The “Lying” H-Shaped with Double Contour Plication of the Anterior Aponeurosis Wall in Abdominoplasty

Abstract

The “lying” H-shaped with double contour plication to muscle aponeurosis decreases longitudinal and transverse diameters of the anterior abdominal wall. Rather than the median xiphoid-pubic fusiform plication, the H-shaped plication recovers the waist and reinforces the epigastrium and hypogastrium, reducing the possibility of recurrent projection at these areas. The “lying” H-shaped with double contour plication strengthens the entire abdominal muscle aponeurosis system, creating an adequate support to restrain the intra-abdominal pressure. Increase of the intrapulmonary pressure happens at the end of plication. It decreases in level at the end of the surgery, but remains from 15 to 20 % higher in relation to the intrapulmonary pressure setting prior to the plication. No further respiratory distress is reported by the patients a day after the surgery or late postoperative period. The vertical branch centered in the abdominal midline makes possible to centralize the umbilicus in the midline of the abdomen. The approach of the lines of the vertical branch mobilizes the umbilicus transversally, repairing its lateral displacement, by attaching it at the abdominal midline. Closure of the horizontal branches enables to shorten the longitudinal length of the anterior abdominal aponeurosis. The degree of shortening of the anterior abdominal aponeurosis can arrive up to 6 cm long, depending on the width of the horizontal branch ellipses. The double contour of the transverse plication also allows the umbilicus mobilization taking it to an appropriate position in the abdominal wall. It also reduces the distance of the xiphoid-pubis allowing lowering and fixation of the cutaneous flap without tension, with better accommodation of the cutaneous flap. Even though a wide dissection of the skin flap at the epigastrium is needed to perform the “lying” H-shaped with double contour plication, the aforementioned complications did not occur. This happens due to the longitudinal shortening of the muscle aponeurosis system which facilitates the down displacement and easy accommodation of the skin flap toward the pubis, where it is fixed without tension. Absence of tension at suprapubic area avoids pubis elevation, suture dehiscence, and skin necrosis after the skin closure. In addition, a wide dissection of the skin flap in the upper abdomen is necessary to avoid the formation of a skin bulge along the edge of the plication, particularly if the plication is very large. Long-term maintenance has been achieved with the “lying” H-shaped with double contour plication.