INTRODUCTION
Abdominoplasty is a type of plastic surgery that is carried out for essentially
aesthetic purposes. In recent years, it has become a common procedure among
women who desire to improve their body image, self-esteem, mental health, sexual
relations, and quality of life. One of the most important steps in this surgical
procedure is the reconstruction of the umbilicus.
The characteristics of the umbilicus include a depressed scar surrounded by skin
folds, located in the anterior abdominal wall, approximately 18-23 cm from the
vulvar commissure, 4 cm above and 2 cm below the horizontal line that passes by
the two anterior superior iliac spines1.
The umbilicus has an elliptical shape in the vertical direction, or T-shape with
a longitudinal axis that passes vertically in the midline. The mean diameter of
the umbilical cord ranges from 1.5 to 2 cm, with a conical depression whose
vertex is attached to the anterior muscular wall of the abdomen2.
Anatomical studies performed by Dick in 19703 showed four fibrous cords connected to the umbilical surface,
which are responsible for the displacement of the umbilicus in the posterior
direction. These fibrous structures originate from traces of the umbilical vein,
the urachus, and the two umbilical arteries.
The umbilicus is the only natural scar on the body, and is therefore an important
and essential aesthetic component of the abdomen. Given that customs and fashion
increasingly stimulate the exposure of the abdomen, the secondary umbilical scar
of dermolipectomy is a frequent concern of surgeons and patients.
The concern with aesthetics, however, does not coincide with the development of
abdominoplasty. In the 19th century in France, some techniques removed the
umbilicus alongwith the abdominal flap4.
Weinhold Zentralb, in 1909, was the first to retain the umbilicus during
abdominal dermolipectomy5.
In 1924, First performed the first umbilical transposition. Since then, many
geometric shapes were attempted to obtain a scar that was close to the natural
shape of the umbilicus. In 1931, Flesch-Thebesius and Weisheimer preserved a
skin triangle in the umbilicus6,7. Prudente, in
19438, and Andrews, in 19569, performed a transposition through
circular incisions, leaving it in a skin cylinder. In 1957, Vernon10, also using a transposition of circular
forms observed many stenoses at the umbilicus, which became challenging.
In 1979, Avelar11 presented his technique
wherein multiple “Vs” shaped incisions were made on the inner face of the
umbilicus, breaking the scar into three flaps. In this sense, other Brazilian
authors, such as López-Tallaj & Gervais, in 2001, Saldanha et al., in 2003,
D’Assumpção, in 2005, and Mello & Yoshino in 200912-15,
also proposed the use of various geometric shapes in search of the “ideal
umbilicus”.
Since the introduction of classic abdominoplasty, the umbilicus is preserved in
its original position and is refixed through a hole in the abdominal flap. Even
with the advancement of many techniques, the umbilicus continues to be fixed in
the same manner.
In modern abdominoplasty, several forms have been created, with respect to both
the umbilical scar and the cutaneous flap opening, with the sole objective of
obtaining a result that resembles the natural umbilicus. Round, oval,
drop-shaped, triangular forms with upper or lower base, and lozenges have been
proposed. However, they all have a scar that surrounds the entire perimeter of
the umbilicus16,17.
OBJECTIVE
To minimize the unsightly scarring effects associated with omphaloplasty, we
propose the use of a technique that has demonstrated positive operative results
and results in a more natural scar and with a lower rate of postoperative
complications.
METHOD
In this study, 88 female patients between 27 and 62 years of age, with a mean age
of 43 years, underwent surgery using the “Y”/“V” technique between June 2012 and
May 2015.
Our marking was performed with the patient in an upright position, the midline
being marked in the preoperative period and reinforced after asepsis of the
patient and the operative region to prevent possible lateral displacement of the
neoumbilicus (Figure 1).
Figure 1 - Surgical marking.
Figure 1 - Surgical marking.
All procedures were performed after epidural and intravenous sedation
administered by the team anesthesiologist. After asepsis, the surgery began with
the use of a no. 15 scalpel blade on the skin and was followed by the detachment
of the abdominal flap with an electric scalpel. The detachment extends up to the
umbilicus, with the umbilicus being isolated with a round-shaped scalpel blade
no. 15 (Figure 2).
Figure 2 - Isolation of the umbilicus.
Figure 2 - Isolation of the umbilicus.
After isolation of the umbilicus, we continue with the elevation above the
umbilicus up to the xiphoid appendix, forming a tunnel without extending this
detachment laterally to prevent vascularization problems of the flap. After
completing the detachment, we raise the head of the patient and evaluate the
amount of the flap that will be resected based on the previous marking. Once the
flap is removed, and plication of the rectus abdominis is performed, we
specifically perform the proposed technique.
The fixation of the umbilical stump is performed with separate sutures in the
aponeurosis of the rectus abdominis muscles, being evaluated based on its
mobility based on the thickness of the panniculus resulting from the definitive
abdominal flap (Figure 3). The rounded
resected umbilical island is modeled with curved scissors to attain a “Y” shape,
with the removal of a skin triangle in the cephalic portion and rectified on its
right and left sides to form a “Y” (Figures 4 and 5).
Figure 3 - Fixed umbilical stump.
Figure 3 - Fixed umbilical stump.
Figure 4 - Umbilical island in the shape of a “Y”.
Figure 4 - Umbilical island in the shape of a “Y”.
Figure 5 - Modeled umbilical island.
Figure 5 - Modeled umbilical island.
After fixing the abdominal flap in the lower scar, marking the location of the
neoumbilicus in the abdominal skin flap is held in the form of “Y,” by using a
maneuver that introduces the hand by the lateral opening of the flap, where, by
contiguity, the umbilicus is palpated, and this is projected into the skin after
the introduction of a 25 × 7 needle in the direction of the index finger of the
surgeon, which is on the umbilical island fixed to the aponeurosis, without
which the surgeon can be injured (Figure 6).
Figure 6 - Maneuver that enables the location of the umbilicus.
Figure 6 - Maneuver that enables the location of the umbilicus.
This point is marked on the lower portion of the surgeon’s finger. After this
first point, a new marking is made with methylene blue at a distance of 1.0 to
1.5 cm in the middle line above point 1 (depending on the thickness of the
panniculus and the width of the patient to avoid large or small neoumbilicus on
the patient’s abdomen). Thereafter, two lateral and superior points are marked
between 0.5 and 1.0 cm of point 2, thus forming the “Y” proposed in this
technique (Figure 7).
Figure 7 - Marking with methylene blue.
Figure 7 - Marking with methylene blue.
At this point, the skin is incised on top of the “Y” marking (Figure 8), and a fat cylinder is removed
from the already fixed abdominal flap (Figure 9). To prevent umbilical stenosis, two “slivers” of the lateral flaps
of the Y are removed to accommodate the umbilical suture better (Figure 10).
Figure 8 - Incision on top of the “Y” marking.
Figure 8 - Incision on top of the “Y” marking.
Figure 9 - Withdrawal of a fat cylinder from the previously fixed abdominal
flap.
Figure 9 - Withdrawal of a fat cylinder from the previously fixed abdominal
flap.
Figure 10 - Withdrawal of “slivers” of the lateral skin flaps of the “Y”
incision.
Figure 10 - Withdrawal of “slivers” of the lateral skin flaps of the “Y”
incision.
The umbilical suture begins with the triangular skin flap, formed by the incision
in “Y” next to the vertex of the “V” removed on the umbilical island, allowing
the descent of this flap and upper intraumbilical accommodation, which provides
the concealment of the scar at this level (Figure 11). Subsequently, the bottom vertex of the umbilical island is fixed
to the bottom vertex of the “Y” incised in the abdominal flap. Two lateral
sutures are held next to the upper lateral vertices of the umbilical island and
the lateral sides of the “Y” incised in the skin (Figure 12).
Figure 11 - Umbilical sutures.
Figure 11 - Umbilical sutures.
Figure 12 - Sutured umbilicus.
Figure 12 - Sutured umbilicus.
After these four pillars of fixation, the suture is completed with two more
sutures at each side and two sutures between the initial triangular flap and the
lateral vertices of the Y. 4-0 colorless nylon sutures are used.
Finally, with respect to the neoumbilicus, there is an open Y-shape, with its
triangular caudal part and the cephalic part embedded within the panniculus of
the abdominal flap, which provides more aesthetics to the neoumbilicus and a
reduction in abdominoplasty stigma with a more apparent and sutured umbilicus
(Figure 13).
Figure 13 - Immediate postoperative aspect.
Figure 13 - Immediate postoperative aspect.
Finally, wound dressing was performed using neomycin and the introduction of a
ball-shaped gauze, which was replaced by a silicone umbilical mold after 48 h
after surgery. The umbilical sutures are removed after 7 days, and the condition
of scar is observed at this time.
RESULTS
A significant decrease in cases of umbilical stenosis was demonstrated in
patients who underwent surgery in our study compared to the incidence noted with
circular, oval, and other techniques. Additionally, a more natural shape is
observed compared to an abdomen without a scar(Figures 14 to 19).
Figure 14 - Pre-operative aspect.
Figure 14 - Pre-operative aspect.
Figure 15 - Immediate postoperative aspect.
Figure 15 - Immediate postoperative aspect.
Figure 16 - 15 day postoperative aspect.
Figure 16 - 15 day postoperative aspect.
Figure 17 - 30 day postoperative aspect.
Figure 17 - 30 day postoperative aspect.
Figure 18 - 60 day postoperative aspect.
Figure 18 - 60 day postoperative aspect.
Figure 19 - One-year postoperative aspect.
Figure 19 - One-year postoperative aspect.
Complications include suture dehiscence in three cases, wherein we observed that,
in these patients, the panniculus was denser (3.4%), umbilical stenosis
developed in 1 patient (1.13%), color changes in the scar occurred in 4 patients
(4.54%), keloid scars developed in 2 patients (2.27%), which were surgically
corrected after 6 months.
Altogether, 11.34% of patients experienced complications; thus, we conclude that
the technique was efficient and reduced umbilical scarring, requiring constant
studies and adaptations to prevent the complications noted above.
It is important to note that a thorough physical examination and a good
indication for surgery will lead to better results, considering all the factors
involved during surgery.
DISCUSSION
There are several techniques for the construction of the neoumbilicus. The main
techniques used are a circular shape, “V” shape and other designs proposed by
several authors. To date, in our experience, the more harmonious and natural
results, from the aesthetic point of view, are obtained with non-circular
designs because they result in less stenosis of the umbilical scar.
Our proposed technique is easy to perform, with good aesthetic results, and a
more natural postoperative abdomen after dermolipectomy with regard to the
acceptance by patients of the resulting umbilical scar.
The final open Y format is closer to the natural aspect of an abdomen that has
not been operated on.
Other authors perform neo-omphaloplasties in non-circular forms, with
satisfactory results in relation to the aesthetic natural look of the
neoumbilicus.
CONCLUSION
The technique reported in this study is a good alternative to other techniques
used in the treatment of the neoumbilicus. Long-term monitoring and increasing
the number of cases will be important in evaluating the technique and defining
its use.
This proposed technique is simple to implement, providing a better long-term
aspect of the umbilicus, with improved natural results and prevents frequent
stenoses of the umbilicus that occurs with techniques that attempt to achieve a
round-shape. It was called “Y” due to the shape of the incision on the skin of
the abdominal flap for the formation of the neoumbilicus.
We suggest its use after the analysis of these cases, which proved to be
satisfactory for both the surgeon and the patients who submitted to abdominal
dermolipectomy, thus increasing the technical and tactical arsenal of the
clinical surgeon.
COLLABORATIONS
VHMG
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; conception and design of the study;
completion of surgeries and/or experiments; writing the manuscript
or critical review of its contents.
|
VAG
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; writing the manuscript or critical
review of its contents.
|
FAG
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; writing the manuscript or critical
review of its contents.
|
PCCCJ
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; conception and design of the study;
writing the manuscript or critical review of its contents.
|
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1. Universidade Federal de Minas Gerais, Belo
Horizonte, MG, Brazil.
2. Hospital Mater Dei, Belo Horizonte, MG,
Brazil.
3. Sociedade Brasileira de Cirurgia Plástica, São
Paulo, SP, Brazil.
4. Clínica MC Médicos, Montes Claros, MG, Brazil.
5. Faculdades Integradas Pitágoras, Montes Claros,
MG, Brazil.
Corresponding author: Fernando de
Azevedo Gonçalves, Avenida Aida Mainartina, nº 100 - Ed. Veneza, Apto 105 -
Ibituruna, Montes Claros, MG, Brazil. Zip Code 39408-007. E-mail:
feazegoncalves@gmail.com
Article received: October 31, 2016.
Article accepted: June 22, 2018.
Conflicts of interest: none.