|Year : 2019 | Volume
| Issue : 4 | Page : 182-186
The suprapubic deepithelialized inferiorly based random flap designed to fill the tissue deficiency at supraumbilical area to prevent the concave deformity in abdominoplasty
Aret Cerci Ozkan, Burcak Tumerdem Ulug
Private Practice, Istanbul, Turkey
|Date of Submission||22-Dec-2018|
|Date of Acceptance||21-Jan-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Aret Cerci Ozkan
Incirli Caddesi Bayrak Apt. No. 89/7, Bakirköy, Istanbul
Source of Support: None, Conflict of Interest: None
Introduction: The most critical tissue in abdominoplasty is the midsagittal part of the supraumbilical region with the highest risk of hemodynamic disturbance. Here, the skin is also thinner compared to the neighboring lateral tissues. This may result in postoperative suprapubic depression. Methods: An easy technique is designed to prevent this suprapubic depression. While making the transverse incision, deepithelialized suprapubic flap is kept in place attached to the suprapubic region. The medial supraumbilical deficient tissue is brought down with the abdominoplasty flap and lowered over the deepithelialized suprapubic flap. Results: Follow-up with the patients is between 1 month and 2 years. We have no longer observed any concave deformity. Discussion: Another technique described in the literature designed to prevent the concave deformity is deepithelization of the tongue of tissue projecting from the lower end of the abdominal flap and folding this back to double up the thickness of fat in this area. Nevertheless, the median distal end of the abdominal flap is hemodynamically the poorest part of the flap. Preparing deepithelialized tongue and folding it back raises the vascular insufficiency risk. Suturing the upper edge and the sides of the supraumbilical flap to deep tissues of the abdominal flap distribute the tissue tension to deeper parts, thus reduce the incision tension with reduced scar tension at the midline. Conclusion: The suprapubic random flap is an assurance for prevention of concave deformity and helps to reduce the tension of transverse incision at the midline, thus may reduce the risk of scar formation.
Keywords: Abdominoplasty, concave, deformity, suprapubic, supraumbilical
|How to cite this article:|
Ozkan AC, Ulug BT. The suprapubic deepithelialized inferiorly based random flap designed to fill the tissue deficiency at supraumbilical area to prevent the concave deformity in abdominoplasty. Turk J Plast Surg 2019;27:182-6
|How to cite this URL:|
Ozkan AC, Ulug BT. The suprapubic deepithelialized inferiorly based random flap designed to fill the tissue deficiency at supraumbilical area to prevent the concave deformity in abdominoplasty. Turk J Plast Surg [serial online] 2019 [cited 2020 Feb 19];27:182-6. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/182/267938
| Introduction|| |
A well-contoured abdomen is highly important because it displays the person as fit, attractive, and healthy. Abdominoplasty is one of the most important operations for reshaping of the contour of the abdomen for better appearance. Nevertheless, as in all esthetic surgeries, it is very critical to pay attention to technical details which improve esthetic results and therefore patient satisfaction.
The most critical part of tissue in abdominoplasty operation is the midsagittal part of the supraumbilical region. This part carries the highest risk of hemodynamic disturbance.
The skin at this part is thinner than the adjacent neighboring lateral tissues. This tissue discrepancy is obviously related to the preparation of the umbilical stalk. Sufficient thickness of the umbilical stalk and its careful plication are essential for safe umbilical blood circulation. Supraumbilical soft-tissue deficiency may occur even with the thinnest preparations of the umbilical stalks. In addition, the skin in this area maybe deformed due to the expansion caused by skin stretching during pregnancy. This inharmony may result in late postoperative suprapubic depression if proper care is not given to fill this tissue discrepancy.
During the transverse incision at the time of abdominoplasty, beveling is usually recommended to save some fatty tissues above the incision in order to match the upper flap deficiencies. Nevertheless, this would be an uncertain and unsafe amount of tissue and usually will not sufficiently fill the median supraumbilical deficient space.
Sinder  originally reported the suprapubic dermoadipose flap technique to prevent this postoperative contour deformity in the 1970s.
Mayer and Loustau  used this flap for reshaping of the postpregnancy abdomen; they put forward that their technique is especially indicated in patients with a low-to-normal body mass index and have a supraumbilical skin due to pregnancy.
We used a similar surgical technique to overcome the contour deformity problem at the suprapubic region after an abdominoplasty patient applied for a revision of this area. You can see one of our own abdominoplasty cases with the late postoperative complication of suprapubic skin depression at the midline [Figure 1]. This skin depression was later revised by lowering the preexisting transverse scar with the addition of a small, deepithelialized inferiorly based random flap in between the new and old incisions, which were matched to the suprapubic tissue defect after reapproximation. This revision technique that we have designed for this specific case has given us the inspiration to use a similar technique for all primary cases in order to prevent the formation of suprapubic depression.
|Figure 1: A concave deformity in one of our patient 1-year postoperative after abdominoplasty and its revision plan|
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| Methods|| |
This very easy technique was designed to address and prevent the postoperative suprapubic depression or concave deformity problem in abdominoplasty operations of 42 female patients (aged between 35 and 62 years), that took place between March 2016 and September 2018.
Before starting the operation by cutting the transverse incision all the way down to the abdominal wall level, the skin is deepithelialized 10–12 cm in length and 8–10 cm in width at the suprapubic region just above and adjacent to the incision. Scissors technique is used for deepithelialization. Then, while making the transverse incision, this deepithelialized region was kept in place attached to the suprapubic region by turning the scalpel around the lateral and upper edges of this deepithelialized region. Thus, an inferiorly based deepithelialized random flap was created which is also supplied from the abdominal wall perforators. Then, the abdominoplasty flap was raised as described in classic books.
Toward the end of the operation, the medial supraumbilical deficient tissue is brought down with the abdominoplasty flap and just lowered over the previously prepared deepithelialized and inferiorly based suprapubic flap. The flap is trimmed according to the needs of the defect. If there is no tissue deficiency, the flap is discarded. Multilayered suturing of both this flap and the whole transverse incision is preferred. Deep fat layers are approximated with 2-0 and 3-0 vicryl sutures [Figure 2], then the subdermal layer and finally the dermal layer with 3-0 and 4-0 monocryl sutures, respectively.
|Figure 2: (a) Peroperative view showing the supraumbilical tissue deficiency, deepithelialized suprapubic random flap and its settlement under the tissue deficiency. (b) Diagrammatic illustration of the supraumbilical tissue deficiency and the deepithelialized suprapubic random flap|
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In 29 of the 42 cases, we trimmed the prepared flap to reduce its volume in order to fit the defect. In seven cases, we have obliged to cut the dermis full thickness at the base of the flap, and in four cases, we have cut the base little more and created an island flap for better alignment of the abdominal flap with the skin at the level of the pubic symphysis. In 11 cases, we removed the flap near the end of the operation because there was no risk of suprapubic tissue deficiency.
| Results|| |
Follow-up with the patients is between 1 month and 2 years. Majority of them were satisfied with the result. We did not observe any suprapubic defect or concave deformity [Figure 3], [Figure 4], [Figure 5]. We observed late postoperative suprapubic bulging in two cases. We performed liposuction to the bulging at the 6th-month postoperative period. In two cases in whom an island flap has been prepared, we observed soft-tissue hardness (fat necrosis?) at the suprapubic area. We decided just to observe without any intervention. These two patients were heavy cigarette smokers having previous Pfannenstiel incision. After observing these soft-tissue harnesses in two cases, we checked the flap viability more cautiously in patients with cesarean section and in heavy smokers.
|Figure 3: (a) Preoperative anterior view of a patient having an abdominoplasty. Suprapubic deepithelialized random flap has been used to fill the supraumbilical defect. Scars existing at the upper abdominal region are due to endoscopic cholecystectomy operation. (b) 18-month postoperative anterior views of the same patient having an abdominoplasty.(c) Preoperative lateral view of the same patient having an abdominoplasty. (d) 18-month postoperative lateral view of the same patient having an abdominoplasty|
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|Figure 4: (a) Preoperative anterior view of a patient having an abdominoplasty. Suprapubic deepithelialized random flap has been used to fill the supraumbilical defect. (b) 24-month postoperative anterior view of a patient having an abdominoplasty. (c) Preoperative lateral view of the same patient having an abdominoplasty. (d) 24-month postoperative lateral view of the same patient having an abdominoplasty|
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|Figure 5: (a) Preoperative anterior view of a patient having an abdominoplasty. Suprapubic deepithelialized random flap has been used to fill the supraumbilical defect. (b) 20-month postoperative anterior view of a patient having an abdominoplasty. (c) Preoperative lateral view of the same patient having an abdominoplasty. (d) 20-month postoperative lateral views of the same patient having an abdominoplasty|
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Other than these, we were also faced with altered complications unrelated with our above-described technique such as small unilateral dog ears in two patients and lower median abdominoplasty flap desquamation in one patient who was also a heavy smoker. We also encountered localized hypertrophic scars in five patients. Dog ears were revised in the 6th-month postoperative period. All lower abdominal desquamations healed spontaneously by reepithelialization. Hypertrophic scars are fading slowly with the aid of local steroid injections, silicone sheath, and massage with extractum cepae-heparin-allantoin gel.
| Discussion|| |
The abdominal area has sand valley bulges rather than having a flat appearance. The thin skin around the umbilicus that comes down to the lower midline leads to a concave deformity. Presence of the deepithelialized flap approaching just underneath the lowest median part of the abdominal flap fills the deficient space nicely and prevents the development of any suprapubic depression or concave deformity. Besides preventing depression, this flap can even help to create additional fullness at the lower abdomen, which can be considered more attractive than a flat lower abdomen. Another technique described in the literature which designed to prevent the concave deformity is deepithelization of the tongue of tissue projecting from the lower end of the abdominal flap and folding this back to double up the thickness of fat in this area. Nevertheless, it should be kept in mind that the median distal end of the abdominal flap is already hemodynamically the poorest part of the flap. Elongating this hemodynamically poor region with deepithelialized tongue and furthermore folding it back raises the vascular insufficiency risk considerably. However, the flap prepared from the suprapubic region is highly safe with dual blood supply. It is an inferior random flap and also it is supplied by abdominal wall perforator vessels. If necessary, it is still safe to cut the random flap base and create an island flap over the abdominal wall. Preparation of an island flap or at least full-thickness cut of the dermis at the base of the flap has sometimes needed for better alignment of the abdominal flap and lower skin at the level of the pubic symphysis, but of course, especially for island flap preparation, the patients' age, cigarette smoking habits, presence of a Pfannenstiel incision, quality of the tissues, and volume of the flap should be cautiously considered to prevent any possible fat necrosis or other hemodynamic problems of this island flap.
This hemodynamic safety has another very important advantage. If any vascular insufficiency and necrosis problem happen in the lowest median part of the abdominoplasty flap, the presence of healthy and well-nourished deepithelialized flap underneath this region is an assurance for easier and faster recovery with the secondary healing of any localized necrosis of abdominoplasty flap complication at the lowest midline. The incidents of skin necrosis vary between 3% and 4.4% even if a limited dissection technique is used, preserving an adequate number of perforating vessels. The most important risk factor for this complication is tobacco consumption, which triples the risk. Performing abdominoplasties along with other esthetic operations at the same time also increase the risk of skin necrosis. Hence, this flap can be also considered for protection purposes against the possibility of necrosis in smokers. The risk of abdominal skin necrosis also can be checked with SPY intraoperative imaging system.
Suturing the upper edge and the sides of the supraumbilical flap to deep tissues of the abdominal flap may help distribute the tissue tension to deeper parts, especially at the midline, thus reducing abdominal tissue and the incision tension. Reduced tissue tension at the midline means better blood circulation in this area, and reduced scar tension at the midline means better fading scar formation. In addition, tension-bearing polyfilament sutures are also distributed around the suprapubic flap edges away from the scar and deeply located in the abdomen. Thus, the risk of suture extrusion is also reduced. According to the published literature, suture extrusion occurs in at least 5% of cases. Midline incision with reduced tension can be approximated with thinner monofilament sutures with lower suture extrusion risk. All of these measures may also help reduce the abdominal scar inflammation and eventually positively affect scar quality at the midline. Uneven and localized hypertrophic scars are usually related to the utilization of thick polyfilament sutures causing localized poor microcirculation adjacent to the knot.
Rising the level of upper abdominal incision high above the standard umbilical level may be another alternative to reduce the risk of concave deformity because at the upper levels there will be no more tissue discrepancy and obviously no need to think to fill it with anything. Nevertheless, this option carries more important risks such as very tense closure with the very tight abdomen increased postoperative circulatory problems, especially at the level of the suprapubic area over abdominal flap and increased scar problems. Upper abdominal incision above the umbilical level may also cause abnormal elevation of the mons pubis and genitalia. It is stated in the literature that normal elevation of the mons pubis and consequent exposure of the clitoris may cause a significant improvement in sexual functioning and sexual satisfaction after abdominoplasty. Nevertheless, excessive elevation of the mons pubis may cause vulvar/clitoral pain, pelvic floor dysfunction, and anatomic alterations with or without lesions after abdominoplasty.
After observing fat necrosis in our two cases, we acted more cautious to use this flap in patients with Pfannenstiel incision and in heavy smokers. As the dermofat flap is raised off the fascia before reaching the rectus muscles in cesarean section, dual blood supply may be totally disturbed endangering the suprapubic flap viability. Thus, we are very cautious about the presence of Pfannenstiel incision since its presence denotes circulatory compromise risk in our suprapubic flap. In its presence, we either or we check its vascularity cautiously without rising it off the fascia.
Mayer and Loustau  have preferred the use of this flap in thin-skinned women having multiple pregnancies. We have preferred to prepare this flap in all cases at the beginning of the operation and then trim or discard according to the needs of the cases. They also have preferred to raise the flap off the fascia. We have never preferred to raise it off the fascia, but in some cases, we have cut the base for better closure of the incision.
The suprapubic flap, which has been prepared at the beginning of the operation, can easily be tailored according to the amount of supraumbilical defect near to the end of the operation. The need for this flap can be considered on a case-by-case basis. The existence of this flap during the operation guaranties tissue support for the suprapubic area in case of deprivation, but if it seems not to be necessary near to the end of the operation, it can be canceled. During approximation of the abdominal flap to lower incision, it is possible to trim it to fit in the deficient part of the supraumbilical area and if there is no risk of suprapubic depression for that specific case and furthermore if its presence is causing any undesired suprapubic bulging, it can either partially or totally be removed easily. Hence, this technique can optionally be performed or canceled according to the needs of patients. Optional practices almost always comfort the surgeon because reversible techniques are always preferable, safe, tried and applied with complacency.
| Conclusion|| |
The preparation of the suprapubic random flap at the beginning of the operation is an assurance for prevention of concave deformity, for better secondary healing in case of any lower abdominal vascular complication, and help to reduce the tension of transverse incision at the midline, thus may reduce the risk of scar formation.
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Conflicts of interest
There are no conflicts of interest.
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