Reply

Sir: I appreciate the letter by Drs. Repta and Hunstad. They point out that they have identified a group of patients whose abdominal wall laxity is so marked that merely correcting their diastasis will lead to undercorrection of their abdominal protrusion. They refer to this finding as “global myofascial laxity.” In doing so, they have perceptively addressed an important aspect of abdominal wall reconstruction and diastasis recti repair: laxity. The authors proceed to describe their method of diastasis repair, which extends well lateral to the medial borders of the rectus muscles and is performed under muscular relaxation. The authors’ clinical findings lend support to my conclusion in the article entitled “Diastasis Recti: Clinical Anatomy”1 that, “contrary to current thought, abdominal wall protrusions are caused by the stretching of the entire abdominal wall and not only the linea alba.” The issue of the laxity of the musculofascial abdominal wall has been addressed at some length in my previous article on this subject, “Liposuction Abdominoplasty: An Evolving Concept.”2 In it, “the lax (or overstretched) abdominal wall” was defined as an “envelope that is larger than its contents and capable of accommodating more volume without additional stretching.” In addition, in that article, a detailed description was included of my approach to preoperative and intraoperative assessment of laxity. Because I continue to perform all my abdominoplasty procedures under local anesthesia, I have the opportunity to evaluate the laxity of the muscular abdominal wall under conditions that are as close to physiologic as possible. During surgery, laxity is assessed as the degree of tension required to approximate the rectus fascia until the abdominal wall feels tight and appears flat. I have also determined for myself a scale for laxity: grade I denotes minimal laxity, grade III denotes a very lax abdomen, and grade II is somewhere in-between. My opinion about the intraoperative assessment of laxity differs from that of Drs. Repta and Hunstad. In my opinion, the intraoperative assessment and repair of diastasis under muscle relaxation may tend to overcorrect fascial laxity. Therefore, I had devised a segmental approach to diastasis repair, in which only the most protruding segment of the abdominal wall is repaired. I believe that this segmental approach satisfies the requirements for musculofascial repair and prevents unnecessary recurrences of abdominal protrusions. My technique for diastasis repair is similar to that of Drs. Repta and Hunstad in that the fascial plication is confined to the anterior fascia and extends beyond the medial edges of the recti muscles. In addition, interrupted, figure-of-eight sutures (no. 1 Vicryl; Ethicon, Inc., Somerville, N.J.) in one or two layers add a vertical tightening component to the otherwise horizontal repair. DISCLOSURES The author has no financial interest in any of the products, devices, or drugs mentioned in this reply or in the article being discussed. Daniel Brauman, M.D., M.B., B.S. Weill Medical College of Cornell University White Plains, N.Y.