Omphaloplasty based on an isosceles triangle with double fixation in abdominoplasty
Onfaloplastia em triângulo isósceles e com dupla fixação na abdominoplastia

INTRODUCTION

Abdominoplasty or abdominal dermolipectomy was described by Kelly¹ in 1899 and is among the most common plastic surgery procedures.

Liposuction combined with abdominal dermolipectomy was described by Avelar² in 1998 and has subsequently been accepted as a routine procedure by other authors^3-6.

Despite advances in various techniques and adaptations of this procedure, there is still no unanimous agreement on the creation of an umbilical scar, which remains a major challenge in abdominal plastic surgery.

The umbilical scar divides the human body exactly in the middle, according to Marcus Vitruvius⁷, a Roman architect, and this concept was perfected by Leonardo da Vinci in 1490. The evolution of omphaloplasty began in 1924, when Frist⁸ performed the first transposition of the umbilicus. Since then, many variations have been used in an attempt to approximate the appearance of the original umbilicus.

In the 1970s, Baroud⁹ and Regnaut⁷ used horizontal incisions in the abdominal flap, while in 1978, Avelar¹⁰ used a star-shaped incision.

Several techniques have been described: Juri et al.¹¹ proposed the use of a V-shaped incision, Massiha et al.¹² added a circular umbilical incision and a triangular incision in the abdominal flap, Malic et al.¹³ used an inverted U-shaped incision in the flap, and Castillo et al.¹⁴ used Y-shaped de-epithelized skin flaps.

Several authors^{2,7,8,9,13,15} have used various geometric shapes (Mercedes star, lozenge, ellipse, cross, rectangle, shield shape, infinity logo, and y-shape) in an attempt to obtain a more natural result in the creation of the umbilicus, but there is still no consensus on the best technique.

OBJECTIVE

To demonstrate the applicability and satisfaction with omphaloplasty based on an isosceles triangle with double fixation in abdominoplasty.

METHODS

This study included 97 female patients, with a mean age of 45 years (range, 25 to 65 years) who underwent omphaloplasty between January 2014 and December 2015.

The surgeries were performed at the STK-Plastic Surgery Center in Belo Horizonte, MG, by the same surgeon.

All patients received the same pre-, intra-, and postoperative care.

The guidelines of the principles of Helsinki were followed.

Surgical technique

The abdominal flap was freed using an isosceles triangular incision, with an upper base measuring 2 cm and sides measuring 2.5 cm (Figure 1A and B).

Figure 1 - A: Demarcation of the umbilicus still fixed to the abdominal flap; B: Upper base of the umbilicus measuring 2 cm, with sides measuring 2.5 cm.

Figure 1 - A: Demarcation of the umbilicus still fixed to the abdominal flap; B: Upper base of the umbilicus measuring 2 cm, with sides measuring 2.5 cm.

The abdominal flap was provisionally fixed in the suprapubic region (Figure 2).

Figure 2 - Provisional fixation of the dermal-fat flap in the pubic area.

Figure 2 - Provisional fixation of the dermal-fat flap in the pubic area.

The demarcation of the new umbilical implantation site began with a linear, 2-cm horizontal incision in the abdominal flap in place of the original projection of the umbilicus in the skin (Figure 3).

Figure 3 - Linear, horizontal, 2-cm incision on the abdominal flap at the level of the projection of the original umbilicus in the skin.

Figure 3 - Linear, horizontal, 2-cm incision on the abdominal flap at the level of the projection of the original umbilicus in the skin.

A triangle measuring approximately 0.5 cm was then removed from the middle third of the lower border of this incision (Figure 4 A and B).

Figure 4 - A and B: Removal of a triangle measuring approximately 0.5 cm from the middle third of the lower edge of this incision.

Figure 4 - A and B: Removal of a triangle measuring approximately 0.5 cm from the middle third of the lower edge of this incision.

Once the skin incision was made at the new umbilical site, the flap fixation site was released to the suprapubic region. This flap was lifted to expose the detachment area and umbilicus. Fixation was performed with 3-0 monofilament nylon between the medial region of the upper edge of the new umbilical incision and the aponeurosis of the rectus abdominis at the upper base of the umbilical pedicle (Figures 5 and 6).

Figure 5 - Suture fixation with 3-0 monofilament nylon between the medial region of the dermis in the upper portion of the umbilical incision with the aponeurosis of the rectus abdominis.

Figure 5 - Suture fixation with 3-0 monofilament nylon between the medial region of the dermis in the upper portion of the umbilical incision with the aponeurosis of the rectus abdominis.

Figure 6 - Mounting the upper abdominal flap to the cephalic base of the umbilical stump.

Figure 6 - Mounting the upper abdominal flap to the cephalic base of the umbilical stump.

Next, the upper portion of the new umbilical incision was attached with a transcutaneous U-point to the upper portion of the umbilicus (Figure 7), with the knot buried in the umbilicus.

Figure 7 - Transcutaneous U sutures joining the central portion of the umbilical base in the subdermal region of the upper portion of the umbilical incision.

Figure 7 - Transcutaneous U sutures joining the central portion of the umbilical base in the subdermal region of the upper portion of the umbilical incision.

The umbilicus was transferred through the incision in the abdominal flap (Figure 8).

Figure 8 - Transfer of the umbilicus through the abdominal flap incision.

Figure 8 - Transfer of the umbilicus through the abdominal flap incision.

The angles of the umbilical triangle correspond to the angles of the flap incision and are fixed with 4-0 nylon monofilament (Figure 9).

Figure 9 - Fixation of the angles of the umbilical triangle to the angles of the skin incision.

Figure 9 - Fixation of the angles of the umbilical triangle to the angles of the skin incision.

Suturing of the umbilicus at the new site was completed with interrupted U sutures, using 4-0 monofilament nylon with knots buried in the umbilicus (Figure 10).

Figure 10 - Fixation of the umbilical scar on a new bed using interrupted U sutures.

Figure 10 - Fixation of the umbilical scar on a new bed using interrupted U sutures.

Finally, the inferior portion of the new umbilical incision was fixed in the abdominal flap to the aponeurosis of the rectus abdominis in the caudal portion of the umbilical pedicle, avoiding displacement of the umbilicus in the postoperative period and minimizing traction on the umbilical scar (Figure 11).

Figure 11 - Fixation of the infraumbilical portion of the abdominal flap to the aponeurosis of the rectus abdominis in the caudal portion of the umbilical stump.

Figure 11 - Fixation of the infraumbilical portion of the abdominal flap to the aponeurosis of the rectus abdominis in the caudal portion of the umbilical stump.

The abdominal flap was then pulled up to the suprapubic line for definitive fixation. Silicone umbilical belts were used in all patients.

RESULTS

The 97 patients were followed for up to 12 months after classic abdominal dermolipectomy with omphaloplasty based on an isosceles triangle with double fixation. A questionnaire was used for self-evaluation (Table 1) at 1 year postoperatively. Patients were asked about the degree of satisfaction with the umbilical abdominoplasty scar and whether they would recommend the surgery to a friend; they were also encouraged to write any comments related to the surgery.

Table 1 - Patient self-assessment of satisfaction.

In all, 85.5% of the patients were very satisfied with the final outcome of the procedure, 8.2% were satisfied, and 6.1% were slightly satisfied. With respect to the umbilical scar, 82.5% were very satisfied, 10.3% were satisfied, and 7.2% were slightly satisfied.

Only 11 patients commented on the size of the abdominoplasty scar and 18 complained of severe postoperative pain.

The surgeon assessed these 97 abdominoplasty patients at 90, 180, and 360 days postoperatively. At 1 year, the patients were evaluated for umbilical position on the abdomen, type of scar (atrophic, hypertrophic, and contracted), and scar depth; the overall results were satisfactory, with a low rate of complications (Figures 12, 13, 14, 15).

Figure 12 - A: Preoperative appearance; B: Immediate postoperative appearance.

Figure 12 - A: Preoperative appearance; B: Immediate postoperative appearance.

Figure 13 - A: preoperative appearance; B: Postoperative appearance at 3 months.

Figure 13 - A: preoperative appearance; B: Postoperative appearance at 3 months.

Figure 14 - A: preoperative appearance; B: Postoperative appearance at 6 months.

Figure 14 - A: preoperative appearance; B: Postoperative appearance at 6 months.

Figure 15 - A: preoperative appearance; B: Postoperative appearance at 12 months.

Figure 15 - A: preoperative appearance; B: Postoperative appearance at 12 months.

The complications are listed in Table 2.

Table 2 - Scar complications.

DISCUSSION

The degree of satisfaction with abdominoplasty is usually high because of visible postoperative improvement, compared to the appearance of an abdomen affected by multiparity and fluctuations in body weight.

A poor-quality umbilicus compromises satisfaction with abdominoplasty, and the choice of an appropriate technique is a challenge for the plastic surgeon.

The technique described herein, with abdominal flap fixation to the aponeurosis of the rectus abdominis, superior and inferior to the umbilicus, avoids traction on the umbilical scar, favors the healing process, and promotes a natural appearance, approximating that of an ideal umbilical scar.

The 7 patients who reported poor satisfaction with the umbilical scar underwent a second surgical procedure for correction. This group included 2 patients with an enlarged scar, 2 with a hypertrophic scar, and 3 with scar contraction. Another patient with contraction had an unsatisfactory outcome, but the evaluation was made by the surgeon alone. All other patients reported being satisfied or very satisfied with the umbilical scar.

The 5 patients who would not recommend the surgery to a friend thought that the scar would be smaller, despite being given preoperative information. These 5 were among the 8 who reported only slight satisfaction with the abdominal scar.

Only 11 patients reported expecting a different appearance. Another 18 reported postoperative pain.

CONCLUSION

Omphaloplasty based on an isosceles triangle with double fixation was easy to perform and resulted in a more natural appearance, with overall patient satisfaction.