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Abdominoplasty and diastasis recurrences

A fantastic, faraway land.

Surgery, for women with diastasis of the rectus, is that fantastic and distant land to which all would like to land for be reborn. Some - most - of them come up against a harsh reality: in the National Health System, diastasis can only be operated on under certain, and limited, conditions:

In the NHS, therefore, theoretically only patients with 'high degree diastasis', a history of severe obesity and a BMI below 30 could be operated on: in essence, formerly obese patients who have lost weight, perhaps after bariatric surgery, and that meet at least 4 of the 5 inclusion criteria set out in the regulations. A very small percentage of patients with diastasis of the rectus.

Even assuming, however, that one succeeds in passing this very strict selection (often thanks to the surgeon who, at his own risk given the controls currently in place in the NHS, closes one or both eyes), patients are generally offered only one surgical option: abdominoplasty.

But how effective is abdominoplasty? In particular, what can we say about abdominoplasty and diastasis recurrences?

Abdominoplasty and recurrence of diastasis of the rectus

I was recently invited to speak about REPA, the endoscopic repair of diastasis of the rectus, at the ISHAWS congress (Italian Society of Hernia and Abdominal Wall Surgery) held in Naples in the first week of December. In my presentation, among others, I showed this slide:

abdominoplasty, abdominoplasty complications, abdominoplasty and diastasis recurrences

Obviously, for insiders, this image is not particularly striking; it is common knowledge: the invasiveness of abdominoplasty, the large discolourations, the scar that even if perfect (as in the photo) is still very large, and then the most serious complications: necrosis of the flap (those dark areas on the surgical wound, in practice 'dead flesh'...) and of the umbilicus. These are all things that a surgeon knows, but above all the patient needs to know.

The patient, at the time of the visit, wants to be reassured: "Doctor, tell me this will never happen to me!" And some may even say or play it down: everything, in the end, sometimes seems like a piece of cake. But it is not.

And what about diastasis recurrences after abdominoplasty? This is where it gets serious: because the surgeons themselves deny it, lying. Here is another slide I presented on the same occasion:

abdominoplasty and diastasis recurrences, abdominoplasty complications

This image, yes, caused a stir and sparked a heated debate at times. First of all, you probably don't know this, but the newspaper publishing the article in question, Surgical Endoscopyis one of the most important and serious in the surgical world. It follows that the problem is serious, but what is the problem? Well, the fact that, of 14 publications on abdominoplasty repair analysed, 9 reported that there were no recurrences in the postoperative period is a problem: because IS NOT CREDIBLE, and this, in medicine, is a BIG problem. As I always tell visiting patients, in medicine the 0% and the 100% do not exist: and especially in abdominal wall surgery recidivism, whether in a small or large percentage, is always there. Everyone, even the world's greatest wall surgeon, has their recurrences: ALL. The fact that in two-thirds of the papers examined in this article, the authors state that they have not relapsed can mean two things: either that they are lying, or that their recurrences have gone to another surgeon.

See this other slide:

abdominoplasty complications and diastasis recurrences

This article by Hernia from 2011 reviews results published in scientific papers with high-quality (i.e. very reliable) data on the follow-up of patients operated on for diastasis of the rectus with various techniques (mainly abdominoplasty).

Hernia is the most important journal of abdominal wall surgery currently published in the world.

The data in this case changes a lot. Here are some examples:

  1. In the work published by Van Uchelen et al. in 2001 (The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography) diastasis recurrences after abdominoplasty are 40%. FORTY PER CENT.
  2. Oscar Ramirez, a surgeon known the world over for inventing a revolutionary technique for repairing large abdominal hernias (still one of the most widely used techniques today) reports (Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach) about the 3% of CUTANEOUS LEMBAL NECROSIS (see the first photo above...)
  3. Zukowski et al. overall describe the appearance of postoperative complications (non-secondary: epidermolysis, skin necrosis, wound infections, chronic neuralgia...) in 15% of operated patients. FIFTEEN PER CENT.

I will not bore you any further. All this is to say that magicians do not exist in surgery. The 0% of complications does not exist. The 100% of successes does not exist. There is the surgeon's commitment to take all possible measures to minimise postoperative problems. There is the experience of the surgical team (it is not the same to have performed 10 endoscopic REPA repairs, or 10 abdominoplasties, or to have done 100). There is professional honesty. For example, I always warn patients who come to me for abdominal wall pathology that there are postoperative complications to consider:

  • Relapses after REPA: approximately 2%; after inguinal hernioplasty: less than 5%
  • Seromas after REPA: approximately 7%
  • Prosthesis infections: very few (I had only one) but possible

just to give a few examples. As always (and patients usually do not know this) the success of an intervention is determined at 90% BEFORE the intervention itselfand depends on correct patient selection, the choice of the most appropriate technique in each case (it is called 'tailored surgery') and the adoption of all necessary measures, before and after surgery, to reduce complications (pre-operative gymnastics, bandages, drug treatment, etc.). 

A complication is not a defeat, nor does it necessarily call into question the ability of the operator: it is always a multifactorial eventdifficult to predict, in which the "patient-side human component" plays an important role (e.g. diastasis is an expression of collagen disease: probably in patients in whom diastasis recurs the disease is particularly advanced), as does the surgical technique choice (Is the plication of the recti under tension? Was a net used? Does the patient have an adipose apron or an excess of skin, for which abdominoplasty is indicated, or does she not have one and therefore there is no indication for abdominoplasty? Are you willing to accept the scarring results of the operation or its degree of invasiveness? Have we decided to operate on an obese patient? One on whose postoperative compliace - i.e. the ability, or willingness, to carry out medical orders in the postoperative period - do we have any doubts? What are the inherent limitations of the proposed technique, and is there a better technique? Is the technical solution proposed by the surgeon the best for the surgeon or the patient?).

Remember all these things when your surgeon proposes the his solution for your rectus diastasis.

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