Journal of Aesthetic & Reconstructive Surgery

Description

The philosophy of procedure is to free the patient from the burden of the excess skin, elimination of the excess fat and to obtain a tight muscle corsage. Despite the lack of accurate statistics, abdominoplasty represents a big chunk of the flow at any plastic surgery clinic. It is believed, the tighter the reinforcement, the better the abdomen reaches its scaphoid shape. Its prevalence is multifactorial, either due to repeated pregnancies, weight fluctuation, ventral hernia, and lack of proper exercise or due to the surge of bariatric procedures leading to increase in the demand for full abdominoplasty. The improvement of the silhouette comes at a price of a scar.

Abdominal Compartment Syndrome

The normal intra-abdominal pressure ranges from 3 and 15mmHg. Despite its popularity, abdominoplasty is not a risk-free intervention. Complications range from a minor wound dehiscence or infection to more serious problems like deep venous thrombosis (1.1% risk) & pulmonary embolism (0.8%). Intraabdominal hypertension (IAH) and Abdominal Compartment Syndrome (ACS) are not synonyms, yet they are always linked together.

This is due to the magnitude of morbidity and mortality allied to them. Their impact affects the central nervous system, GIT, cardiovascular & pulmonary systems, liver and kidney. The breast meridian was then identified (from the mid clavicular point to the mid breast bisecting the breast into two halves). The position of the Infra Mammary Fold (IMF) was identified and marked 2cm from the midline and 2cm from the anterior axillary line. Lastly the new nipple position was then marked; achieved by using a flexible ruler positioned under the breast to mark the anterior projection of the IMF. Their effect on the abdominal wall itself is almost always forgotten. IAH vividly diminishes abdominal wall blood flow.

Rectus sheath blood flow decreases up to 58% of baseline at an Intra-Abdominal Pressure (IAP) of only 10mmHg. These findings may justify the impaired wound healing & higher rates of infection. The quest for the ideal methods to measure IAP is still on going. Pressure can be measured through any organ directly affected by the IAP. These readings can be done in a continuous or intermittent fashion. The well-established routes for assessment are through: The bladder, stomach, rectal, vaginal, inferior vena cava or through a direct peritoneal pressure.

Intra-Abdominal Pressure

The tight internal corsage increases the Intra-Abdominal Pressure (IAP). A three- way Foley's catheter has an extra irrigation port to the standard balloon inflation port and urinary drainage port, allowing injection of the required amount of saline without separating the urinary collecting bag from the urinary drainage port, hence having a closed system, decreasing the occurrence of infection. However, in this study despite the use of a two way Foley's catheter as an open system, because it was more feasible and more economical with the available resources, no cases of urinary tract infections were reported. A 4.5cm diameter circle was drawn within the areola using the cookie cutter. The new IMF was remarked when the patient was in supine position and the final step prior to commencing was comparing measurements on both sides. One gram of broad spectrum antibiotics was given to the patient on induction of anesthesia after testing for allergy.

They were operated upon between the periods of January 2019 to January 2020 using the inferior pedicle inverted T breast reduction technique. Diabetic patients, smokers and patients with bleeding tendencies were excluded from the study. The patients were randomly divided into two equal groups of 15 patients each arranged by alternate sequential manner. In the first group an inverted V flap was used in the IMF region at the point of junction between the vertical and horizontal limbs of the inverted T. This is a flap shaped as an inverted V over the infra-mammary fold on the inferior pedicle that is not de-epithelialized.

In the second group (Group Z) a non-invasive zip line suture device was placed at the junction between the vertical and horizontal limbs of the inverted T design after skin closure. The zip line device is an adhesive hydrocolloid formed of two strips attached in the center by polyurethane straps which are pulled on to support tautness in a fashion not unlike that of closing a zipper. Both techniques took approximately 3 hours intra-operatively. Also it is important to note that the mean IAP values (mentioned below) and results were similar in all three studies, hence the use of a 2 way Foley's catheter didn't have a drastically different outcome on this study. In this study, 50-100ml of saline were injected in the bladder through the catheter's port after emptying it, which is in harmony with Neto et al.'s study. As opposed to Al Basti et al., who injected 350ml of normal saline, just below the volume required to initiate the bladder muscle contraction.

BMI was calculated. Examination of breast skin for signs of striae, intertrigo or maceration was undertaken. Breast examinations were performed while the patient was upright, sitting, leaning forward and lying supine for detection of any mass or breast abnormalities. The location and length of the potential scars of the inverted T technique were described to all patients. Routine investigations were undertaken including full blood picture, coagulation profile, the injection of less than 100cc of normal saline lead to air bubbles in the system. In this study, as well as in the studies of all measurements were obtained when the zero standard level was at the level of the patient's symphysis pubis to avoid under or over estimation of intra-abdominal pressure.