Aesthetic operations of the abdominal wall have evolved from skin excision to fascial plication and muscle transposition. Many techniques have been advocated without objective proof of superiority. Weight reduction after abdominoplasty is an aesthetic improvement that is easily quantified. The use of mesh for hernia repair and abdominal wall reconstruction is well established. The combination of mesh and plications for aesthetic abdominoplasties has been reported previously.1,2 During abdominoplasties, the authors have observed atrophic, stretched, and torn fascia. Fascial plication produces additional fascial stretching and tearing. Mesh reinforcement increases passive wall tension directly and active wall tension indirectly by Starling's law. Increased abdominal wall tension generates increased intraabdominal pressure3 (Laplace's law, P = T/r). The increased intraabdominal pressure increases respiratory energy consumption and increases intragastric pressure, which creates satiety.4 Increased energy consumption and decreased food volume required to achieve satiety produce rapid onset and permanent weight loss.
A 3-year retrospective review was performed on 44 consecutive abdominoplasties. Thirty-seven patients underwent abdominoplasties with mesh reinforcement. Of these, 18 had anterior rectus sheath plication and 19 had linea alba plication and bilateral plications lateral to the anterior superior iliac spine (Fig. 1). The patient's preoperative weight was compared with the postoperative weight at last follow-up. Weight reduction at 36 months occurred in 86 percent of the patients with bilateral plications but in only 33 percent of those without (Fisher's exact test, p = 0.0085). The bilateral plication group was divided into four subgroups based on preoperative body mass index. The body mass index reduction by each subgroup was 0.4, 1.9, 3.5, and 5.3 for the normal weight, overweight, obese, and extremely obese groups, respectively. The bilateral plication group had increased weight loss, and the loss increases with increasing body mass index. These findings suggest abdominoplasty with mesh reinforcement and bilateral plication specifically improves the abnormal pathologic findings associated with increased weight. The abdominal wall may be a major component in determining weight and supports a biomechanical negative feedback weight control model.
In normal weight patients, abdominoplasty with mesh reinforcement and bilateral plication may be used prophylactically to prevent future weight gain. In overweight patients, abdominoplasty with mesh reinforcement and bilateral plication is therapeutic, resulting in weight loss, and patients may become normal weight. In obese patients, abdominoplasty with mesh reinforcement and bilateral plication can reduce weight into the overweight class but usually not to normal weight. In this group, it may be possible to place a tissue expander beneath the mesh to sequentially reduce the abdominal volume while maintaining wall tension. When the desired body mass index is achieved, the expander would be removed and the mesh oversewn. The current restrictive or malabsorptive bariatric surgical procedures temporarily create negative energy balance, forcing weight loss. When these patients achieve the minimal weight, they may undergo abdominoplasty with mesh reinforcement and bilateral plication as an adjuvant for additional reduction or to allow reversal of the bariatric surgery while maintaining the reduced weight. Abdominal wall bariatric surgery offers a new class of operations to augment wall function that may prevent obesity, treat obesity, or enhance the current bariatric surgical techniques.
Gary M. Horndeski, M.D.
Elisa Gonzalez, P.A.
Mainland Medical Center
Texas City, Texas
1.Marques A, Brenda E, Pereira M, de Castro M, Abramo A. Plicature of abdominoplasties with Marlex mesh. Ann Plast Surg
2.Prado A, Andrades P, Benitez S. Abdominoplasty: The use of polypropylene mesh to correct myoaponeurotic-layer deformity. Aesthetic Plast Surg
3.Toranto R. The relief of low back pain with the WARP abdominoplasty: A preliminary report. Plast Reconstr Surg
4.Pedersen J, Larsen J, Drewers A, Arveschoug A, Kroustrup J, Gregersen H. Weight loss after gastric banding is associated with pouch pressure and not pouch emptying rate. Obes Surg
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