Triangular mattress suture in abdominal diastasis to prevent epigastric bulging

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.

LEVEL OF EVIDENCE: 4

Minimally invasive bilayer suturing technique for the repair of concomitant ventral hernias and diastasis recti

BACKGROUND

According to EHS guidelines, mesh repair is recommended in case of concomitant diastasis recti (DR) and ventral hernia more than 1 cm in diameter. Since in this situation, the higher risk of hernia recurrence may be attributed to the weakness of aponeurotic layers, in our current practice, for hernias up to 3 cm, we use a bilayer suture technique. The study aimed at describing our surgical technique and evaluating the results of our current practice.

METHODS

The technique combines suturing repair of the hernia orifice and diastasis correction by suture, and includes an open step through periumbilical incision and an endoscopic step. The study is an observational report on 77 cases of concomitant ventral hernias and DR.

RESULTS

The median diameter of the hernia orifice was 1.5 cm (0.8-3). The median inter-rectus distance was 60 mm (30-120) at rest and 38 mm (10-85) at leg raise at tape measurement and 43 mm (25-92) and 35 mm (25-85) at CT scan respectively. Postoperative complications involved 22 seromas (28.6%), 1 hematoma (1.3%) and 1 early diastasis recurrence (1.3%). At mid-term evaluation, with 19 (12-33) months follow-up, 75 (97.4%) patients were evaluated. There were no hernia recurrences and 2 (2.6%) diastasis recurrences. The patients rated the result of their operation as excellent or good in 92% and 80% of the cases at global and esthetic evaluations, respectively. The result was rated bad at esthetic evaluation in 20% of the cases because the skin appearance was flawed, due to discrepancy between the unchanged cutaneous layer and the narrowed musculoaponeurotic layer.

CONCLUSION

The technique provides effective repair of concomitant diastasis and ventral hernias up to 3 cm. Nevertheless, patients should be informed that the skin appearance can be flawed, because of the discrepancy between the unchanged cutaneous layer and the narrowed musculoaponeurotic layer.

The Effect of Quilting Sutures on the Tension Required to Advance the Abdominal Flap in Abdominoplasty

BACKGROUND

Quilting sutures attaching the abdominal flap to the aponeurosis contribute to the prevention of seroma formation following abdominoplasty. The sutures distribute the tension over the subcutaneous tissue along the flap length, theoretically decreasing tension at the distal (cutaneous) end of the flap. This is expected to reduce the risks of necrosis, dehiscence, and enlarged or hypertrophic scars.

OBJECTIVES

This study sought to verify whether quilting sutures decrease the tension required to advance the dermal-fat flap in abdominoplasty.

METHODS

Thirty-four women undergoing abdominoplasty with quilting sutures participated in the study. The tensile force required for flap advancement was measured with a digital force gauge before and after placement of quilting sutures and then compared. Differences in tensile force were tested for correlations with BMI, age, weight of flap tissue removed, number of previous pregnancies, and postoperative complications, including seroma formation, hematoma, necrosis, dehiscence, and enlarged or hypertrophic scars.

RESULTS

A mean reduction in tension of 27.7% was observed at the skin suture after the placement of quilting sutures (P < 0.001). No significant correlation was found between reduced flap tension and BMI, age, weight of tissue removed, or number of births. One case of seroma formation and 2 cases of enlarged scars were observed, but no case of hematoma, necrosis, or wound dehiscence was detected.

CONCLUSIONS

The use of quilting sutures to attach the abdominal flap to the aponeurosis of the anterior abdominal wall reduced tension at the advancing edge of the flap in abdominoplasty.

Diastasis recti repair with onlay mesh

INTRODUCTION

Diastasis recti represents a midline contour abnormality of the anterior abdominal wall that is secondary to attenuation of the linea alba. Severe diastasis recti is defined as attenuation of the linea alba as well as the linea semilunaris. Treatment options are variable and include conditioning exercises and surgical repair with or without mesh. This manuscript will review the indications and technique of onlay mesh for correction of severe diastasis recti.

METHODS

Abdominoplasty with diastasis repair has been performed in 63 women from January 2010 to January 2020. Of these, 4 had repair for severe diastasis that included plication and onlay mesh. The mesh was polypropylene in 3 patients and silk in 1 patient. Indications for onlay mesh included severe diastasis as a means of further reinforcing the strength of the anterior rectus sheath.

RESULTS

Of the 4 patients, all tolerated the operation well without morbidity. Natural contour was established in all. There were no infections, seromas, delayed healing or mesh removals. All drains were removed by 7 days.

CONCLUSION

The use of an onlay mesh has demonstrated success and should be considered in select patients for the surgical management of severe diastasis.

Surgical techniques for repair of abdominal rectus diastasis: a scoping review

Rectus diastasis is characterized by widening and laxity of the linea alba, causing the abdominal content to bulge. Rectus diastasis is treated either conservatively with physiotherapy, or surgically, surgical treatment showing especially convincing results. The primary aim of this study was to describe surgical techniques used to correct abdominal rectus diastasis. Secondary, we wished to assess postoperative complications in relation to the various techniques. A systematic scoping review was conducted and reported according to the PRISMA-ScR statement. PubMed, Embase, and Cochrane Library were searched systematically. Studies were included if they described a surgical technique used to repair abdominal rectus diastasis, with or without concomitant ventral hernia. Secondary outcomes were recurrence rate and other complications. A total of 61 studies were included: 46 used an open approach and 15 used a laparoscopic approach for repair of the abdominal rectus diastasis. All the included studies used some sort of plication, but various technical modifications were used. The most common surgical technique was classic low abdominoplasty. The plication was done as either a single or a double layer, most commonly with permanent sutures. There were overall low recurrence rates and other complication rates after both the open and the laparoscopic techniques. We identified many techniques for repair of abdominal rectus diastasis. Recurrence rate and other complication rates were in general low. However, there is a lack of high-level evidence and it is not possible to recommend one method over another. Thus, further randomized controlled trials are needed in this area.

A Comprehensive, Evidence-Based Literature Review of the Surgical Treatment of Rectus Diastasis

BACKGROUND

Rectus diastasis is a common condition that can result in a protruding abdomen, causing cosmetic and functional disability. Although it is usually repaired during abdominoplasty or herniorrhaphy, there is a lack of consensus with regard to the repair indications and optimal surgical techniques. The goal of this study is to provide an updated review of the surgical techniques used for rectus diastasis repair and their comparative efficacy.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Embase, and Cochrane databases were searched for articles that discussed the surgical management of rectus diastasis and reported on either outcomes, complications, or recurrence rates. Data detailing surgical techniques were extracted, and pooled analyses of complication and recurrence rates were performed, controlling for surgical approach, common variations in technique, and an associated herniorrhaphy.

RESULTS

Thirty-seven studies describing 45 techniques were included. An open rectus diastasis repair was performed in 24 of the studies. After controlling for an associated herniorrhaphy, there was no statistically significant difference in surgical complication and recurrence rates between open and laparoscopic approaches (p = 0.165 and p = 0.133, respectively). Although a double-layer suture closure was associated with a significantly lower rate of complications (p = 0.002), no significant difference was found for suture type absorbability.

CONCLUSIONS

Surgical repair of rectus diastasis is safe and effective through both open and laparoscopic approaches. Although suture type absorbability does not affect complication or recurrence rates, a double-layer suture closure can decrease surgical complications. The pooled analysis of complication and recurrence rates can help improve informed consent and patient education.

Abdominal Wall Plication and Correction of Deformities of the Myoaponeurotic Layer: Focusing on Materials and Techniques Used for Synthesis

The different types of sutures utilized in plications and for correction of diastasis during abdominoplasty are reviewed and discussed. Because correction of abdominal deformities also involves fascia and muscle advancement, this review also covers the suture materials used in muscle advancement. The selection of specific techniques to treat different types of abdominal wall deformity is also considered. This is important, because the outcome when correcting these deformities depends not only on suture materials but also on employing the optimum technique. A PubMed/Medline search was performed with the following search terms: rectus diastasis, diastasis recti, diastasis recti abdominis, correction of rectus diastasis, abdominoplasty. Relevant articles identifying the type of suture (rapidly absorbable, slowly absorbable, nonabsorbable), monofilament or multifilament sutures, antibiotic-coated sutures, and barbed sutures were evaluated. In addition, articles about surgical technique comparing continuous and interrupted sutures, in both the anterior and posterior aponeurosis, to correct rectus diastasis are discussed. Efficacy of suture materials was evaluated based on the long-term results and recurrence rates reported in these articles. The current literature provides sufficient data to recommend a single-layer continuous suture, with slowly absorbable sutures of 0 polydioxanone or 2-0 nylon, for correction of abdominal diastasis. An interrupted triangular suture is a good alternative to correct the vertical elongation of the myoaponeurotic layer that occurs after pregnancy.

Management Strategies for Diastasis Recti

Diastasis recti is a relatively common condition in which there is a midline abdominal bulge that can affect a variety of individuals. The etiology and diagnosis is well understood and optimal management depends on the degree of severity. Patients at high risk for diastasis recti include multiparous women, obese patients, and those with multiple previous operations. Diagnosis includes clinical examination and assessment of symptoms. Physical characteristics include a midline abdominal bulge without a fascial defect. Classification systems are based on the degree of separation between the paired midline rectus and myofascial deformity. Optimal management varies and includes simple plication of the midline defect, extensive plication of the anterior abdominal wall, and sometimes the use of resorbable or nonresorbable mesh.

Single-Layer Plication for Repair of Diastasis Recti: The Most Rapid and Efficient Technique

Background

Plication of the anterior rectus sheath is the most commonly used technique for repair of diastasis recti, but is also a time-consuming procedure.

Objectives

The aim of this study was to compare the efficacy and time required to repair diastasis recti using different plication techniques.

Methods

Thirty women with similar abdominal deformities, who had had at least one pregnancy, were randomized into three groups to undergo abdominoplasty. Plication of the anterior rectus sheath was performed in two layers with 2-0 monofilament nylon suture (control group) or in a single layer with either a continuous 2-0 monofilament nylon suture (group I) or using a continuous barbed suture (group II). Operative time was recorded. All patients underwent ultrasound examination preoperatively and at 3 weeks and 6 months postoperatively to monitor for diastasis recurrence. The force required to bring the anterior rectus sheath to the midline was measured at the supraumbilical and infraumbilical levels.

Results

Patient age ranged from 26 to 50 years and body mass index from 20.56 to 29.17 kg/m2. A significant difference in mean operative time was found between the control and study groups (control group, 35 min:22 s; group I, 14 min:22 s; group II, 15 min:23 s; P < 0.001). Three patients in group II had recurrence of diastasis. There were no significant within- and between-group differences in tensile force on the aponeurosis.

Conclusions

Plication of the anterior rectus sheath in a single-layer with a continuous suture showed to be an efficient and rapid technique for repair of diastasis recti.

Level of Evidence 1

Prevalence of Body Dysmorphic Disorder Symptoms and Body Weight Concerns in Patients Seeking Abdominoplasty

BACKGROUND

Body dysmorphic disorder (BDD) is one of the most common psychiatric conditions found in patients seeking cosmetic surgery, and body contouring surgery is most frequently sought by patients with BDD.

OBJECTIVES

To estimate the prevalence and severity of BDD symptoms in patients seeking abdominoplasty.

METHODS

Ninety patients of both sexes were preoperatively divided into two groups: patients with BDD symptoms (n = 51) and those without BDD symptoms (n = 39) based both on the Body Dysmorphic Disorder Examination (BDDE) and clinical assessment. Patients in the BDD group were classified as having mild to moderate or severe symptoms, according to the BDDE. Body weight and shape concerns were assessed using the Body Shape Questionnaire (BSQ).

RESULTS

The prevalence of BDD symptoms was 57%. There were significant associations between BDD symptoms and degree of body dissatisfaction, level of preoccupation with physical appearance, and avoidance behaviors. Mild to moderate and severe symptoms of BDD were present in 41% and 59% of patients, respectively, in the BDD group. It was found that the more severe the symptoms of BDD, the higher the level of concern with body weight and shape (P < .001). Patients having distorted self-perception of body shape, or distorted comparative perception of body image were respectively 3.67 or 5.93 times more likely to show more severe symptoms of BDD than those with a more accurate perception.

CONCLUSIONS

Candidates for abdominoplasty had a high prevalence of BDD symptoms, and body weight and shape concerns were associated with increased symptom severity.

Is it possible to repair diastasis recti and shorten the aponeurosis at the same time?

BACKGROUND

Abdominal wall deformity secondary to pregnancy is multidirectional. Plication of the anterior rectus sheath is the most widely used technique for correction of this condition. However, it would be desirable to simultaneously perform the transverse and longitudinal repair of this deformity. The aim of this study was to assess changes in the length of the musculoaponeurotic layer after diastasis recti repair using triangular mattress sutures.

METHODS

Thirty-one women with Nahas' type III/A deformity were divided into two groups: the triangular mattress suture (TS) group and the continuous suture (CS) group. All patients underwent conventional abdominoplasty and diastasis recti repair with medial longitudinal plication performed between two metal clips. The two types of suture were used in both groups. In the TS group, after a CS was performed and removed, TSs were used and maintained in place. In the CS group, the order of suture placement was reversed. The distance between clips was measured before and immediately after suturing and at 3 weeks and 6 months postoperatively using plain abdominal radiographs. Statistical analysis was conducted using Friedman's analysis of variance and Wilcoxon's test.

RESULTS

The use of TSs significantly reduced the length of the aponeurosis compared with both the intraoperative situation without suture (P<0.001) and the use of CS (intraoperatively and 6 months after surgery; P<0.001).

CONCLUSION

The repair of diastasis recti using TSs resulted in vertical shortening of musculoaponeurotic layer immediately after the procedure and in the long term.

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.

A systematic review on the outcomes of correction of diastasis of the recti

PURPOSE

Diastasis or divarication of the rectus abdominus muscles describes the separation of the recti, usually as a result of the linea alba thinning and stretching. This review examines whether divaricated recti should be repaired and tries to establish if the inherent co-morbidity associated with surgical correction outweighs the benefits derived.

METHODS

EMBASE, MEDLINE and the Cochrane library were searched for ('divarication' OR 'diastasis') AND ('recti' OR 'rectus'). A standard data extraction form was used to extract data from each text. Due to the lack of randomised control trials, meta-analysis was not possible.

RESULTS

Seven studies report that patient satisfaction was high following surgery. The most common complication seen was the development of a seroma. Other common complications included haematomas, minor skin necrosis, wound infections, dehiscence, post-operative pain, nerve damage and recurrence, the rate of which may be as high as 40%.

CONCLUSIONS

Further studies are required to compare laparoscopic and open abdominoplasty techniques. Patients and physicians should be advised that correction is largely cosmetic, and although divarications may be unsightly they do not carry the same risks of actual herniation. Progressive techniques have resulted in risk reduction with no associated surgical mortality. However, the outcomes may be imperfect, with unsightly scarring, local sepsis and the possibility of recurrence.

Rectus diastasis corrected with absorbable suture: a long-term evaluation

BACKGROUND

Correction of rectus diastasis (RD) is performed during most abdominoplasties. This study aimed to evaluate the long-term result of RD correction when the plication of the anterior rectus sheath is performed with an absorbable suture.

METHODS

Abdominoplasty was performed for 12 women who presented with Nahas' type A musculoaponeurotic deformity. The RD was measured preoperatively with two computed tomography (CT) scan slices at two levels: 3 cm above and 2 cm below the umbilicus. The bony levels at which the slices were taken served as a reference for the postoperative CT scans. During the operation, the RD was measured with a ruler at the same levels as the preoperative CT scan slices. The force necessary to bring the medial edge of the rectus muscle to the midline was measured on both levels with a dynamometer. Plication of the anterior rectus sheath was performed using a double-layer 0-PDS (polydioxanone) suture. Postoperative CT scans were performed 3 weeks after the operation. A long-term follow-up CT scan was performed 32-48 months postoperatively for every patient.

RESULTS

The 3-week postoperative CT scan proved that the correction of RD was achieved by the procedure. Despite the fact that there were different abdominal wall resistances and that the average weight gain during this period was 4.5 kg, the long-term CT-scans showed no recurrence of RD for any patient of this series in either the superior or inferior abdomen.

CONCLUSION

Plication of the anterior rectus sheath with PDS suture to correct RD seems to be a long-lasting procedure.

Abdominoplasty and its effect on body image, self-esteem, and mental health

The impact of abdominoplasty on the quality of life of abdominoplasty patients was assessed 1- and 6-months postoperatively. Forty women aged 25 to 60 years were divided into study group (25 patients who underwent abdominoplasty) and waiting-list control group (15 patients). Three questionnaires (Body Shape Questionnaire [BSQ], Rosenberg Self-Esteem Scale [RSE/UNIFESP], and Short Form 36 Health Survey Questionnaire [SF-36]) were administered to the study group (preoperatively, 1- and 6-months postoperatively) and control group (on 2 occasions 6 months apart). A significant positive impact on body image, self-esteem, and mental health was found 1- and 6-months postoperatively. Significant differences were observed in role physical, role emotional, and vitality 1-month postoperatively. In the control group, significant differences were found for vitality. There was a significant improvement in Comparative perception of body image (6-month assessment) in the study group compared with controls. Abdominoplasty improved body image, self-esteem, and mental health.

Use of a submuscular resorbable mesh for correction of severe postpregnancy musculoaponeurotic laxity: an 11-year retrospective study

BACKGROUND

The management of severe postpregnancy musculoaponeurotic laxity remains a challenge for plastic and reconstructive surgeons. Several techniques have been proposed, but there is no consensus on the best treatment. The authors report the validity of their abdominoplasty method.

METHODS

From May of 1995 to May of 2006, a retrospective chart review was conducted on 52 women who underwent the authors' abdominoplasty technique. The average age was 39 years (range, 25 to 60 years). They had an average of 3.2 children (range, two to six). The average preoperative body mass index was 23.5 (range, 20 to 31.5). None of the patients included had preexisting medical conditions. The posterior rectus fascia was released and plicated at the midline. A resorbable mesh was used to reinforce the plication and to reduce the tension of the traction.

RESULTS

Follow-up ranged from 6 months to 11 years, with an average of 54 months. Complications included a bladder injury in one patient during posterior fascia release and epigastric bulging in one woman immediately after extubation. The local complications were seromas in two patients, skin flap necrosis in one smoking patient, and umbilical necrosis in one patient. Four patients required minor scar revision and liposuction under local anesthesia. There were no cases of systemic complications. No incidence of infection, dehiscence, or extrusion of the mesh was noted. All patients were completely satisfied.

CONCLUSION

The release and plication of the posterior rectus sheath associated with the use of submuscular resorbable mesh is a long-lasting and reliable procedure in multiparous women with severe myoaponeurotic laxity.

An efficient way to correct recurrent rectus diastasis

BACKGROUND

Recurrent rectus diastasis is a troublesome complication because its correction requires an extensive procedure.

CASE REPORTS

Two patients with recurrent rectus diastasis secondary to abdominoplasty corrected by plication of the anterior rectus sheath are presented. These patients had lateral insertion of the rectus muscles. They were treated by the advancement of the rectus muscles after undermining of the posterior rectus sheath and a two-layer closure to correct the rectus diastasis. Good cosmetic results and postoperative pain control were achieved in both cases.

DISCUSSION

The causes, prevention, and treatment for this type of rectus diastasis are described. The main reason for recurrence of this deformity in these patients was lateral insertion of the rectus muscles on the costal margins. On the basis principle, an efficient technique to correct this deformity is described. A postoperative compute tomography scan with slices made at the same bony level as the preoperative control examination demonstrated total correction of rectus diastasis over a long-term follow-up evaluation.

CONCLUSION

Advancement of the recti muscles seems to be a reliable method for correcting recurrent rectus diastasis in patients with lateral insertion of the recti muscles.