasty repairs, except for the increased recurrence rates seen with the r-TARRD robotic technique (p < 0.05). CONCLUSION: Although current data on minimally invasive approaches is limited, our review reveals that both open and minimally invasive approaches are viable options for diastasis recti repair in postpartum women. Identifying the optimal approach for diastasis recti repair should rely on the patient's desired treatment outcome. If the patient indicates a desire for the removal of excess abdominal subcutaneous tissue, abdominoplasty may be a better surgical approach. Alternatively, if the patient puts a greater emphasis on shorter recovery time and smaller surgical incisions/scars, minimally invasive approaches may be a better surgical option.

Combined Surgery (Mommy-Makeover) Compared to Single Procedure (Abdominoplasty) in After-Pregnancy Women: A Prospective Study on Risks and Benefits.

BACKGROUND: Mommy-makeover is becoming very popular to help them reshaping their own bodies and restoring self-perception, hardly stressed by childbearing-related changes. However, debate exists in the literature concerning safety and aesthetic outcome in patients undergoing combined procedures. The study aims to shed a light on advantages and disadvantages in mommy-makeover technique compared to conventional abdominoplasty with a particular attention to psychological aspects. MATERIALS AND METHODS: In total, 37 women were enrolled at Campus Bio-Medico Hospital in Rome between October 2019 and January 2022. All of the patients were eligible for both abdominoplasty only and mommy-makeover. We proposed to the patients both procedures explaining risks and benefits; then, based on the preference of the single patient, we performed either mommy-makeover (Group A) or abdominoplasty alone (Group B). In order to evaluate patients' satisfaction and safety, multiple questionnaires were administered 9-month postoperatively (BUT, POSAS, visual perception, etc.). RESULTS: The sample analyzed was composed of 37 patients (treatment group = 18, control group = 19). In the pre-post comparisons of BUT-A performed, there were statistically significant differences recorded in both groups and for all observed variables. The significance values were all less than 1% (p < 0.01). CONCLUSIONS: Combined surgery proved not to be inferior in terms of patient safety. At the same time, the effectiveness in improving diastasis-related symptoms is fully comparable with single surgery. Treatment group showcases a considerable superiority in terms of body-image perception improvement and overall patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does Concomitant Umbilical Hernia Repair Increase the Risk of Complications in Abdominoplasty? A Propensity Score Matched Analysis.

BACKGROUND: Patients seeking cosmetic abdominoplasty often have umbilical hernias. Optimal management and safety of concomitant umbilical hernia repair with abdominoplasty is not well described. OBJECTIVES: The goal of this study was to compare complication rates following abdominoplasty with or without umbilical hernia repair. METHODS: A retrospective propensity score matched cohort study of patients who underwent an abdominoplasty at Massachusetts General Hospital was performed. Direct umbilical hernia repair was performed by making a fascial slit inferior or superior to the umbilical stalk. The fascial edges were approximated with up to three 0-Ethibond sutures (Ethicon, Raritan, NJ) from the preperitoneal or peritoneal space. Propensity score matching was used to adjust for confounding variables. RESULTS: The authors identified 231 patients with a mean [standard deviation] age of 46.7 [9.7] years and a mean BMI of 25.9 [4.4] kg/m2. Nine (3.9%) had diabetes, 8 (3.5%) were active smokers, and the median number of previous pregnancies was 2. In total, 223 (96%) had a traditional abdominoplasty, whereas 8 (3.5%) underwent a fleur-de-lys approach. Liposuction was performed on 90%, and 45.4% underwent simultaneous breast or body contouring surgery. The overall complication rate was 6.9%. Propensity scores matched 61 pairs in each group (n = 122) with closely aligned covariates. There was no significant difference in total complication rates between abdominoplasty alone vs abdominoplasty with hernia repair. There were no cases of skin necrosis or umbilical necrosis in either group. CONCLUSIONS: Performing umbilical hernia repair with abdominoplasty is safe when utilizing the technique reported in this series.

The Safety and Effects of Pregnancy after Abdominoplasty: A Systematic Review of the Literature.

BACKGROUND: As advanced maternal age and bariatric procedures have become more common, the number of women seeking pregnancy after having abdominoplasty has increased. This has traditionally been a relative contraindication and counselled against, though there are little data in the literature regarding the potential effects to mother and baby. METHODS: A systematic review of Medline and Embase databases was performed to identify cases of pregnancy occurring after abdominoplasty. Data were extracted and analysed for presentation. RESULTS: 17 studies encompassing 237 patients met inclusion. Mean age was 33.08 years. Mean parity prior to first pregnancy after abdominoplasty 2.13. Previous bariatric surgery was reported in 31.75%. Body contouring procedure was abdominoplasty (94.51%), body lift (3.80%) and other (1.69%). Rectus plication was performed in 89.74%, where reported. Mean time between abdominoplasty and pregnancy was 3.75 years. Method of delivery was Caesarean section in 43.63%, and vaginal delivery in 56.37%. Mean gestational age at delivery was 38.90 weeks. Preterm delivery (<37 weeks) was reported in 9.85%, and low birthweight (<2500 g) was reported in 7.22%. Diagnoses or complications were documented in 14 studies (136 patients). These were grouped as foetal/neonatal (n = 21), maternal (n = 104) or abdominal wall/aesthetic (n = 96); and are detailed within. There were no neonatal or maternal mortalities in any study. A lower-than-expected spinal anaesthetic block was stated in 3 cases. Mean follow-up was 8.5 months. CONCLUSION: Pregnancy should not be contraindicated after abdominoplasty. The data presented allow clinicians to have an evidence-based discussion and provide information for shared decision-making. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The monsplasty: Surgical and functional outcomes using an effective and reproducible surgical technique.

BACKGROUND: The available literature on monsplasty remains sparse and most of the reports are limited to the description of one surgical technique, with limited to no post-operative data. This study aims to describe a reproducible monsplasty surgical technique and to analyze the post-operative functional and esthetic outcomes. METHODS: Patients with at least grade 2 mons pubis ptosis were included in the study and observed for 3 months. Pre- versus post-operative analysis included body image, psychological function, sexual function, urinary function, hygiene maintenance of the pubic area, and post-operative complications. An additional retrospective analysis of a larger group of patients was also performed. RESULTS: Between April 2021 and January 2022, a total of 25 patients were included in the prospective study. They reported a significant improvement in body image (p < 0.001), satisfaction with the abdomen (p < 0.001), and sexual functioning (p = 0.009). Functionally, improvements were recorded with regard to visualization of the genitalia (36%), hygiene maintenance of the pubic area (32%), sex life (48%), genital sensitivity (24%), and urinary continence (4%). Patient satisfaction was very high. There were no major complications. The retrospective study included 80 patients between 2010 and 2021, with a mean follow-up time of 18 months. No major complications were noted. CONCLUSION: Monsplasty is a simple and fast procedure that can truly bring an added value to the patient's satisfaction and functional outcomes. It can be incorporated in both esthetic and reconstructive abdominoplasties and should be a standard component of the procedure for cases with mons ptosis grade 2 or higher. EVIDENCE BASED MEDICINE LEVEL: Level II.

Simple plication alleviates physical symptoms in patients with post-gestational rectus diastasis.

PURPOSE: To evaluate our surgery for post-gestational rectus abdominis muscle diastasis using slowly absorbable monofilament suture and eight weeks of abdominal binder in terms of recurrence rate, complications, and effect on patients' physical and cosmetic complaints. METHOD: In a retrospective cohort study, all 44 patients operated between 2014 and 2020 were invited to a follow-up using ultrasound, clinical examination, and questionnaires regarding symptoms before and after surgery. RESULTS: 89% of invited patients participated, with a median follow-up of 36 months. There was one recurrence caused by severe postoperative nausea and vomiting, which was the most common complication. Most procedures were safe, but two patients experienced Clavien-Dindo grade 3 complications. Patients reported feeling limited or taking precautions after surgery for a median of 8.5 months. Of all included patients, four responded that the operation did not alleviate their primary complaint. The remaining 35 patients (90%) experienced complete or partial alleviation of their primary complaints and would undergo the procedure again if needed. CONCLUSION: Post-gestational diastasis recti can be associated with a large number of physical symptoms and functional complaints and can safely be operated using a single running plication of the anterior rectus fascia with a slowly absorbable suture, with fair cosmetic results, excellent effect on symptoms, few complications and high levels of patient satisfaction. Future research must determine which symptoms and findings should indicate surgery.

Postbariatric Abdominoplasty: A Comparative Study on Scarpa Fascia Preservation Versus Classical Technique.

BACKGROUND: Abdominoplasties performed with Scarpa Fascia preservation, improve recovery and reduce complications, particularly seroma. Bariatric patients who experience massive weight loss frequently seek body contouring procedures and represent a high-risk group. This study aimed to evaluate the effects of abdominoplasty with Scarpa Fascia preservation versus the classical technique in a bariatric population. METHODS: A retrospective observational cohort study was performed between March 2015 and March 2021 in 65 postbariatric patients who underwent a classic full abdominoplasty (group A, N = 25) or a similar procedure except for the preservation of Scarpa fascia (group B, N = 40). Total and daily drain output, time until drain removal, long drainers (≥ 6 days), length of hospital stay, emergency department visit, readmission to the hospital, reoperation, local and systemic complications were the outcomes evaluated. RESULTS: Group B had a 3-day reduction in time until drain removal (p < 0.001), a 62.6% reduction of total drain output (p < 0.001) and a 3-day reduction in the length of the hospital stay (p < 0.001). Long drainers (≥ 6 days) were highly reduced (from 56.0% in group A to 7.5% in group B) (p < 0.001). There was a lower incidence of liquid collections in group B, with a 66.7% reduction in seroma incidence. CONCLUSIONS: Abdominoplasty with Scarpa Fascia preservation improves recovery by reducing drain output, allowing earlier drain removal and reducing long periods with suction drains. It also reduces hospital stay and seroma incidence. This technique modifies the high-risk postbariatric patient in such a major way that he behaves like a nonbariatric. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Presentación de una nueva clasificación de plicaturas en abdominoplastia / Presentation of a new classification in abdominoplasty plications

Introducción y objetivo: El concepto de abdominoplastia se ha redefinido en los últimos años siendo el manejo del componente musculoaponeurótico un elemento fundamental para mejorar el contorno de la pared abdominal. Sin embargo, las indicaciones de plicatura no están claramente establecidas, encontrando descritas innumerables técnicas por diversos autores. El presente trabajo tiene por objetivo revisar la evidencia referente a las técnicas quirúrgicas de plicatura abdominal y proponer una clasificación de las mismas. Material y método: Búsqueda en la literatura de las técnicas quirúrgicas de plicatura en abdominoplastia y presentación de una clasificación original para las mismas. Resultados: Proponemos una clasificación de plicaturas basada en 3 elementos topográficos. El primero, la región anatómica predominante donde se realiza la plicatura (Tipo I o de línea alba, Tipo II o de rectos y Tipo III o de oblicuos). El segundo, la relación con el nivel del ombligo (supraumbilical, infraumbilical o supra-infraumbilical). Y el tercero, la orientación en el espacio de la plicatura (vertical, transversa u oblicua). Conclusiones: Consideramos que nuestra clasificación aporta una nomenclatura objetiva para la descripción de las plicaturas en abdominoplastia, ayudando así a definir sus indicaciones y a mejorar la comunicación de resultados. (AU)

Background and objective: The concept of abdominoplasty has been redefined in recent years, being the management of the musculoaponeurotic component a key element to improve abdominal wall contour. However, indications for plication are not clearly established, and countless techniques have been described by various authors. The objective of this work is to review the evidence regarding the surgical techniques of plication and propose a new classification for them. Methods: A search was carried out in the literature about surgical techniques of plication in abdominoplasty, and from this, an original classification for abdominoplasty plications is presented. Results: Our classification is based on 3 topographic elements. First, the main anatomical region where the plication is performed (Type I or linea alba, Type II or rectus abdominis and Type III or oblique muscles). Second, the relationship with umbilicus level (above, below or above-and-below). And third, the orientation in the space (vertical, transverse or oblique). Conclusions: Our classification provides an objective nomenclature for the description of plications in abdominoplasty, thus helping to define its indications and improve the communication of results. (AU)

One-step totally robotic Hartmann reversal and complex abdominal wall reconstruction with bilateral posterior component separation: a technical note.

AIM: This paper describes a robotic approach to combined gastrointestinal continuity restoration and complex abdominal wall reconstruction after Hartmann's procedure complicated by large midline and parastomal hernias. METHODS: A robotic Hartmann reversal is performed, followed by robotic retromuscular abdominal wall reconstruction of all ventral defects with bilateral posterior component separation using the double-docking approach. Surgical steps are thoroughly described, and the accompanying video highlights critical steps of the procedure, anatomical landmarks and technical details relevant to successful completion. RESULTS: Complete restoration of the anatomy was achieved with an operative time of 6.5 h. Mobilization occured on day 1, and bowels were opened on day 3. Surgical discharge was possible on day 5. No intra-operative surgical complication occurred and follow-up at 6 months showed no recurrence or mid-term complication. CONCLUSION: Combined minimally invasive reconstruction of the gastrointestinal tract and abdominal wall was feasible using a robotic system. In addition, potential advantages of postoperative rehabilitation and reduced surgical site complications are suggested. Prospective evaluation of the technique is ongoing.

Clinical Evaluation of 310 Abdominoplasties and Measurement of Scar Level.

BACKGROUND: Most published studies on abdominoplasty focus on methods to reduce the risk of seromas. These methods include limited dissection (lipoabdominoplasty), quilting sutures, and preservation of the Scarpa fascia. Quantitative evaluation of the aesthetic result has been lacking. METHODS: A retrospective study was undertaken of all patients undergoing abdominoplasty in the author's practice from 2016 to 2022. A full abdominoplasty was performed, usually with liposuction (87%). All patients were treated under total intravenous anesthesia without paralysis or prone positioning. A single closed suction drain was removed 3 or 4 days after surgery. All procedures were performed as outpatients. Ultrasound surveillance was used to detect any deep venous thromboses. No patient received chemoprophylaxis. The operating table was flexed, often to 90°. Deep fascial anchoring sutures were used to attach the Scarpa fascia of the flap to the deep muscle fascia. Measurements of the scar level were made at intervals after surgery up to 1 year. RESULTS: Three hundred ten patients were evaluated, including 300 women. The mean follow-up time was 1 year. The overall complication rate, which included minor scar deformities, was 35.8%. Five deep venous thromboses were detected. There were no hematomas. Fifteen patients (4.8%) developed seromas that were successfully treated by aspiration. The mean vertical scar level 1 month after surgery was 9.9 cm (range, 6.1-12.9 cm). There was no significant change in scar level at subsequent follow-up times up to 1 year. By comparison, the scar level in published studies ranged from 8.6 to 14.1 cm. DISCUSSION: Avoidance of electrodissection reduces tissue trauma that causes seromas. Flexed patient positioning during surgery and deep fascial anchoring sutures are effective in keeping the scar low. By avoiding chemoprophylaxis, hematomas can be avoided. Limiting the dissection (lipoabdominoplasty), preserving the Scarpa fascia, and adding quilting (progressive tension) sutures are unnecessary. CONCLUSIONS: Total intravenous anesthesia offers important safety advantages. Avoiding electrodissection is effective in keeping seroma rates at a tolerable level (5%), and the scar low and more easily concealed. Alternative methods present disadvantages that may contribute to a suboptimal aesthetic result and require additional operating time.

Classic Versus Scarpa-sparing abdominoplasty: An infrared thermographic comparative analysis.

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to have several clinical advantages. The mechanisms behind its efficiency have been the subject of several studies. Three theories have been proposed, relating to mechanical factors, lymphatic preservation, and improved vascularization. This study aimed to further investigate the possible vascular impact of Scarpa fascia preservation by using a thermographic analysis. METHODS: A single-center prospective study was conducted, involving 12 female patients randomly and equally assigned to one of two surgical procedures: classic (Group A) and Scarpa-sparing abdominoplasty (Group B). Dynamic thermography was applied before and after surgery (one and six months), and two regions of interest (ROIs) were considered. The latter had the same location on every sample, and corresponded to areas where different surgical planes had been used. Static thermography was applied intraoperatively, and four ROIs were considered, located over Scarpa and over the deep fascia. The respective thermal data were analyzed. RESULTS: The general characteristics of both groups were identical. Preoperative thermography demonstrated no differences between groups. Intraoperative higher thermal gradients between lateral and medial ROIs were observed in Group B (P = 0.037, right side). Dynamic thermography at one month demonstrated a trend for better thermal recovery and better thermal symmetry (P = 0.035, 1-min mark) in Group B. No other differences were found. CONCLUSION: Dynamic thermography presented a better response when Scarpa fascia was preserved: stronger, faster, and more symmetric. Based on these results, improved vascularization may have a role in explaining the clinical efficiency of a Scarpa-sparing abdominoplasty.

Vergleich zweier Techniken der Umbilikoplastik bei 72 Patientinnen nach Brustrekonstruktion mit freier DIEP-Lappenplastik.

INTRODUCTION: The appearance of the umbilicus after DIEP flap surgery or abdominoplasty plays an important role in aesthetic perception (1). Although the umbilicus has no function, there is no doubt about the importance of its shape for the self-esteem of patients, especially after breast cancer (2). In the present study, we compared two of the preferred techniques described in the literature on 72 patients in terms of aesthetic outcome, complications and sensitivity: the caudal flap (domed shape) and the oval shape of the umbilicus. PATIENTS AND METHODS: Seventy-two patients who underwent a DIEP flap for breast reconstruction between January 2016 and July 2018 were retrospectively included in this study. Two techniques for umbilical reconstruction were compared: the transverse oval shape of the umbilicus and umbilicoplasty using a caudal flap, which results in a dome shape of the umbilicus. To compare the aesthetic results, an evaluation by the patients and an assessment by three independent plastic surgeons were carried out at least 6 months postoperatively. Patients and surgeons were asked to rate the general appearance of the umbilicus, including scarring and shape, on a scale from 1 to 6 (1=very good, 2=good, 3=fair, 4=sufficient, 5=poor, 6=insufficient). Furthermore, the occurrence of wound healing disorders was examined, and patients were asked about the sensitivity of the umbilicus. RESULTS: Both techniques showed similar degrees of aesthetic satisfaction (p=0,49) as part of the patients' self-assessment. The plastic surgeons gave the caudal flap technique a significantly better rating than the umbilicus with a transverse oval shape (p=0,042). More wound healing disorders occurred in the caudal lobule (11,1%) compared with the transverse oval umbilicus. However, this was not significant (p=0,16). A surgical revision was not necessary. The caudal flap umbilicus showed a tendency to improved sensitivity (60 vs. 45%), but this was not significant (p=0,19). CONCLUSION: Patient satisfaction showed similar results for the two methods of umbilicoplasty. On average, both techniques were given a good rating for their results. However, surgeons rated the caudal flap umbilicoplasty as more aesthetically pleasing.

Endoscopic treatment of diastasis recti: Training method and literature review.

INTRODUCTION: Endoscopic treatment of diastasis rectus abdominis offers the possibility of correcting the condition without complete abdominoplasty. The purpose of this study was to develop a training method on fresh cadavers models based on a literature review on this surgery. MATERIAL AND METHODS: The endoscopic procedure considered involved the insertion of a 10mm suprapubic trocar and of 5mm trocars in each iliac fossae. The muscle suture is done using running barbed suture. The surgery was performed on eight fresh cadavers to estimate the learning curve for this intervention, which was estimated with the CUSUM method. A systematic literature review in the PubMed database was performed, and 20 articles that met the inclusion criteria were analyzed. RESULTS: The learning curve threshold was reached after 6 operations and can be separated into two phases. The most common complication of this surgery is seroma, it is encountered in 3 to 27% of cases according to the studies. Diastasis recurrence is rare, occurring in less than 2% of cases. In comparison, open surgical treatment of diastasis recti is associated with a higher risk of hematoma, skin necrosis and longer operating times. Recurrence rates are similarly low after open and endoscopic repair. Mesh reinforcement is indicated in cases of diastasis wider than 5cm, diastasis recurrence, severe musculoaponeurotic laxity, or hernia larger than 1cm. CONCLUSION: The data in the literature indicate that laparoscopic surgery is an efficient and safe approach to correct diastasis of the rectus muscles and can be offered by plastic surgeons to selected patients.

Concurrent abdominal body contouring and hernia repair are safe choices: An analysis of the 2015-2020 ACS-NSQIP database.

BACKGROUND: Concurrent hernia repair (HR) with abdominal body contouring procedures (ABD), panniculectomy, and abdominoplasty, has been discussed as a strategy. The purpose of this study is to evaluate potential medical and surgical complications following concurrent ABD-HR, with a greater emphasis on cosmetic abdominoplasty. METHODS: The 2015-2020 ACS-NSQIP datasets were utilized to identify patients who underwent ABD or ABD-HR. Propensity score (PS) matching was used to reduce selection bias by equating groups (ABD vs. ABD-HR) based on covariates. Bivariate analyses of independent variables by our outcomes of interest were performed using the Pearson Chi-Square and Fisher's Exact tests for categorical variables and the Wilcoxon rank-sum test for continuous variables. RESULTS: Of the 14,115 patients identified in the ACS-NSQIP, 13,634 had ABD, while 481 had both ABD and HR. Following PS-matching of the cohorts, ABD (n = 481) and ABD-HR (n = 481), bivariate analysis of the combination of incisional, umbilical, and epigastric hernias indicated longer operative times (mean: 209.6 min) (P < 0.001) and a longer hospital length of stay (mean: 1.9 days) (P < 0.001). The incidence rate of postoperative complications such as wound dehiscence, deep venous thromboembolism, DVT, unplanned return to the OR within 30 days, and other medical complications revealed no significant differences between the two cohorts. A sub-group analysis of wound complications found no significant difference for any wound type. Analysis was also conducted for each type of hernia separately, yielding the same results. CONCLUSION: Our results show no increase in postoperative morbidity when combining ABD and HR compared to ABD alone, suggesting that these procedures can be safely performed concurrently and regardless of the type of hernia.

Alternative Abdominal Wall Plication Techniques: A Review of Current Literature.

Abdominoplasty is one of the most common procedures performed in plastic surgery. By removing redundant skin and fat tissue, body contouring narrows the waist and achieves a naturally flattened appearance. To achieve this, one technique frequently utilized is plication of the abdominal rectus sheath. Although abdominal wall plication is commonly performed during abdominoplasty, there is a lack of consensus regarding which plication method provides the best outcomes. Each variation addresses some of the common intraoperative and postoperative complications of abdominoplasty. These include extended operating time, rupture of the plication, epigastric bulging, and patient postoperative dissatisfaction. Many plication techniques have been described in the literature, but no single technique has been adopted by plastic surgeons as the gold standard. Here we present a narrative comparison of current published literature reporting novel or modified abdominoplasty plication techniques. This includes diagrams of each procedure, sutures utilized, and key concepts of each plication technique. Discussion regarding how these modifications change operating time, alter epigastric bulging, and improve the ability to narrow the waist is provided. The purpose of this paper is to provide a concise source document for plastic surgeons to reference when choosing a plication method to use during abdominoplasty.