The abdominal silhouette: the deformation of your belly, Post-Partum Abdominal Wall Insufficiency (PPAWI), diastasis.
The surgery of the function and the silhouette of the abdominal wall is one of our now already old concerns. It is about the surgery of the diastasis, the abdominal protrusion, sometimes associated with a ventral hernia. In women, it is often partly the consequences of pregnancies (Post-Partum Abdominal Wall Insufficiency (PPAWI),).
In standing position, association of an abdominal protrusion and an umbilical hernia.
In standing position: periumbilical central protrusion.
We have an original vision of this problem:
The abdominal wall can be artificially divided into two parts : superficial and deep.
Superficial: the skin and the more or less thick subcutaneous tissues. The correction of “abnormalities” at this level (excess skin or adipose tissue, etc.) is the domain of “aesthetic” plastic surgery. Usualy lassical parietalists do not have a natural vocation to be a plastic surgeon, they have not received the ad hoc training.
Excess skin.
In lying position, visualization of the diastasis (belly depression aspect).
Lying on the back, the supraumbilical depression corresponds to the diastasis.
Deep: the muscles and their fibrous envelopes (the aponeuroses). The correction of anomalies at this level (groin hernia or incisionnal hernia, diastasis), is the domain of parietology, a domain recently individualized from the so-called general surgery. Plastic surgeons do not usually have this special knowledge, which requires the use of specific techniques and materials (parietal reinforcement prosthesis, etc.).
But the abnormalities are often associated, (excess of skin and fat, parietal laxity with a hernia or a Diastasis…) in these cases it is necessary to act on the two superficial and deep parts at the same time in order to “repair” the totality of the abdominal wall, in its function (muscles and aponeuroses) and in its visual and aesthetic appearance (skin and subcutaneous tissue).
The specificity of our practice is to propose this multidisciplinary approach (the parietalist and the plastic surgeon work at the same time) and to consider the surgical act for the benefit of the entire abdominal wall. The result is a functional improvement (a stronger abdominal wall, improving the patient's daily life in his physical activities, improving back and lumbar static problems...) and an aesthetic improvement (improvement of the silhouette with restoration of muscular reliefs).
This original approach, which has been familiar to us for more than 20 years, particularly allows the management of postpartum abdominal insufficiency.
Postpartum abdominal wall insufficiency, often resulting from multiple or twin pregnancies, is a deformation of the silhouette with sometimes an unaesthetic appearance of the skin (folds, stretch marks...). The curvature and protrusion are constituted by the distension of the envelope of the muscles, by the widening of the linea alba which leads to a spreading of the muscles (diastasis), possibly associated with an umbilical or supra-umbilical hernia. In addition to the aesthetic damage, this results in muscular dysfunction and a loss of some physical capacities.
This parietal pathology must imperatively be considered in its entirety (superficial and deep part of the wall). The exact nature of the abnormalities must be assessed by clinical examination, and sometimes with the help of a complementary examination (CT scan).
After the assessment and taking into account the expectations and requests of the well-informed patient, it will be possible to propose (OR NOT) a surgical correction on one or both parts of the wall. If both levels of the wall are involved, a consensus will be sought between the patient, the plastic surgeon and the parietal surgeon to elaborate an adapted solution
It is often a relatively complex surgical act, with its own constraints during the postoperative period, with possible complications which will have been exposed as clearly as possible.
This type of management is also adapted to corrections that may be necessary in patients who have had morbid obesity corrected by diet or bariatric surgery. Here the management is more often purely plastic, but the preoperative assessment must conform to the previous scheme.
The usual delay of the institutions (CPAM, private insurances...) in the recognition of these types of pathologies (diastasis) obliges that all or part of the treatment is at the charge of the patient, "cosmetic surgery". However, in a certain number of cases, a prior agreement can be arranged with the CPAM. This is particularly the case for reconstructive surgery after a very significant weight loss.
The pathologies often associated (hernia, incisional ventration) can of course also give rise to reimbursement by the CPAM and private insurance.
In all cases, the estimation of the cost of the operation is a step to be taken into account and explained precisely.
TECHNICAL NOTIONS
The resection of excess skin and fat, reshaping the silhouette, is performed by the plastic surgeon, the incision is low, hidden in the bikini line.
The skin marking of the incision circumscribing the resected skin area.
The reinforcement of the muscular and aponeurotic planes is performed by the parietal surgeon. It consists of placing a very large parietal reinforcement tulle in the abdominal wall; the use of prosthetic material allows the effect given by the superficial remodeling to be maintained.
The skin closure (redraping) is performed according to the principles of plastic surgery.
L'hospitalisation dure environ 2 à 3 jours, la surveillance et les soins locaux étant ensuite assurés en consultation externe.
Aspect of the scar after several weeks
Aspect of the scar one year after the operation
Another exceptional example of parietal reconstruction with remodeling of the silhouette in a patient with postoperative sequelae, with long median dystrophic scar, important diastasis of the rectus muscles, and important excess skin and fat under the umbilicus..
Preoperative appearance: note the dystrophic median scar, the skin marking of the diastasis and the excess skin and fat under the umbilicus
Immediate postoperative aspect, after resection of the excess skin and fat under the umbilical: note the significant remodeling of the silhouette secondary to the re-tensioning of the superficial and deep planes (intra parietal prosthesis in place).