URLD ( Ultrarapid Limited Dissection Abdominoplasty ) Is Safe with Caesarean Section

Abdominoplasty is not advisable with caesarean section because of high incidence of complications. We have changed the technique of proper abdominoplasty to ultrarapid limited dissection abdominoplasty in 25 women undergoing caesarean section successfully and found that there was no incidence of any complication usually described with proper abdominoplasty, and we recommend that limited dissection abdominoplasty can be combined with caesarean section.


Introduction
Flat abdomen is the desire of every female.It is distorted because of pregnancy when abdominal muscles and fascia are stretched, along with skin.There may be fat deposition of different grades.
After delivery the abdomen becomes unsightly in almost all females.Imposed upon this, the scar of caesarean adds the ugliness of the abdomen.
There are two reports in literature which depicts that caesarean section should not be combined with any tummy tuck or abdominoplasty procedure as it is fraught with danger (1.2).We have changed the concept and proved that abdominoplasty can be safely combined with caesarean section by successfully combining caesarean section and abdominoplasty in 25 patients but changing the technique of abdominoplasty to ultra rapid limited dissection abdominoplasty.

Material and Method
We have done ultra rapid limited dissection abdominoplasty in 25 women undergoing caesarean section excluding the patients in whom the indication of caesarean section was fetal distress.First the incision was made which was lower than standard pfannestiel (Figures 1-4).After making the incision the flap of abdominal wall consisting of skin and subcutaneous tissue was raised.Both procedures had taken not more than 5 minutes.After raising the flap the gynaecologist had to complete the caesarean section and stitch back up to peritoneum and posterior rectus sheath.At this point we took over from gynaecologist and did reefing of anterior rectus sheath and excised the skin from the skin flap which was raised already.Only that much skin was excised which after wards gave tensionless closure.It was very important consideration.Too much skin was not excised.No transposition of umbilicus was attempted.The reefing of anterior rectus sheath and skin excision had not taken more than 10 minutes.

Result
Scar was low in every patient and all patients were satisfied with scar.There was no wound infection, no skin dehiscence.Along with this the looseness of abdomen was reduced and patient got comparatively flat abdomen.There was residual looseness in all women but they were happy as all of them were of opinion that had the abdominoplasty was not done with caesarean they would not have got to get it done in nonpregnant state.

Discussion
The flat abdomen is the quest of every female.There is no doubt that pregnancy spoils the abdomen.International literature does not agree with abdominoplasty with caesarean section [1].Ali in his study of 50 patients found that nine patients (18%) developed wound infection; three of them (9%) developed wound dehiscence.It is high incidence of complications and would demand that standard abdominoplasty should not be combined with caesarean section.In our study there was no wound infection or wound dehiscence.It was because we have not done standard abdominoplasty and resected only that much skin after which stitching was not under any tension.In a proper abdominoplasty the skin is stitched under some tension and may necrose giving rise to infection and wound dehiscence.Apart from this other factor might be that we have not taken prolonged time in doing abdominoplasty which was just 15 minutes extra, it might also be a factor in avoiding infection because if interior of abdomen is exposed for prolonged time to external environment, incidence of infection might increase.In    their study, six patients (12%) developed lower abdominal skin necrosis; three of them (6%) were treated conservatively and healed by secondary intention, while surgical debridement and secondary sutures were needed in the other three patients (6%).In our study there was no necrosis, which had already been explained by limited resection and tension free closure.Residual abdominal skin redundancy was found in 9 patients (18%) in their study but in our study all of the patients had residual skin redundancy which can be explained because we had done limited dissection abdomniplasty and had already explained to patients that it was not proper abdominoplasty and aesthetic results would be suboptimal.However suboptimal aesthetic result without complications is better than achieving ideal aesthetic result but more complications.Just adding 15 minutes procedure and no complications, procedure would be acceptable to more and more women all over the world, later on if they wish, they could go for proper abdominoplasty.In another study also [2] similar complications were reported when they combined abdominoplasty with caesarean section.We agree with both studies and are of opinion that full abdominoplasty should not be combined with caesarean section however limited dissection ultra rapid abdominoplasty can be safely combined with caesarean section.
This was not true to combining abdominoplasty with hysterectomy which had been described by all authors as safe [3]- [5].

Conclusion
Ultra rapid limited dissection abdominoplasty can be safely combined with caesarean section.There is no complication except that aesthetic results are less than ideal.Patients can go for proper abdominoplasty at later date in non-pregnant state if they are not satisfied with aesthetic results.But our patients never expressed desire to undergo proper abdominoplasty afterwards, because if that was so they might not have opted for abdominoplasty with caesarean section.They have opted for ultra rapid abdominoplasty with caesarean fully knowing that the aesthetic results would be less than ideal and that their husband would never agree for proper abdominoplasty in non-pregnant state as an independent procedure.