INTRODUCTION

Abdominoplasty is among the most popular cosmetic procedures in plastic surgery in recent years¹. Their search not only impacts body contouring issues, but also improves patients’ quality of life and self-esteem of patients².

From the perspective of body image, the navel is a key part since it has a definitive role in the aesthetics of the abdominal wall. Its absence, distortion, or poor healing compromises the surgical outcome³.

Due to its importance, the construction of the neoumbilicus, which aims to seek a natural position, in the midline, at the level of the superior iliac crests, with a minimal evident scar³, and 1.5 to 2 cm in diameter4, is a determining factor for postoperative success^5,6.

Several techniques have been described in the literature, but all with their limitations^7-10.

More recent options, which try to deepen the scar, not making it visible, present complications, such as a flattened navel¹¹.

Furthermore, neo-umbilical stenosis is a frequent complication in surgical tactics that aim to construct a small umbilicus or result in circular or concentric scars^12-15.

When the umbilical stump is long, it needs to be shortened, which may result in other complications, such as stenosis or discharge from the neoumbilicus¹⁶.

Due to the complexity of the issue and the search to improve and develop a surgical tactic with better results, Viterbo¹⁷ (1998) described the H-shaped technique for omphaloplasty. In it, using four rectangular flaps, there is the reconstruction of the lateral walls of the navel, with good results and lower rates of aesthetic complications.

OBJECTIVE

This article summarizes the surgical possibilities presented in the Revista Brasileira de Cirurgia Plástica (RBCP) in the last 20 years and reintroduces the surgical technique in H.

METHOD

In order to carry out a qualitative review of the literature, a study of publications in the RBCP from 2000 to 2021 was carried out.

Surgical technique

In the navel, which will be removed from the abdomen, we mark four lines in the longitudinal direction, from the bottom to the edges, creating a division of four equal parts in the umbilical circumference (Figure 1A). Next, two transverse lateral lines are drawn, deeply connecting the longitudinal lines, in order to delimit two lateral flaps, with the base having ¼ of the circumference of the umbilicus and the length half of the base, and these values may vary, for correct very deep navels (Figure 1B). Then, two more transversal lines are drawn, superficially joining the longitudinal lines (Figure 1C).

Figure 1 - Right side view: Four longitudinal lines are drawn from the bottom to the edges (A); two lateral transverse lines are drawn in a vertical plane, deeply joining the longitudinal lines (B); two transverse lines are drawn, superficially joining the longitudinal lines in a horizontal plane (C); a capital letter “H” is drawn where the new navel will emerge (D).

Figure 1 - Right side view: Four longitudinal lines are drawn from the bottom to the edges (A); two lateral transverse lines are drawn in a vertical plane, deeply joining the longitudinal lines (B); two transverse lines are drawn, superficially joining the longitudinal lines in a horizontal plane (C); a capital letter “H” is drawn where the new navel will emerge (D).

After making the incisions, we will release the navel as a “bow-tie,” with a central part and two lateral flaps. Then, a simple stitch is applied, leaving the thread long for easy flap location.

After displacement, traction, resection, and suture of the abdominal flap, we mark the place where the umbilicus will emerge, the design of the capital letter “H” inside a square that will have dimensions of ¼ of the umbilicus circumference (Figure 1D).

After incising the skin, we will have two flaps, one on the upper base and the other on the lower base. These flaps will have the same dimensions as the navel flaps, that is, a base equal to ¼ of the circumference of the navel and a length equal to half the base.

The abdominal wall and umbilicus flaps will be sutured to be perfectly interposed (Figure 2).

Figure 2 - Appearance at the end of the procedure in right lateral view: suture of the abdominal wall and umbilicus flaps (preferably with non-absorbable monofilament thread).

Figure 2 - Appearance at the end of the procedure in right lateral view: suture of the abdominal wall and umbilicus flaps (preferably with non-absorbable monofilament thread).

RESULTS

RBCP Articles

For the sum of the descriptors “omphaloplasty,” “umbilicus,” “neoumbilicus,” or “umbilicoplasty,” “umbilical scar,” or “neo-omphaloplasty,” 38 articles were found.

By analyzing the titles and abstracts, 7 articles were excluded, as they focused on post-great weight loss and pathological alterations of the navel or mini-abdominoplasty.

Due to the small number of articles that fit the 5 inclusion criteria, we decided to conduct a qualitative review, allowing the inclusion of articles with at least three of the five inclusion criteria.

Among those selected for abstract evaluation, 20 articles were excluded for not including at least three of the following criteria: patients’ age, follow-up time, description of the technique, complications, and report of satisfaction; in addition to excluding those that were just case reports or predominantly included patients after major weight loss.

In the end, 11 articles^18-28 were included for full reading and analysis by two independent researchers (BFMN and LVM), with only 7 having all five criteria, 1 having four criteria, and 3 having three. The summary of the data found is in Table 1.

Table 1 - Summary of article data included for full reading and analysis.

Article	No. of patients	Age	Time to follow-up	Satisfaction	Complications
Technique for umbilicoplasty, avoiding one of the main stigmas of abdominoplasties18	100	X	+ 3 months	Full of patient - 89%; Full of surgeon - 85%; Reasonable of patient - 11%; Reasonable for the surgeon - 13%; Patient dissatisfaction - 0%; Surgeon dissatisfaction - 2%.	2 cases - circular contracture of the new navel (2%).
Routine neo-omphaloplasty in abdominoplasties19	46	X	2 to 19 months	X	1 case - erasure of the scar (keloid scar) (2.1%); 3 cases - dehiscence (6.5%).
Triangular umbilicoplasty with dermal flap20	194	X	X	188 patients (96.91%) Had positive satisfaction; In 186 cases (95.88%) the surgeons had positive satisfaction.	5 cases - Epidermolysis in umbilical stump (10.8%); 3 cases - umbilical narrowing due to scar retraction (6.5%).
Technique with umbilical pedicle in a “kite” and incision of the skin of the abdomen in a “Y”21	31	28 and 57 years	6 months	bad 0; reasonable 3.2%; good 6.5%; very good 12.9%; Excellent 77.4%.	5 cases - epidermolysis of the stump (16.1%); 1 case - necrosis of the retail (3.2%); 3 cases - epidermolysis of creases (9.6%); 1 case - stenosis stigma (3.2%); 1 case - visible scar (3.2%).
Vertical incision umbilicoplasty: description of the technique and evaluation of satisfaction22	128	25 to 62 years	40 months	92.2% of the patients were very satisfied, and the technical evaluation by the evaluating surgeon attested to a degree of 88.8% satisfaction.	2 cases - umbilical scar suture dehiscence (1.5%); 4 cases - hypertrophic scar (3.1%); 2 cases - Stenosis (1.5%); 1 case - umbilicus necrosis (0.7%).
Omphaloplasty: Y/V technique23	88	27 to 62 years	36 months	It does not explain patient satisfaction.	3 cases - Suture dehiscence in (3.4%); 1 case - umbilical stenosis (1.13%); 4 cases - chromic alterations of the scar (4.54%); 2 cases - scars with keloid (2.27%).
Cosmetic and functional surgery of the umbilicus: transumbilical plication technique24	30	26 to 59 years	X	X	Hassle-free.
Omphaloplasty: “infinity” technique25	418	21 to 73 years	120 months	91% satisfaction.	9 cases - partial dehiscence (2.1%); 7 cases - stenoses (1.5%); 5 cases - keloids (1.1%).
Neo-omphaloplasty without a scar26	127	31 to 50 years	4 to 10 months	“All patients monitored and evaluated presented results considered good by the themselves and by the surgeon”.	It does not describe the numbers: partial erasure of the umbilical depression; epidermolysis of the flap dermis.
Isosceles triangle omphaloplasty with double fixation in abdominoplasty27	97	25 to 65 years	Up to 12 months	82.5% if felt very satisfied; 10.3% satisfied; 7.2% not very satisfied.	3 cases - stenoses (3%); 2 cases - hypertrophic (2%); 2 cases - atrophic (2%).
Neo-omphaloplasty with X incision in 401 consecutive abdominoplasties28	401	23 to 67 years	5 to 36 months	43 patients rated their result: 67.4% - Excellent; 23.2% - Very good; 9.3% - Good. Evaluation of surgeons: 77% -Excellent; 18% - Very good; 5% - Good.	16 cases - Infection (3.9%); 11 cases - seroma (2.7%); 6 cases - necrosis (1.5%); 4 cases - hematoma (1%); 2 cases - dehiscence (0.5%).

Table 1 - Summary of article data included for full reading and analysis.

Due to the lack of standardization and the use of systematic evaluation methods, it was impossible to carry out statistical analyses regarding the inclusion criteria.

DISCUSSION

Even after the most varied surgical techniques, Umbilical reconstruction remains an important challenge for plastic surgeons. Attention should be given to the umbilical anatomical units and their maintenance or creation - bun, mamelon, and umbilical sulcus^4,29. For many, the ideal shape sought is an oval or “T” navel with a vertical orientation of small dimensions, similar to that of young women^22,30.

The absence of anatomical patterns or the presence of distortions, pathological scarring, and stenosis, among other complications, can lead to dissatisfaction with the result, in addition to having difficult surgical correction³¹.

Vernon³² (1957) was the first surgeon to describe the transposition technique for creating a new navel in abdominoplasty. The surgery described consisted of a circular technique. Other authors continued to develop new approaches, but still in circular scars³³. Grazer & Goldwyn³⁴ (1977), in a study of 10,574 patients who underwent abdominoplasty, reported that 45% claimed to have stenosis or cicatricial contracture in the navel. Rosique et al.³⁵ (2009) reported a seven times greater chance of these complications when using the circumferential tactic.

Intending to seek better results, Avelar³⁶ (1978) described a technique with an internal scar by creating a star-shaped flap, in which the resulting scar presented variation in direction, thus reducing complications such as stenosis and cicatricial retraction. Other techniques based on non-circular scars were developed after these, but with aesthetic results that are often unsatisfactory¹¹.

Despite the various umbilicoplasty options described in the literature, the senior author sought an alternative that would provide more satisfactory results. Thus, in 1998, he published the “H” technique, in which four rectangular flaps are interposed alternately, and the resulting scar presents eight 90-degree changes in direction. Thus, the great advantage of this tactic is the possibility of avoiding tensions and superficializations and being safe regarding the presence of retractions. Furthermore, the technique allows the superficializing or deepening of the navel, with the variation of the perpendicular lines that delimit the flap.

When observed in an orthostatic position, the horizontal scar of the lower flap is deeply positioned unapparent. The more superficial scars are arranged longitudinally in the lateral flaps, and to avoid the appearance of these, also reducing the risk of the navel becoming flat, it must be attached to the aponeurosis.

Neo-omphaloplasty with the H-shaped technique presents a surgical tactic that provides a satisfactory aesthetic result with a deeply located horizontal scar, making it an excellent option in the plastic surgeon’s arsenal (Figures 3 to 5).

Figure 3 - Female patient, 35 years old, 11 years before and after surgery.

Figure 3 - Female patient, 35 years old, 11 years before and after surgery.

Figure 4 - Female patient, 29 years old, preand 2 years after surgery.

Figure 4 - Female patient, 29 years old, preand 2 years after surgery.

Figure 5 - Female patient, 35 years old, preand 6-month postoperative period.

Figure 5 - Female patient, 35 years old, preand 6-month postoperative period.

CONCLUSION

Omphaloplasty in abdominoplasties can be performed in several ways, providing surgeons with a wide range of alternatives.

The H technique is one of these tools which can be widely used and bring consistent results.