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Hello community, how are we today. Enrique Villanueva, musculoskeletal interventional radiologist

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and soft tissue specialist as an advisor for Isaacs. In recent years and since

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2018 we have learned the aesthetic view of plastic surgeons and what they really need

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to be able to perform a personalized anatomical marking. We have evolved that to

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be able to understand then what diastasis of the Linea Alba is. And something very innovative which is the diastasis

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of the semilunar lines, something that was not described and that we can see by ultrasound now,

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How to really mark pre and post surgery? How to evaluate the cellular tissue?

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Where is Camper? Where is Scarpa in liposuction? All this we can understand

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using a high resolution ultrasound such as the L15 or a Clarius L20.

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In this way we can also. If you do grafting, evaluate the vascular pedicles to

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be able to do the fat graft. In this episode we are only going to see how to evaluate the

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linea alba, the rectus abdominis and how you can mark all the part of the abdominal

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wall to be able to do your anatomical and high precision marking procedure with the

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ultrasound. Important then in abdominal wall to be able to identify that in plastic surgery and in

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abdominal wall procedures we divide the abdominal wall into supraumbilical and infraumbilical.

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We are going to work and mark a bit everything that is supraumbilical, since there are very important points

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like the Linea Alba. We are going to see the rectus abdominis, semilunar, external oblique,

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diastasis of the semilunar line. And we are also going to see if there is NOA fat which is the

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NO FAT, which is that retroperitoneal fat. And we are going to identify then the anterior and

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posterior belly of the rectus abdominis where you can inject. We are going to identify if there is Camper

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Scarpa in this procedure and the thickness of the subcutaneous cellular tissue. So in the midline

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we are going to start with our L15 transducer. As always, please. One centimeter

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below the line or surface anatomy reference in abdominal wall is the peritoneum.

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It is important that we always locate the peritoneum and there we are going to leave one centimeter of

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depth. In this way we are going to be able to have a certainty of what we are evaluating and

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we are going to be able to then identify all the structures that we want to evaluate. We begin supraumbilical

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we see how our left and right rectus abdominis looks, we see how

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the distance of our Linea Alba looks at this level. And

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it is important that for surgery if you want to do a very high definition surgery,

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a complete body definition the linea alba or the average over 2.5

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centimeters, the distance over 2.5 centimeters. That is called diastasis. Ready? Here

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we are going to measure the averages then. We continue in the middle third. We see our linea alba again.

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We measure again. Here we have 15.4 millimeters. We continue going up and here

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we are already going to the subxiphoid area. We see on the right side and on the left side how the

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costal insertion of the rectus abdominis is already seen and we see a very

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small linea alba of less than 3.3 millimeters. In this way we already reviewed our

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Linea Alba. Here we see at the subxiphoid level how there is a thickening of the retroperitoneal

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fat or the fat called. No fat. That is important because if you are going to do

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a liposuction, lipo-marking and are going to define the contour of the patient, it is likely that she will also

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go to nutrition and change habits. And this fat is a fat that has an important metabolic context

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Now we go and return supraumbilical and we are going to analyze the

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subcutaneous cellular tissue. And never stop looking at your Linea Alba, because the Linea Alba can

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have a solution of continuity and that is a gastric hernia, evaluate it always dynamically.

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We can tell the patient to push out the abdomen or to inflate the abdomen or to

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use force to contract and you will see how it bulges through there our hernias. In this case we do not

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have it subcutaneous tissue. We are going to measure the subdermal space to the fascia of the

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Linea Alba and this is our thickness of the subcutaneous cellular tissue. You can evaluate the

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thickness of the subcutaneous cellular tissue of the entire abdominal wall and in that way you can

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do a qualitative and quantitative control of the thickness of the subcutaneous cellular tissue and be able to

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evaluate during the surgery and after the surgery, what is the final thickness that this

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fat has. It is important and we are averaging that an adequate healthy thickness is

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at least 1.5 millimeters of thickness below the skin. That would be the

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ideal so that we can have a fat that metabolically generates security

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for the patient. We continue observing then the subcutaneous cellular tissue and as you can see, two

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hyperechoic lines are seen at the level of the subcutaneous cellular tissue. These two hyperechoic lines

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one and two are Camper and Scarpa, and everything that is below the

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Scarpa is deep fat. Many surgeons around the world do Deep Plane. Liposuction.

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And it is important to know that thickness. In that way they will be able to understand what technology they can

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use if they do not use technology or how much liposuction to be able to do the lipo-marking in that area

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your patient requires. In this way we have evaluated midline important

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and do not forget in the midline and periumbilical. We have to identify what I call

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masses of the abdominal wall. The masses of the abdominal wall with the boom of the Ozempic. We have to

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identify if there are tracts and thickening of the subcutaneous cellular tissue associated with injections

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of fat tissue, fat tissue, like in the PICs or insulin dependents. And if they are

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women, we always have to infraumbilical identify if it is possible or probable that these

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lesions in subcutaneous cellular tissue have to do with endometriosis. So anatomical awareness

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also has to do with pathological anatomical awareness. Let's look for endometriosis,

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which probably that could be one of the causes of weight changes in your patient. And it is

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important because you sometimes in surgery think it is a fibrosis now in midline

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supraumbilical. I go periumbilical and I stay with a rectus abdominis. Look how rectus

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abdominis looks with transverse traces. If we are transverse, I turn clockwise

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and there we are going to observe our metamer. Look how the transition looks. There

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we see an echogenic line that divides the rectus abdominis into superior belly and inferior belly.

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I'm going to go cephalad, yes, and there we're going to see how there's a transition and we see

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our first transition. And that is a metamer. So, what do we do in the midline?

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We can mark our first metamer. In this way we are going to be able to start making

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anatomical marking. We continue cephalad, rectus abdominis in longitudinal.

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And look, here our metamer appears again in the midline. And there then we

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mark again where metamer number two is located. In this way we are going to

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start looking for the metamer. Remember, we begin periumbilical. I see our rectus

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abdominis, we rotate clockwise, we see how the superior belly and inferior belly of the rectus

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abdominis are. I go cephalad and there I begin to see the rectus transitions. And

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those are the metamers. Perfect, now I return. Periumbilical.

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I go towards the outer face, towards the flank and look how we are going to see this second transition and this

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transition between rectus abdominis, transversus, internal oblique and external oblique is what

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forms our semilunar line. An important tip. If you inject and do a

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block between the transversus and the internal oblique, it is a total block and that can improve the

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surgical experience of your patient. Now, do not forget that in your L15 ultrasound

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we also have an augmented reality mode, an artificial intelligence mode

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where it can help you understand the anatomical structures, mainly in

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patients who perhaps have sarcopenia and that we have a structure very mixed between the

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fat and between the muscles. This is one of the advances of how we can mark the abdominal wall

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in the midline. Remember to evaluate diastasis hernias. Superficial fat masses,

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deep fat.