Abdominoplasty

Carly Winegar

Anatomy● Layers of the abdominal:

○ Subcutaneous fat ○ Scarpa’s Fascia○ External Oblique Muscle○ Internal Oblique Muscle○ Transversus Abdominus Muscle○ Transversalis Fascia

Physiology

● Subcutaneous fat composed of adipocytes○ Acts as padding for internal organs and energy reserve○ Thermoregulation (insulation)

Pathophysiology

● No disease or injury● Patient wants procedure for cosmetic purposes

Diagnostic Exams

● History and Physical● Direct Observation

Surgical Intervention

● Thinning the upper abdominal fat, tighten the abdominal muscles, and remove excess subcutaneous fat and skin from the mid- to lower abdomen, and creation of new belly button.

Special Considerations

● If patient is planning to bear children they should delay undergoing this procedure until all pregnancies are complete.

● Full abdominoplasty is considered a major surgery and can take 2-5 hours to complete.

● Test the fiberoptic retractors prior to patient arriving in the OR.

Anesthesia

● General

Positioning

● Supine

Skin Prep

● Pubic hair should be removed● Beginning at site of low abdominal

transverse incision, prep should extend to nipple line, to mid-thighs and bilaterally as far as possible.

Draping

● Entire abdomen outlined with 4 towels and laparotomy drape

Incision

● Low transverse incision○ Made low enough so the scar will be hidden

by the patient’s undergarment or bathing suit as well as regrowth of the pubic hair

● Umbilical incision

Supplies

● Sterile Umbilical Template (“cookie cutter”)● Large number of laparotomy sponges● Marking pen● Abdominal girdle● Bovie Scratch Pads

Equipment

● Closed wound drainage system (surgeon’s preference)● Fiberoptic retractor set● ESU pencil with long blade tip

Instrumentation

● Plastic Instrument set● Extra Crile hemostats and Kocher clamps● Several #10 knife blades

Procedural Steps

● Surgeon marks incision using the marking pen● A low transverse incision in the shape of a “W” is made down to the level of

the rectus sheath● A small inferior flap is created; bleeding controlled with cautery● Dissection begins on superior flap that extends beyond the level of the

umbilicus○ Much of initial dissection accomplished with electrocautery in cut or blend mode

Procedural Steps cont.

● Second incision is made around umbilicus using sterile template, commonly called the “cookie cutter” to ensure incision is a perfect circle

● Umbilicus is freed from the skin and subcutaneous tissue, allowing i to remain attached to its pedicle or base

● Flap dissection continues superiorly to the level of the outline of the ribs bilaterally (fiberoptic retractor may be used according to surgeon’s preference)

Procedural Steps cont.● The superior flap is retracted to reveal the rectus abdominis muscle ● The muscle and its fascia (sheath) is pulled together and sutured to firm the

abdominal wall and accentuate the waistline. ● The skin flap is then pulled down, the new location for the umbilicus is

marked, and the excess tissue is removed. ● An opening is created for the umbilicus using the “cookie cutter” template

and structure is sutured into position

Procedural Steps cont.

● The wound is then closed in layers ● One or two closed wound drainage systems may be placed, with the tubing

exteriorized through the lateral wound edges.● Staples may be used to close the skin layer● A small dressing is placed over the umbilicus and a pressure dressing over

the transverse incision.● Surgeon may request an abdominal girdle placed on patient.● https://youtu.be/KwRBAm8hIeU

Counts

● Initial Count● Closing Rectus Abdominis muscle and fascia● Closing Scarpa’s fascia● Closing Subcutaneous fat● Closing Skin● Final Count

Dressing Material

● Small dressing over umbilicus● Pressure dressing over transverse incision● Abdominal girdle

Specimen Care

● Removed adipose and skin sent to pathology

Prognosis

● Patient transported to the PACU● Patient’s bed should be slight flexed for comfort.● Patient will be hospitalized overnight● Hypodermic injections of narcotic pain medications are given for the first 24

hours● Although it will be difficult for the patient to stand erect, ambulation (walking

around) is encouraged as soon as possible

Prognosis: No Complications

● Drains remain in place for 2-3 weeks after patient is discharged from hospital. Patient education regarding wound and drain care is necessary.

● Patient should have an appointment with the surgeon approximately 1 week post-op to remove external sutures or staples and another week or two later for taking out the drains.

● It may take several weeks for the patient to return to normal activities.

Prognosis: Complications

● Postoperative SSI● Hemorrhage● Severe edema● Less-than-desired cosmetic results● Death

Wound Class/ Management

● Class I: Clean

Mini Abdominoplasty

Carly Winegar

Anatomy, Pathology, Physiology, Exams

● Same as total abdominoplasty

Surgical Intervention

● Tightening (by removing) of skin below the belly button

Special Considerations

● Very similar to full abdominoplasty but typically with shorter scar, and does not address skin above belly button, and new belly button not created.

Anesthesia

● General or Local

Positioning, Skin Prep, Draping

● Same as full abdominoplasty

Incision

● Low transverse Incision● Usually smaller than incision on full abdominoplasty, but it is surgeon/

patient specific.

Supplies, Equipment, Instrumentation

● Same as full abdominoplasty

Procedural Steps

● Surgeon marks incision using the marking pen● A low transverse incision is made down to the level of the rectus sheath● A small inferior flap is created; bleeding controlled with cautery● Dissection begins on skin and subcutaneous tissue to create flap

○ Much of initial dissection accomplished with electrocautery in cut or blend mode

Procedural Steps cont.

● The flap is retracted to reveal the rectus abdominis muscle ● The muscle and its fascia (sheath) is pulled together and sutured to firm the

abdominal wall. ● The skin flap is then pulled down, and the excess tissue is removed.● The wound is then closed in layers

Procedural Steps cont. ● One or two closed wound drainage systems may be placed, with the tubing

exteriorized through the lateral wound edges.● Staples may be used to close the skin layer● A small dressing is placed over the umbilicus and a pressure dressing over

the transverse incision.● Surgeon may request an abdominal girdle placed on patient.● https://youtu.be/soGg3Sn-3kE?t=1m58s

Counts

● Initial Count● Closing Rectus Abdominis muscle and fascia● Closing Scarpa’s fascia● Closing Subcutaneous fat● Closing Skin● Final Count

Dressings

● Pressure dressing over low transverse incision● Surgeon may request pelvic girdle

Specimen Care

● Removed adipose and skin sent to pathology

Prognosis

● Patient transported to the PACU● Patient’s bed should be slight flexed for comfort.● Although it will be difficult for the patient to stand erect, ambulation (walking

around) is encouraged as soon as possible● Patient should have an appointment with the surgeon post-operatively to

remove external sutures or staples or drains.● It will likely take much less time for a patient to return to regular activity

after a mini abdominoplasty than a full abdominoplasty

Complications

● Postoperative SSI● Hemorrhage● Severe edema● Less-than-desired cosmetic results● Asymmetry ● Death

Wound Class/ Management

● Class I: Clean