References
1. Suleiman S, Johnston DE 2001 The abdominal wall an overlooked source ofpain. Am Fam Physician 64 431 -438 2. Robinson JN, Abuhamad AZ 2000 Abdominal wall and umbilical cord anomalies. Clin Perinatol 27 947-978 3. Stoll C, Alembik Y, Dott B, Roth MP 2001 Risk factors in congenital abdominal wall defects omphalocele and gast-roschisi a study in a series of 265,858 consecutive births. Ann Genet 44 201-208 4. Schild RL, Hoch J, Plath H, Geissen C, Fahnenstich H, Dame C, Hansmann M 1999 Perinatal...
Anesthesia for Liposuction and Abdominoplasty
Anesthesia may be divided into four broad categories local anesthesia, local anesthesia combined with sedation, regional anesthesia and general anesthesia. The ultimate decision to select the type of anesthesia depends on the type and extent of the surgery planned, the patient's underlying health condition and the psychological disposition of the patient. For example, a limited liposuction of less than 500 ml of fat from a small area in a healthy patient, with limited anxiety, could certainly...
Ilioinguinal Nerve
The ilioinguinal nerve follows a course identical to that of the iliohypogastric nerve. It runs downward and forward between the transverse abdominis and internal oblique. It enters the inguinal canal by piercing the internal oblique to lie between it and the overlying external abdominal oblique aponeurosis. Within the inguinal canal, the ilioinguinal nerve descends inferior and lateral to the spermatic cord in the male, or the round ligament of the uterus in the female. As it emerges via the...
Indirect Inguinal Hernia
Indirect inguinal hernia Fig. 1.19 occurs when the processus vaginalis persists, connecting the peritoneal cavity of the abdomen and that of the scrotum or major labium. Indirect inguinal hernia is common in all ages and in both sexes. Kahn and Hamlin 45 concluded that patent processus vaginalis is not always a prerequisite for the occurrence of indirect inguinal hernia. It is often associated with cryptorchid testis and hydrocele. Incarcerated indirect inguinal hernia may occur as a...
Iliohypogastric Nerve
The iliohypogastric nerve courses posterior to the psoas major and exits through its lateral border posterior to the kidney and anterior to the quadratus lumborum and the iliacus muscles. Near the iliac crest, it pierces and provides innervation to the transverse abdominis and internal abdominal oblique muscles, and splits into lateral and anterior branches. The lateral branch distributes cutaneous branches to the gluteal region, while the anterior branch pierces the internal and external...
Genitofemoral Nerve
The genitofemoral nerve L1, L2 pierces the psoas major and emerges on the anterior surface of that muscle. It descends posterior to the ureter and gonadal vessels, and usually divides anterior to the lower third of the psoas major into femoral and genital branches. In the male, the genital branch enters the deep inguinal ring, innervates the cremasteric muscle, emerging from the superficial inguinal ring to supply the scrotum. In the female it follows a similar course and distributes sensory...
Hypertension
Early studies revealed a significantly increased risk of perioperative mortality in patients with untreated hypertension 92, 93 . The reduction in mortality from cardiovascular and cerebral vascular disease resulting from proper treatment of hypertension has been widely accepted 94-96 . Although somewhat controversial, most authors concur that preoperative stabilization of hypertension reduces perioperative cardiovascular complications such as ischemia 97-99 . Patients with undiagnosed or...
Rectus Abdominis
The rectus abdominis Figs. 1.5, 1.6, 1.8-1.10, 1.16 , a paired longitudinal muscle on both sides of the mid-line, widens as it descends through the rectus sheath, maintaining distal and proximal attachments. Proxi-mally, it attaches to the xiphoid process and the costal cartilages of the fifth through the seventh ribs. Distally it attaches via a medial tendon to the pubic symphysis, interlacing with the opposite muscle and via a lateral tendon to the pubic crest, extending to the pecten pubis...
Obstructive Sleep Apnea
According to the National Commission on Sleep Disorders Research, approximately 18 million Americans suffer with obstructive sleep apnea OSA . Unfortunately, the majority of patients with OSA remain undiagnosed 123 . The incidence of sleep apnea increases among obese patients 124 . Since the target population for major liposuction and abdominoplasty includes patients with morbid obesity, concern about OSA becomes more germane. OSA is a result of a combination of excessive pharyngeal adipose...
Inferior Epigastric Artery
The inferior epigastric artery Fig. 1.3 is a branch of the external iliac artery that ascends obliquely along the medial margin of the deep inguinal ring, posterior to the spermatic or round ligament. It may arise from the femoral artery, or, very rarely from the obturator artery. It pierces the transversalis fascia to enter into the posterior wall of the rectus abdominis at the level of the arcuate line. This vessel penetrates the posterior sheath near the middle of the lower abdomen and the...
Preoperative Evaluation
The time and energy devoted to the preoperative preparation of the surgical patient should be commensurate with the efforts expended on the evaluation and preparation for anesthesia. The temptation to leave preoper- ative anesthesia preparation of the patient as an afterthought must be resisted. Even if an anesthesiologist or CRNA is to be involved later, the surgeon bears responsibility for the initial evaluation and preparation of the patient. Thorough preoperative evaluation and preparation...
Skin
The skin is of average thickness, and loosely attaches to the underlying tissue. It exhibits certain surface markings such as the umbilicus, linea alba, linea semiluna-ris, epigastric fossa, and McBurney's point. The umbilicus, a midline fibrous cicatrix covered by a folded area of skin, is an important anatomical landmark in the anterior abdomen that marks the original attachment of the fetal umbilical cord. In young adults, it is usually located at the level of the intervertebral disc between...
Umbilical Hernia
Umbilical hernia, common among African-American children, is associated with failure of complete closure of the umbilical orifice during the 1st year of postnatal life 2 . It is often noticed when the infant cries, which raises the intra-abdominal pressure and causes protrusion of part of the intestine. Surgery becomes essential when the defect is relatively large and persists beyond the age of 4, or becomes incarcerated. In the adult, umbilical hernia may develop more commonly in women,...
Introduction Pfz
Since the development of the first outpatient surgical program in 1966 and the first freestanding surgical centers in 1969, the number of surgeries performed outside of the hospital setting has dramatically increased. An estimated 70 of all elective surgery is performed in an outpatient setting 1 , and more than 50 of aesthetic plastic surgeons perform most of their procedures in an office setting 2 . The popularity of surgeries performed outside of the hospital setting is a consequence of...
Richters Hernia
Richter's hernia, which was first described in 1598, refers to the hernial protrusion that contains only a portion of the intestinal wall at any site in the anterolateral abdomen. The involved segment incarcerates or strangulates and may undergo gangrene, but symptoms of ischemic bowel or complete intestinal obstruction are often absent. The hernial sac most commonly occurs at the femoral and inguinal rings and is associated with a high mortality rate 70 . Richter's femoral hernia exhibits...
Fluid Replacement
Management of perioperative fluids probably generates more controversy than any other anesthesia related topics. Generally, the typical, healthy, 60-kg patient requires about 100 cc of water per hour to replace metabolic, sensible, and insensible water losses. After a 12-h period of fasting, a 60-kg patient may be expected to have a 1-liter volume deficit on the morning of surgery. This deficit should be replaced over the first few hours of surgery. The patient's usual maintenance fluid needs...
Subcostal Artery
The subcostal artery courses inferior to the last rib and anterior to the 12th thoracic vertebra. It lies posterior to the sympathetic trunk, thoracic duct, pleura and diaphragm. Then, it descends into the posterior abdominal wall posterior to the lateral arcuate ligament accompanied by the corresponding vein and nerve. As it continues anterior to the quadratus lumborum and posterior to the kidney, the right subcostal artery courses behind the ascending colon, whereas the left subcostal artery...
Actions
With the pelvis fixed, the recti act as flexors of the lumbar vertebral column with the thorax fixed, they draw the pelvis upward. The recti come to action as flexors, Abdominal , Oblique Muscle amp Aponeurosis Abdominal , Oblique Muscle amp Aponeurosis Fig. 1.17. Course of a hernial sac in the indirect inguinal hernia. Observe the inguinal canal, inferior epigastric vessels and the protruding hernial sac Fig. 1.17. Course of a hernial sac in the indirect inguinal hernia. Observe the inguinal...
Diabetes Mellitus
Although patients with diabetes mellitus have a substantially increased surgical mortality rate than non-diabetic patients 105 , these complications are more likely to be a consequence of the end-organ disease such as cardiovascular disease, renal disease, and altered wound healing 106-108 . While evidence suggests that tight control of blood sugar in insulin-dependent diabetics slows the progression of end-organ disease 109 , tight control is associated with additional risks such as...
Preoperative Risk Assessment
The ultimate goals of establishing a patient's level of risk are to reduce the probability of perioperative morbidity and mortality. The preoperative evaluation is the crucial component of determining the patient's preopera-tive risk level. There is compelling evidence to suggest that the more coexisting medical conditions a patient has, the greater the risk for perioperative morbidity and mortality 25, 44 . Identification of preoperative medical conditions helps reduce perioperative mortality....
Femoral Hernia
A femoral hernia presents a hernial sac that protrudes anterior to the pectineal Cooper's ligament and through the femoral canal, a potential space between the lacunar ligament and the femoral vein. The femoral ring, which is the upper margin of the femoral canal, is the medial portion of the lacuna vasorum. It is bounded anteriorly by the extension of the transversalis fascia, and posteriorly by the continuation of the pectineal fascia. The neck of the hernial sac is always distal and lateral...
Action
The effect of contraction of the transverse abdominis on the vertebral column is not clear, despite its role as a compressive force resisting intra-abdominal pressure. Posterior Layer of the Rectus Sheath Posterior Layer of the Rectus Sheath Fig. 1.16. Posterior layer of the rectus sheath, arcuate line of Douglas, internal abdominal oblique, and transverse abdominis Fig. 1.16. Posterior layer of the rectus sheath, arcuate line of Douglas, internal abdominal oblique, and transverse abdominis It...
Internal Abdominal Oblique Muscle
The internal abdominal oblique Figs. 1.9,1.10 muscle is much thinner and lies deep to the external abdominal oblique. It arises from the iliac crest and the lateral two-thirds of the inguinal ligament, as well as from the tho-racolumbar fascia. Fibers of this muscle, particularly those from the iliac crest and thoracolumbar fascia, pursue a reverse course perpendicular to that of the external abdominal oblique, extending for the most part upward and medially. The part of the muscle that...
Contents
Ivo Melvin A. Shiffman, Sid Mirrafati List of 1 Anatomy of the Abdominal Wall 2 Anesthesia for Liposuction and Abdominoplasty 3 Tumescent Anesthesia for Abdominal Liposuction 4 Abdominoplasty History and Techniques 5 Patient Consultation and Instructions for Abdominoplasty 6 Abdominolipoplasty Classification and Patient Selection Steven G. Wallach, Alan Matarasso 70 9 Personal Approach to Aesthetic Abdominal Deformities Ivo Pitanguy, Henrique N. Radwanski 102 10 Abdominoplasty Techniques A...
Superficial Fascia
The superficial fascia Fig. 1.2 is a soft and movable layer, which comprises, to a great extent, a single variably fatty superficial layer known as Camper's fascia. The amount of fat in Camper's fascia varies depending on the nutritional status of the individual. In the male, it continues inferiorly with the dartos layer of the scrotum and outer layer of the penis and spermatic cord, where it becomes thinner, lacking adipose tissue. In the female, it continues with the superficial fascia...
Pyramidalis Muscle
The pyramidalis Fig. 1.17 , an inconstant small muscle which is absent in approximately 25 of the population, originates from the symphysis pubis and pubic crest and inserts into the linea alba as far as one-third of the distance to the umbilicus. This triangular muscle lies anterior to the lower end of the rectus abdominis and becomes smaller and pointed as it ascends towards the junction of the linea alba and the arcuate line. Although the significance of this muscle is not clear, it is...
Thoracoabdominal Nerves
The seventh and eight intercostal nerves, as is the case with the rest of the intercostal nerves, divide into lateral and anterior cutaneous branches. The lateral branch further divides into anterior and posterior branches, piercing the flat abdominal muscles in the midaxillary line to reach the skin. The anterior cutaneous branches, which represent the terminal branches of the ventral rami of the intercostal nerves, pierce the rectus sheath laterally and emerge anteriorly to reach the skin....
Innervation of the Abdominal Wall
The skin of the anterior abdominal wall is innervated by the ventral rami of the lower five or six thoracic tho-racoabdominal spinal nerves that continue from the intercostal spaces into the abdominal wall Fig. 1.5 . The anterolateral abdomen also receives nerve fibers from the subcostal, iliohypogastric, and ilioinguinal nerves. A typical intercostal nerve runs across the deep surface of the internal intercostal muscle and membrane between the internal and innermost intercostal muscles. It...
Transverse Abdominis Muscle
The transverse abdominis Figs. 1.2, 1.12-1.16 is a wide thin muscular layer that assumes a nearly hori- Fig. 1.12. Transverse abdominis muscle and aponeurosis Fig. 1.12. Transverse abdominis muscle and aponeurosis Cut Edge of the Superficial Fascia and Skin Cut Edge of the Superficial Fascia and Skin Erector Spinae and Transversospinalis Muscles Fig. 1.13. Cross section of the posterolateral abdominal wall showing the external and internal abdominal oblique, transverse abdominis, and the...
Inguinal Canal
The inguinal canal 39 is an oblique tunnel that borders the anterior thigh and extends from the superficial to the deep inguinal ring, running parallel to and above the inguinal ligament. It develops between the 5th and the 32nd week of prenatal life, initially as the processus Pampiniform Plexus Within the Spermatic cord Pampiniform Plexus Within the Spermatic cord Fig. 1.18. Formation of the process vaginalis, descent of the testis, and the spermatic cord vaginalis, a peritoneal evagination...
External Abdominal Oblique
The external abdominal oblique muscle Figs. 1.6,1.7 is the most superficial abdominal muscle that originates from the external surfaces of the lower seven or eight ribs and interdigitates with the serratus anterior and la-tissimus dorsi muscles. Most of the muscle fibers run downward and medially, forming an aponeurosis near the lateral border of the rectus abdominis. The muscle fibers from the lower two ribs descend vertically downward to attach to the iliac crest. Muscle fibers are rarely...
Superficial Epigastric Vein
The superficial epigastric vein drains the inferior part of the anterior abdominal wall and is connected to the paraumbilical and thoracoepigastric veins. This vessel drains via the great saphenous vein into the femoral, external iliac and common iliac veins and eventually into the inferior vena cava. It also drains into the portal vein through the paraumbilical veins and the partially obliterated umbilical vein. Through this venous linkage to both the inferior vena cava and portal vein, a...
Superficial Circumflex Iliac Artery
The superficial circumflex iliac artery arises from the femoral artery near the origin of the superficial epigastric artery. It pierces the deep fascia of the thigh lateral to the saphenous opening and courses laterally toward the anterior superior iliac spine to supply the superficial fascia and skin. It is considered the smallest branch of the femoral artery that anastomoses with the deep circumflex iliac, lateral femoral circumflex iliac and superior gluteal arteries. The course of this...
Extraperitoneal Fatty Tissue
The extraperitoneal tissue subserous fascia is a generally thin connective tissue layer that occupies the area between the peritoneum and the transversalis fascia in the abdomen, and between the peritoneum and the en-dopelvic fascia in the pelvis. It is loose and fatty in the lowest portion, allowing for the expansion of the bladder. The potential space represented by this loose pre-peritoneal layer, the space of Bogros, is used for the placement of prostheses in the repair of inguinal hernia....
Thoracoepigastric Vein
The thoracoepigastric vein drains the middle portion of the anterolateral abdomen and connects the superficial epigastric and superficial circumflex iliac veins to the lateral thoracic vein. The lateral thoracic vein joins the axillary, which continues with the subclavian and brachiocephalic veins and eventually drains with the great saphenous vein this, in turn, joins the femoral vein, which continues with the external iliac and common veins and later with the inferior vena cava. Through these...
Inguinal Hernia
The bony attachments of the inguinal region counteract abdominal thrust, and the presence of natural gaps that exist in this region may allow peritoneal diverticula to externalize and appear as hernias. Inguinal hernia sac, which represents approximately 95 of abdominal wall hernias in the male and 50 in the female, has the highest incidence of onset in the 1st year oflife followed by a second peak between the ages of 16 and 20. Hernial sac traverses the entire length of the inguinal canal from...
Regions of the Abdominal Wall
To accurately describe the locations of visible abnormalities, masses, and pain in a typical clinical write-up, the anterolateral abdomen is divided into nine regions by four imaginary planes two verticals midclavicular midinguinal and two horizontal transpyloric intertu-bercular planes Fig. 1.1 . The transpyloric plane corresponds to the midpoint between the umbilicus and xiphoid process, crossing the pylorus of the stomach at the lower border of the first lumbar vertebra. The subcostal plane...