Current abdominal contouring procedures consist of suction-assisted lipectomy, dermolipectomy, musculoaponeurotic plication or some combination of these approaches. Ideally, this results in sufficient reduction of subcutaneous adipose tissue volume, maximum resection of excess skin and tightening of musculoaponeurotic laxity to create an aesthetic contour of the abdominal wall. As with all aesthetic surgical procedures, the goals of abdominal contouring surgery are to maximize the aesthetic outcome, reduce recovery and minimize morbidity.
Clinical Anatomy
The overall shape of the abdomen varies depending on the fat distribution and musculoaponeurotic constitution. The ideal body shape for women is narrow at the waist and wider at the hips, while in men it should progressively narrow from the chest to the hips. Fat accumulation also differs between the genders. Women demonstrate weight gain in the lower abdomen, hips and buttocks; in men fat accumulation occurs intra-abdominally and circumferentially around the mid-abdomen and flanks. While abdominal wall lipodystrophy can be contoured to obtained a desirable result, intra-abdominal adiposity will limit the level of improvement and should be recognized preoperatively.
The surface landmarks of the abdomen include the costal margin superiorly, the anterior iliac crest and the mons pubis inferiorly and the umbilicus. Located approximately midway between the xyphoid and the pubis, the umbilicus is the most prominent surface feature of the abdominal wall. In the youthful abdomen, the lateral border and inscriptions of the rectus muscles are visible as well; the umbilicus is hooded superiorly and tightly adherent to the deep fascia. The subcutaneous tissue consists of superficial and deep fat, separated by Scarpa's fascia.
The superficial layer is typically dense and fibrous in nature with what has been described as a superficial fascial system. This pervasive system of connective tissue encases and shapes the fat of the trunk and extremities. Scarpa's fascia is a fibrous layer of connective and adipose tissue that forms a discrete layer in the lower abdominal wall.
The deep adipose layer is loose with poorly organized septae. It is disproportionate enlargement of this deep layer in the torso and upper thigh which characterizes fat accumulation even in thin women. When planning abdominal contouring, careful consideration should be given to the three major vascular zones of the abdominal wall.
The mid-abdomen is supplied by the superior epigastric and inferior epigastric arteries, which form the deep epigastric arcade in the region of the umbilicus. Perforators extend through the anterior fascial sheath to supply the overlying skin. The external iliac artery supplies the lower abdomen. The lateral abdomen is supplied by both the intercostal and subcostal arteries.
The intercostal arteries originate from the thoracic aorta and extend to the internal mammary between the external and internal oblique. The superficial external pudendal artery, the superficial epigastric artery and the superficial and deep circumflex iliac arteries are branches of the femoral artery, which also contribute to the lower abdominal wall skin.
The venous drainage system runs parallel to the arterial system. Subsequent consideration will be given to the blood supply to the abdominal wall as related to planning abdominoplasty techniques with particular regard to concomitant liposuction. The abdominal lymphatic drainage is to the axillary lymph nodes above the level of the umbilicus. Below the level of the umbilicus, drainage is to the superficial inguinal lymph nodes.
Disruption of the inferiorly directed drainage will result in postoperative swelling, just above the incision, which with time will resolve. Innervation of the upper abdomen is predominantly from the intercostal nerve. Because both the nerves pass deep into the abdominal musculature and there is overlap of these dermatomes, it is unusual for patients to experience significant paresthesias in the mid and upper abdomen. Sensory abnormalities are commoner in the lower abdomen and pubis, inferior to any incisional disruption of the sensory nerves.
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09132010
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