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M. A. Faria-Correa
Results
I have done approximately 20 cases of minimal incision abdominoplasty from 1989
to 1992, approximately 300 cases of endoscopic abdominoplasty from 1992 to
2015, another 280 cases of endoscopic-assisted abdominoplasty and endoscopic
abdominoplasty from 2015 till now (using both the CO2 and the gasless methods)
and 31 cases of robotic abdominoplasty from 2015 till now. I have many robotic
abdominoplasty patients with up to 5years of long-term follow-up (Figs.11.10 and
11.11) and endoscopic abdominoplasty cases with up to 5- and 20-year follow-up
(Figs.11.6, 11.7 and 11.8). We can observe an important cosmetic improvement, a
much atter abdomen, an improvement in the posture and a natural reconstitution of
the patient’s original anatomy leaving minimal scars, and most of the patients
inform an important improvement in quality of life by reducing their suffering of
back pain and pelvic oor dysfunction.
The rectus plication has been shown to be effective and long-lasting in most of
the cases when the plication method was done using two layers of stitching, the rst
layer interruptive stitches with nylon 00 and the second layer running stitches. It
failed in a few patients that didn’t respect the proper downtime and started exercises
before 6months.
I converted the minimally invasive abdominoplasty into a full abdominoplasty in
about 20 cases. Some patients initially preferred to keep some degree of abbiness
or redundant skin rather than opting for a long scar from skin removal. However, as
they gained weight and experienced increased abbiness due to aging, they eventually requested skin removal.
Overall the results are very satisfactory when it is done in the right patients with
no redundant skin and with realistic expectation and that don’t want scars.
Complications
The complications in minimally invasive abdominoplasty, both endoscopic and
robotic methods, are the same—seroma (Fig.11.19) and haematoma. So far, in a
total number of more than 600 cases in more than 32-year experience, I never had
one case of infection and no skin necrosis, but I had some cases of skin surface
irregularities due to the liposuction and cases of rectus diastasis failure because the
patients started physical activities too early and are not following the recommendation of 6months of no sports but only core muscle re-education exercises. We manage to reduce the incidence of seroma by reducing as much as possible the
undermining area, creating a closed vascular system (Avelar 1999) and stitching the
dermo-adipose ap to the muscle fascia, and suction drainage would have to be
maintained minimal for 2 or 3days or until the drainage over 24h is less than 30cc
(Faria-Correa 1995, 2008).
11 MILA-Minimally Invasive Robotic and Endoscopic Lipo-Abdominoplasty
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Fig. 11.19 Seroma
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Discussion
A proper understanding of the patient concern, a correct diagnosis of the issues
involved and a clear discussion with the patient about the surgical plan and the outcomes are paramount.
Treating patients with over-redundant folds of skin, abbiness and skin damaged
by striae is an easy task. We have no doubt in what to do. Our patients will be very
happy to get a long scar to remove that ugly and redundant skin and get a new body
contouring.
But the situation is not the same when it comes to the treatment of small- and
medium-sized abdominal wall deformities. They ask for scarless minimally invasive procedures that can restore their original anatomy.
Post-gestational deformities are most of the time associated with rectus diastasis,
the stretching of the linea alba, that causes a protrusion in the abdominal wall affecting the function of the core muscle, leading to medical and cosmetic issues. Rectus
diastasis, most of the time, is not limited to the lower abdomen but extends towards
the whole abdomen; that is why rectus plication from the pubis to the xiphoid is
required for a proper functional and cosmetic result.
Many times, the skin is not the patient’s concern. If the skin still presents with
good elasticity with the capacity to retract and also presents with a nice cosmetic
aspect, cutting a fuse of the skin in the lower abdomen will not help in treating small
degree of abbiness, but this will just create unnecessary scars and sometimes cause
a lowering of the umbilicus positioning, distorting the patient’s original anatomy, in
nothing contributing to the beauty of the result.
Liposuction alone will not be enough if there is a rectus diastasis. Liposuction
can be associated with rectus diastasis in very selected cases of real abdominal
lipodystrophy.
Pregnancies can cause an imbalance of the core muscle. After repairing, reconstructing the linea alba, a physiotherapy work may be helpful to achieve the optimal
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M. A. Faria-Correa
result. We recommend a postural re-education with specialized physiotherapist to
reinforce the core muscle, a proper wealthy lifestyle, maintaining the right weight.
Minimally invasive surgery presents many advantages compared to open methods like fast recovery, less pain, lower risk of infection and minimal scars that are
our goals in cosmetic surgery. Plastic surgeons are not well trained in minimally
invasive methods, and it will demand a lot of time, cost and dedication to develop
skills in endoscopic surgery and robotic surgery. Robotic surgery also adds a cost
for the patient, which makes it prohibitive for some patients to afford. In robotic
surgery, an initial limitation is the loss of haptic feedback (force and tactile).
Conventional endoscopy presents with a 2D image view, whereas the da Vinci system presents with a high-denition precise 3D image that compensates the loss of
haptic feedback (Faria-Correa 2016).
But, even if minimally invasive methods present advantages over open methods,
what I consider more important in this technique is the new concept in mini-
abdominoplasty: do not remove skin; plication to be performed using non- absorbable
stitches at least one layer of interruptive stitches and in the whole extension, from
the pubis to the xiphoid; reinserting the umbilical scar in its original site; and liposuction when necessary. The use of minimally invasive technologies of endoscopic
and robotic surgery is just a plus, to add the advantages of minimally invasive surgery and minimal scars (Figs. 11.4, 11.5, 11.10, 11.11 and 11.20).
a b
Fig. 11.20 (a)Award by “The American Society for Aesthetic Plastic Surgery Inc.” in 1996
“Endoscopic Abdominoplasty Technique”. (b) Award of Recognition in 2016 during the
International Congress on “FACE/BODY COUNTOURING & REJUVENATION”: In recognition
of my contribution to plastic surgery bringing mini-abdominoplasty technique to the next level
of a keyhole minimally invasive surgery by introducing the use of endoscopic methods and
robots for rectus plication– ROBOTIC ABDOMINOPLASTY
11 MILA-Minimally Invasive Robotic and Endoscopic Lipo-Abdominoplasty
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Conclusion
We are living a new era in plastic surgery. We have learned a lot about the skin elasticity and capacity to retract. New technologies to help the skin to retract are available. Rectus diastasis so far still needs surgical treatment. Minimally invasive
methods have shown many advantages over the conventional methods, and scars are
one of the most important concerns in our cosmetic patients. Robotics in aesthetic
plastic surgery is still at its infancy stage, but it is very promising considering its
many advantages of minimally invasive surgery associated with high technology
that helps us work through minimal scars with incisions at remote sites, leaving
inconspicuous scars that are the hallmark of plastic surgery. Over the past 30years,
we are seeing an increasing number of female and male patients coming for the
treatment of small- and medium-sized abdominal deformities. Many of them are
presenting with rectus diastasis, with no redundant folds of the skin, with good skin
elasticity and with or without abdominal lipodystrophy. They demand for scarless
procedures that can effectively correct it. Liposuction alone will not be effective
enough in many cases. The long-term evaluation of midline aponeurotic rectus plication, when properly performed, has proved its efciency. Plastic surgeons are
always looking for tools and instruments that can help us to better perform our
procedures with more precision, efcacy, less trauma and faster recovery for our
patients and leaving minimal scars. Since 1991, I started using endoscopic methods
for the treatment of the described deformities. The efcacy of the method in patients
with more than 20years’ follow-up gives me the enthusiasm of going for the next
level. The “gold standard” of the minimal invasive video surgery is the use of robotic
“da Vinci Surgery System” for the plication of the rectus diastasis. In many areas of
application like urology, gynaecology, general surgery, neurosurgery and heart surgery, robot surgery has proved to have many advantages over conventional endoscopic methods due to the robot high-denition three-dimensional surgical view
and amplication of images that makes it much more accurate than the 2D view
provided by the conventional endoscopic methods, the superb precision and a much
larger range of motion of the robot EndoWrist instruments that are comparable to
the human wrist and the stability of the surgical eld, camera and instruments, all
controlled by the surgeon seated at the console in a comfortable position (FariaCorrea 2016). It is time to stop creating unnecessary scars and using minimally
invasive methods in body contouring plastic surgery. It is time for robotics in plastic
surgery.
References
Faria Correa M. Abstracts. Aesth Plast Surg 47 (Suppl 2), 251–562 (2023). https://doi.org/10.1007/
s00266-023-03449-1
Avelar JM.Uma nova tecnica de abdominoplastia-sistema vascular fechado de retalho subdermico
dobrado sobre si mesmo combinado com lipoaspiracao. Rev bras Cir, 1999; 88/89(1/6):3–20
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Avelar JM.Umbilicoplastia-uma tecnica sem cicatriz externa. An do XIII Cong Bra de Cir Plast
Porto Alegre, pp81–82, 1976.
Faria-Correa MA.Abdominoplasty: the South America style. In Ramirez OM, Daniel RK, eds.
Endoscopic Plastic Surgery. NewYork: Springer-Verlag, 1995.
Faria-Correa MA. Abdominoplastia videoendoscopica (subcutaneoscopica). In Atualizacao em
Cirurgia Plastica Estetica e Reconstrutiva. Sao Paulo: Robe Editorial, 1994.
Faria-Correa MA Robotic Procedure for plication of the Muscle Aponeurotic Abdominal Wall.
In New Concepts on Abdominoplasty and Further Applications. 11: 161–177 Springer 2016
Faria-Correa MA.Videoendoscopic abdominoplasty (subcutaneouscopy). Rev Soc Bras Cir Plast
Est Reconstr 7:32–34, 1992a.
Faria-Correa MA.Videoendoscopic subcutaneous abdominoplasty. In Endoscopic Plastic Surgery
2nd edi. IV(16):559-586. Missouri: Quality Medical Publishing, Inc, 2008.
Faria-Correa MA. Videoendoscopy in plastic surgery: brief communication. Rev Soc Bras Cir
Plast Est Reconstr 7:80–82, 1992b.
Lanfranco AR, Castellanos AE, Desai JP, Meyers WC.(2004) Robotic Surgery: A Current
Perspective 239(1):14–21 doi: https://doi.org/10.1097/01.sla.0000103020.19595.7d
Lee HS, Kim D, Lee SY, Byeon HK, Kim WS, Hong HJ, Koh YW, Choi EC (2014). Robot –
assisted versus endoscopic submandibular gland resection via retroauricular approach: a pro-
spective nonrandomized study. British Journal Of Oral And Maxillofacial Surgery (2014)
52(2):179–184. doi: https://doi.org/10.1016/j.bjoms.2013.11.002
Lee J, Chung WY (2014). Robotic thyroidectomy and radical neck dissection using a gasless
transaxillary approach. Robotics In General Surgery (2014) 24:269–270. doi:https://doi.
org/10.1007/978- 1- 4614- 8739- 5_24
Mattei TA, Rodriguez AH, Sambhara D, Mendel Ehud (2014). Current state-of-the-art and future
perspectives of robotic technology in neurosurgery (2014) 37(3):357–366; doi: https://doi.
org/10.1007/s10143- 014- 0540- z
Morris B.(2005, September 25). Robotic surgery: Applications, limitations, and impact on surgical
education. All about robotic surgery. Retrieved from http://www.allaboutroboticsurgery.com/
avrasurgicalrobotics.html
Nahas FX, Augusto SM, Ghelfond C (2001). Suture materials for rectus diastasis: Nylon versus
polydioxanone in the correction of rectus diastasis. Plastic And Reconstructive Surgery. The
division of plastic surgery and radiology, hospital Jaragua. Sao Paulo, BR 107(3):700–706.
Nahas FX, Ferreira LM (2010). Concepts on correction of the musculoaponeurotic layer in abdom-
inoplasty. Clin Plastic Surg (2010) 37:527–538. doi:https://doi.org/10.1016/j.cps.2010.03.001
Nahas FX, Ferreira LM, Augusto SM, Ghelfond C (2004). Correction of diastasis: long-term
follow up of correction of rectus diastasis. Plastic And Reconstructive Surgery (2005)
115(6):1736–1741. doi:https://doi.org/10.1097/01.PRS.0000161675.55337.F1
Nahas FX, Ferreira LM, Ely PB, Ghelfond C (2011). Rectus diastasis corrected with absorbable
suture: a long-term evaluation. Aesth Plast Surg(2011) 35:43–48. doi:https://doi.org/10.1007/
s00266- 010- 9554- 2
Selber JC. (2009). The role of robotics in plastic surgery. Quality Medical Publishing, Inc.
Retrieved from http://www.plasticsurgerypulsenews.com/12/article_dtl.php?QnCategoryI
D=112&QnArticleID=236
Selber JC, Baumann DP, Holsinger FC (2012). Robotic latissimus dorsi ap for breast recon-
struction. Plastic and reconstructive surgery 129(6):1305–12. doi: https://doi.org/10.1097/
PRS.0b013e31824ecc0b
M. A. Faria-Correa
Chapter 12
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Creation ofaNew Umbilicus During
Abdominoplasty andIts Importance
inBody Contouring
JuarezMoraesAvelar
Abstract A normal umbilicus is a scar in the geographical center of the abdomen
in all human beings, as a result of the necrotic tissue that forms a few days after
birth. Usually, it is a scar in the lowest part of a cavity with special skin around it.
The scar is a result of necrosis in the central area of a suitable depression, and each
one exhibits peculiar aesthetic behavior. Reproducing this anatomical region is a
constant challenge to surgeons whenever they perform an operation on this region.
When full abdominoplasty is performed, the plastic surgeon must be very concerned
about the umbilicus because it is an important aesthetical reference point on the
abdominal wall, and recreating it during an operation is a matter of art and skill.
Since the beginning of my activities, I have developed a personal method for
avoiding leaving a circular scar around the umbilicus, to create a natural aesthetic
appearance after full abdominoplasty. The main surgical principle of this method is
to create three triangular skin aps on the umbilicus, and another three cutaneous
ones are cut out of the abdominal panniculus to be sutured in an alternating fashion
with the aps of the umbilicus. Another surgical principle is to suture the skin of the
abdomen to depth to the umbilicus—instead of suturing the umbilicus to the skin of
the abdominal panniculus. In addition, my method can be used for the correction of
several deformities (congenital and acquired) in the umbilical region to create a
natural umbilicus with outstanding results that improve the aesthetic appearance of
the abdominal wall.
Keywords Umbilicus · Creation of an umbilicus · Importance of umbilicus ·
Location of the umbilicus · Abdominoplasty
J. M. Avelar (*)
Brazilian Scientic Institute of Plastic and Reconstructive Surgery, São Paulo, Brazil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_12
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J. M. Avelar
Introduction
The umbilicus—also known as the navel or the belly button—is the rst scar on the
human body, which is the nal result after a natural necrotic phenomenon of the
tissue cord that occurs a few days after birth. It is located in the central region of the
abdominal wall, and it is an important reference point for the aesthetic appearance
of the abdomen. The specic type of skin around the umbilical region resists surgery on this area. It is strategically located in the center of the abdomen and harmoniously balanced with the body, which is always noticed but not easily recreated
during full abdominoplasty.
There are several situations that may damage the appearance of the navel, causing alterations to the umbilical region with physical and psychological repercussions, such as redundant skin, hernias (Fig.12.1), diastasis in the rectus abdominalis
(Fig.12.2), unaesthetic surgical scars from previous operations (Fig.12.3), absences
in the umbilicus from previous operations (Fig.12.4), deviations from the midline
of the abdomen, at surfaces (Fig.12.3), burnt abdominal walls, and some other
abnormalities that may disturb the normal anatomy of the umbilicus (Avelar 2016).
Among several anatomic alterations to the umbilical region, some may cause
more-disruptive disturbances requiring local correction. First, several problems
Fig. 12.1 Surgical correction of diastasis of the muscular abdominal wall through Callia’s technique on lower abdominoplasty without reimplantation of the umbilicus combined with augmentation mastoplasty. Photos (a, c) preoperative of a 34-year-old patient; (b, d) post-operative photos
combined with silastic implant; (e) preoperatory photo of the patient lying down showing severe
diastasis of the umbilical region with patient making effort to elevate the torso trying to sit down
cd
12 Creation of a New Umbilicus During Abdominoplasty and Its Importance in Body…
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ab
215
ef
g
h
Fig. 12.2 Correction of diastasis of the muscular abdominal wall through Callia’s technique without reimplantation of the umbilicus with lower abdominoplasty. Photos (a, c) preoperative of a
34-year-old patient; (b, d) post-operative photos combined with mastopexy with silastic implant;
(e) computerized tomophagy before abdominoplasty presenting diastasis above the umbilicus on
midline; (f) after surgery one can see correction of the diastasis by plication of muscular abdominal
wall; (g) rotinaire tomography before abdominoplasty with diastasis indicated by arrow; (h) after
operation with correction of diastasis with treatment of umbilical hernia
stem from the umbilicus and umbilical region, where severe alterations can be
repaired through surgical treatment via appropriate techniques. So far, the most
important have been those originating from previous surgeries trying to create a new
umbilicus during full abdominoplasty (Figs. 12.3 and 12.4). For this purpose, I
introduced new concepts (Fig.12.5) (Avelar 1976a, b, 1979, 1983) to solve severe
problems, such as the retraction and contraction of the scar around the new umbilicus after surgery, as reported by Grazer and Goldwyn (1977). They published an
important survey in which they found a very high incidence of abnormalities as
scars around the umbilicus with retraction and contraction.
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J. M. Avelar
Fig. 12.3 Reparation of umbilicus region combined with secondary abdominoplasty in a 41-yearold patient underwent surgery elsewhere. Photo (a) patient presenting deep and unaesthetic surgical scar of the previous abdominoplasty and wide and at umbilical region; (b) after secondary
abdominoplasty with reparation of the umbilical and the supra pubic scar as well; (c) same patient
in oblique left view with surgical demarcations; (d) 1year after operation; (e) a close up of the
unaesthetic scars on the umbilicus and supra pubic region; (f) photo in close showing the aesthetic
appearance of the abdomen as well as the harmonious scar of the umbilicus
abc
d
ef
Fig. 12.4 Reconstruction of umbilicus after unsuccessful abdominoplasty in a 42-year-old male
patient underwent elsewhere. Photo (a) patient presented unaesthetic surgical scar due to abdominoplasty and absence of the umbilicus; (b) after reconstruction with remnant skin of the umbilicus
during am secondary abdominoplasty; (c) during surgery one can see an small segment of skin
indicated by a circle; (d) it was possible to create three triangular aps to be sutured to the new
umbilical region; (e, g) photos in close showing unaesthetic appearance to the abdomen without
umbilicus; (f, h) same patient after reconstruction of the umbilicus with three skin aps on the
umbilicus and other three created on abdominal wall similar to rotinaire operation during primary
abdominoplasty
ab
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gh
gh
Fig. 12.4 (continued)
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Fig. 12.5 Creation of the umbilicus during full lipoabdominoplasty. (a) When a circular incision
is done around the umbilicus with reimplantation through circular incision with resection of a
circle of skin, or semi-circular, horizontal or vertical incisions on the abdominal wall are done, the
nal scar will be always a circular one; (b) Avelar’s technique is performed by triangular incisions
around the umbilicus avoiding nal circular scar around the umbilicus
Ever since I started my practice in 1974, I noticed that creation of a circular incision around the umbilical region during full abdominoplasty was the main cause of
the unaesthetic surgical results. Looking for a solution, I developed a method
(Avelar 1976a, b, 1978, 1979, 1983) in which instead of creating a circle around the
new umbilical region, I introduced a star-shaped incision as a new surgical technique (Fig.12.5).
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