Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 262 - файл
.pdf
218
https://t.me/medicina_free
J. M. Avelar
Fig. 12.6 Sequential photos of cutaneous incisions on umbilicus during full abdominoplasty, and
lipoabdominoplasty as well, since the umbilicus is transposed and sutured to the abdominal wall.
Photo (a) my double half semicircular instrument; (b) each segment is introduced on each side of
the umbilicus in order to pull it upward to facilitate cutaneous incisions; (c) after incisions the
umbilicus is in the center of the instrument; (d) close up of the cutaneous surface of the umbilicus
with triangular shape
Method
The main surgical principles of the technique are to create three small triangular
aps on the umbilicus and another three on the cutaneous covering of the abdominal
panniculus to be sutured in a one-by-one alternating fashion (Fig.12.6).
Technique
The creation of a new umbilical region during full abdominoplasty is a routine procedure. All the panniculus below the umbilicus is resected, and its transposition is a
matter of selecting the appropriate surgical approach, such as that introduced by
Vernon (1957)—which removes a circle of skin on the abdominal ap, creating a
circular scar around it (Fig.12.5). Therefore, the reimplantation of the umbilicus on
the abdomen wall opened up a new era in abdominoplasty. Several authors have
published other procedures with vertical, horizontal, and semicircular incisions
(Pitanguy 1967). No matter the type of incision that is performed on the abdominal
wall, the nal result will always be a circular scar around the transposed umbilicus
(Fig.12.5). Even when outstanding surgeons perform the operation, the nal scar
has not been satisfactory to most patients (Figs.12.3 and 12.4).
A remarkable survey carried out by Grazer and Goldwyn (1977) on 10,540
abdominoplasties performed by plastic surgeons from several countries found that
umbilical scar contractures occurred in 45% of the surgeries. According to that survey, 2% of the surgeons believe that some sort of retraction or contraction of the
12 Creation of a New Umbilicus During Abdominoplasty and Its Importance in Body…
https://t.me/medicina_free
umbilical scar always occurs after abdominoplasty when transposition is performed.
Ever since I started my practice in 1974, I paid special attention to creating a natural
umbilical region during abdominoplasty in an attempt to solve some severe problems on the umbilicus associated with abdominoplasty. My original publications
(Avelar 1976a, b, 1979) include descriptions of a new approach that avoids problems such as scars from retraction and contraction (Figs.12.3 and 12.4).
Some of the surgical principles in my approach signicantly diverge from those
of other techniques:
1. The cutaneous incisions on the umbilicus are made by retracing the direction
lines of the skin from outside to inside (Fig.12.6b).
2. The nal scars are similar to those of an atypical Z-plasty, which avoids unaes-
thetic appearance and scars from retraction and contraction.
3. The skin of the abdominal wall is pushed to its lowest depth in order for it to be
sutured to the umbilicus (Fig.12.7b, c).
4. The nal appearance is a natural scar inside the surface of the cavity in the new
umbilical region.
5. The nal scars rest smoothly on the interior of the umbilical cavity (Fig.12.7d.).
Over the years, the basic principles of the method have remained the same, but
according to my observations, some technical details have been revised to improve
the aesthetic results (Avelar 1983), even later on, when full lipoabdominoplasty is
performed (Fig.12.8) (Avelar 1999a, b, c). The technique is performed in two steps:
rst surgical demarcations and then the operation.
219
Surgical Demarcations
Before surgery meticulous demarcation is a mandatory step to creating a new
umbilical region during full abdominoplasty because the umbilicus must be transposed preoperatively. When one performs full abdominoplasty or full lipoabdominoplasty, a new umbilical region must be created to rebuild the abdominal wall.
Demarcations constitute a fundamental step and must follow surgical planning
before any procedure in plastic surgery. For full lipoabdominoplasty, both steps are
essential before the operation and must be carried out with the patient in a standing
position and in a lying position. My preference is to demarcate all references points
at the ofce on the day before surgery with the patient in a standing position and in
a lying position in front of some mirrors so that they can follow my drawings. The
demarcations on the umbilical region are also made according to my approach,
published and presented at the Brazilian Congress of Plastic Surgery and the French
Congress of Aesthetic Surgery (Fig.12.6b, d) (Avelar 1976a, b). First, a circle of
about 2cm in diameter must be drawn around the umbilicus to delimit the umbilical
area on the surface of the abdominal wall. Afterward, a star-shaped incision with
three triangular aps is made. One ap must be directed downward and other aps
directed obliquely upward to the right and to the left (Fig.12.6b, d). On patients
220
https://t.me/medicina_free
J. M. Avelar
Fig. 12.7 Perioperative photos showing demarcation and creation of the new umbilical region
during full abdominoplasty and lipoabdominoplasty using Avelar’s surgical demarcator instrument. Photos (a) the inferior segment is placed on the umbilicus underneath the abdominal ap and
the superior one lies on it and the new umbilical region is already demarcated inside of a circle; (b)
cutaneous incisions were done creating three small triangular aps inside the circle; (c) three skin
aps from the umbilicus are sutured alternatively with the other three from the abdominal wall; (d,
e) local dressing is done with dry gauze inside the umbilicus; (f) the new umbilical region 1week
after surgery showing a natural depression of the umbilicus with rotation of the skin aps from
outside to inside (from surface to deep)
Fig. 12.8 Full lipoabdominoplasty performed on a 45-year-old patient with transposition of the
umbilicus with Avelar’s technique creating a natural umbilical region. Photos (a, c) preoperative
views before surgery; photos (b, d) after surgery
12 Creation of a New Umbilicus During Abdominoplasty and Its Importance in Body…
https://t.me/medicina_free
who have undergone substantial weight loss or who present with excessive cutaneous accidity, the umbilical area shows some downward inclination. However, the
umbilical region is always well identied thanks to its peculiar constitution of skin
with a depression in the center.
The skin area of the abdomen to be resected is also demarcated before surgery.
My preference is to follow Callia’s (1965) technique and Sinder’s (1975) techniques
to leave the smallest possible nal scar.
221
The Operation
The operation itself proceeds in several steps:
(a) Incisions into the umbilicus
(b) The transposition of the umbilicus
(c) Suturing the umbilicus
(d) Dressing
Full lipoabdominoplasty is a procedure of abdominoplasty without panniculus
undermining in combination with the liposuction technique that must be performed
at a hospital under an epidural or general anesthesia. Local inltration with a special solution is carried out before liposuction and skin resection, which are fundamental procedures during the operation. A special solution is prepared: 1000mL of
serum plus 2 mg of epinephrine (1/1000), which makes the dilution 2/1.000.00.
This solution allows surgeons to inltrate the entire abdominal wall and the lateral
sides of the torso. The inltration is carried out on two levels: one on deep area
below the fascia supercialis and on the area where skin resection will not be performed and one on the full thickness of the panniculus where skin resection will be
performed.
Incisions into theUmbilicus
The operation starts in the umbilical region where cutaneous incisions are made
following the star-shaped drawing inside the umbilicus, according to my demarcations (Fig.12.9). Initially, two horizontal incisions are made on the right and left
sides of the umbilicus, according to Sinder’s technique. Afterward, following my
new surgical instrument, which is two-in-one type of a double half circle that is to
be articulated around the umbilical pedicle (Fig.12.6a, b, c). Using this double
half- circle instrument, the surgeon’s assistant pulls the umbilical area upward.
Such a maneuver is useful to elevate the cutaneous surface of the umbilical region
away from the abdominal cavity to avoid accidentally perforating the internal
abdominal organs. Unfortunately, this kind of complication has happened during
surgery even when it was performed by well-qualied plastic surgeons. After cutaneous incisions have been made inside the umbilicus with a pair of scissors, the
222
https://t.me/medicina_free
Fig. 12.9 Diagram from
bottom showing full
lipoabdominoplasty. Two
cutaneous incisions are
done on each side of the
umbilicus to introduce my
semicircular articulated
instrument to lift the
umbilical area in order to
incise triangular incisions
around the umbilicus to
avoid accidental
perforation of the
abdominal cavity which
may damage the internal
viscera
J. M. Avelar
pedicle is dissected downward until the aponeurosis of the musculoaponeurotic
wall has been reached in order to isolate the umbilicus. At the end of this stage, the
cutaneous surface of the umbilicus is now free, showing its triangular shape
(Fig.12.6c, d).
Afterward, liposuction is carried out on the deep layer of the panniculus, which
is below the fascia supercialis, on the superior segment of the abdomen up to the
costal rim, preserving the perforator vessels; a description of this procedure appears
in Chap. X. According to Sinder’s technique, the superior ap after liposuction on
the lamellar layer is then pulled downward to evaluate whether it has reached the
inferior border of the previous demarcations; a description of this part of the procedure appears in Chap. X. At this time, the operating table needs to be bent to conduction an evaluation. Once the evaluation has been completed, the surgical table is
returned to the horizontal position, at which point liposuction is carried out on infraumbilical segment of the full thickness of the panniculus while preserving the perforator vessels and connective tissues. Afterward, the skin resection of the abdominal
wall while tracing the demarcated area is performed. The subcutaneous tissue is
held so that the knife does not damage the subdermal layer underneath, and consequently, no bleeding occurs.
When the patient presents with diastasis in the muscular rectus, it is a good indication that they need to undergo the reinforcement of the musculoaponeurotic structures (Figs. 12.1 and 12.2). I created a device (a dissector instrument) that is
introduced in the umbilical area and moved upward on the midline through the
connective tissue in order to expose the central border of the rectus abdominalis.
The procedure for its plication is carried out on the midline with nonabsorbable
material, making isolated stitches starting from 5cm below the xiphoid process and
12 Creation of a New Umbilicus During Abdominoplasty and Its Importance in Body…
https://t.me/medicina_free
223
up to the umbilical pedicle. Also, below the umbilicus, the aponeurosis is reinforced
from the midline to the pubis.
The Transposition oftheUmbilicus
Once again, the surgical table needs to be bent in order to facilitate the traction of
the pulled-down abdominal ap. On the midline, a temporary stitch is applied to
suture the inferior border of the upper panniculus to the border of the remaining
panniculus in the suprapubic region (Fig.12.10a). Then, the surgical table is returned
to the horizontal position to demarcate the new umbilical area and the point corresponding to its projection on the cutaneous abdominal surface. The midline of the
Fig. 12.10 Demarcation of the new location of the umbilicus on abdominal ap during full lipoabdominoplasty. Photo (a) my special instrument has two segments: one is placed on the umbilicus;
(b) the superior segment is placed on abdominal ap to indicate the nal location; (c) after cutaneous suture of the three aps of the umbilicus with the three ones originating on the abdominal wall
224
https://t.me/medicina_free
J. M. Avelar
Fig. 12.11 Avelar’s surgical instrument for demarcation of the new umbilical region on abdominal
ap during full abdominoplasty and lipoabdominoplasty has two segments articulated between
themselves: the superior one is 1cm shorter than the inferior one. Photos (a, b) oblique views
showing its position during demarcation; (c) posterior surface that one can see the lower segment;
(d) the same surgical instrument with two segments in open position
abdominal wall must be drawn before surgery to establish the correct orientation for
demarcating the new umbilicus at the aesthetic location on the abdomen. I created
an appropriate surgical instrument, which acts as a marker and as a ruler (Fig.12.11),
that allows for achieving the exact position of the new umbilicus and for determining the appropriate distance from where the nal scar will be. This instrument also
protects the aponeurotic wall underneath and avoids damaging the intra-abdominal
organs because it lies smoothly on the already-reinforced aponeurotic wall.
According to my previous publications (Avelar 1983, 1985a, b, c), on later follow up, the umbilicus is pulled upward by the upper abdominal segment. For this reason,
the nal position of the umbilicus is marked at least 1cm lower than its projection
on the abdominal ap (Fig.12.11).
My instrument to determine the new umbilical area has two segments like a pair
of forceps, where the upper one is 1cm shorter than the inferior one so that the exact
projection of the umbilicus can be marked postoperatively (Fig.12.11). Usually, it
is placed approximately 7 to 9cm above the suprapubic incision. Very frequently,
some patients present with a 2 to 4cm increased elongation of that distance 1year
after surgery.
Suturing theUmbilicus
The umbilicus is then sutured with isolated stitches of 5-0 absorbable material.
Following my technique, the tips of the three cutaneous aps of the umbilicus are
sutured between each small triangular skin ap created in the future umbilical
region on the abdominal ap. In other techniques, the tips of the skin aps of the
abdominal wall are sutured between the cutaneous aps of the umbilicus. Therefore,
instead of leaving a circular scar around the umbilicus, which other techniques leave
behind, the nal scar after performing my technique is a “broken” line like an atypical multiple Z-plasty (Fig.12.7b, c, f) (Avelar 1976a, b, 1979). The nal scar has a
12 Creation of a New Umbilicus During Abdominoplasty and Its Importance in Body…
https://t.me/medicina_free
triangular shape, which is very important to avoid scar retraction and even
contracture.
Dressing
Dry gauze is placed inside the umbilical cavity and more gauze over it to maintain
pressure on the umbilical area. Performing such a procedure keeps the aps in their
appropriate positions, avoiding scar-tissue contracture (Fig.12.7d, e). The nal scar
has a triangular shape, which is important to achieve good aesthetical results without any scar-tissue contracture or retraction. The dressing is removed 5 to 6days
after surgery, at which time another dressing with dry gauze is placed inside the
umbilicus, which should be changed every 10days for at least 2months. The nal
result of the umbilical region after abdominoplasty or lipoabdominoplasty always
presents with a smooth scar around the umbilicus in harmony with the abdominal
wall (Figs.12.3, 12.4, and 12.8).
225
Complications
Since Vernon (1957) introduced the transposition of the umbilicus during abdominoplasty, such a procedure has become a mandatory step in all operations of full
abdominoplasty and full lipoabdominoplasty, which may be considered one of the
most important contributions to this eld. Nevertheless, it also brought about many
undesirable complications after operations for patients and surgeons, as reported by
Grazer and Goldwyn (1977) in their important survey, in which they found very
high incidences of abnormalities and scars around the umbilicus with retraction and
contracture. Those complications motivated me to create my technique to solve
some of them. In fact, when my procedure is properly performed, it avoids leaving
a circular scar around the umbilicus. Because the skin around the inner aspect of the
umbilicus is the result of the intussusceptions of the umbilical cord, the direction of
the lines radiates from outside to inside.
Therefore, when a surgeon makes an incision into the skin, it should always follow that direction to avoid leaving scar tissue on the skin. If a circular incision is
made around the umbilicus, it should be made in the opposite direction of the skin.
In almost 40years of practice employing my method on my patients, I have very
seldom left such adverse scars after surgery. Only for one patient have I had to perform scar revision on the umbilicus, because she presented with very bad scaring in
her suprapubic region. I have repaired and reconstructed the umbilicus of several
patients secondarily to abdominoplasty (Figs. 12.3 and 12.4). In other methods
described in the medical literature, the nal result is a tendency to leave circular
scars that may retract or contract (Fig.12.5).
226
https://t.me/medicina_free
J. M. Avelar
Discussion
Vernon’s (1957) description was a remarkable scientic development in abdominoplasty. Afterward, many authors have devised other procedures either with vertical or horizontal incisions or with a semicircular incision (Pitanguy 1977),
always resulting in leaving a circular scar around the transposed umbilicus
(Fig. 12.5). Even when outstanding surgeons perform that operation, the nal
results have not been satisfactory. In a memorable survey reported by Grazer and
Goldwyn (1977), they found very high incidences of abnormalities and scars
around the umbilicus with retraction and contracture. According to the surgical
principles of my technique, the nal scar around the umbilicus is similar to that of
an atypical Z-plasty (Avelar 1976a, b, 1979). In specic, three triangular aps are
created on the umbilicus, which are sutured to another three originating on the
abdominal ap after the traction and resection of its excess (Figs.12.6 and 12.7)
(Avelar 1983). Since I developed and published my method, the creation of a new
umbilical region has changed the surgical principles of abdominoplasty and
lipoabdominoplasty.
One of the most important surgical principles of my technique is to push the skin
of the abdominal wall to the deep structures of the musculoaponeurosis (Fig.12.7).
Such a technique is similar to that used on newborn children insofar as the necrosis
of the umbilical cord is pulled from outside to the lowest depth. The nal scar
remains in the center of the umbilical cavity. As a consequence of this new aspect of
my technique, the three small skin aps created on the abdominal wall move in the
direction of the already-sutured umbilicus close to the aponeurotic structures during
the reinforcement procedure. Thus, the triangular aps are sutured in an alternating
fashion among the three triangular aps created on the cutaneous surface of the
umbilicus. Thanks to such movement of the skin aps, a natural and smooth depression is created around the new umbilicus (Figs.12.4, 12.7, and 12.8). In other meth-
ods described in the medical literature, the umbilicus is pulled from the depth to the
surface of the abdominal wall, leaving a circular scar that may cause retraction and
that frequently causes contracture.
There are descriptions creating four or ve cutaneous aps on the umbilicus.
No matter how many aps are created on the umbilical surface and on the cutaneous covering of the abdominal panniculus, the main surgical principle is to avoid
leaving circular scars. To develop my method, I analyzed as many the geometric
shapes as I could, and I determined that the most dissimilar one to the circle was
a triangle. If another other shape with a greater number of cutaneous aps is
chosen, it will tend to approximate a circle. Such procedures are not new given
that the basic principles are also fundamental to my 1976 method (Avelar
1976a, b).
In selected patients presenting with a very high location of the umbilicus and
with accidity in the muscular abdominal wall, Callia’s procedure (Fig.12.12) ca be
used to correct the diastasis without transposing the umbilicus, even without leaving
a surgical scar around the umbilicus (Figs.12.1, 12.2, and 12.13).
cd
12 Creation of a New Umbilicus During Abdominoplasty and Its Importance in Body…
https://t.me/medicina_free
227
Fig. 12.12 Perioperative photos and diagram showing Callia’s technique for abdominoplasty on
atypical abdomen presenting high umbilicus on the abdominal wall. Photos (a) on prole view one
can see the abdominal ap being pulled upwards through supra pubic incision; (b) section of the
umbilical pedicle providing plication of the abdominal aponeurotic wall; (c) suture of the umbilical
pedicle to muscular after reinforcement of the muscular wall; (d) diagram showing pulling upwards
the abdominal ap exposing the perforator vessels and umbilical pedicle as well
ab
Fig. 12.13 Lower lipoabdominoplasty under Callia’s technique with sectioning of the umbilical
pedicle and its reimplantation combined with reinforcement of the muscular abdominal wall.
Photo (a, c) before surgery in frontal view presenting 17cm from xyphoid process to umbilicus
and 17cm from umbilicus to pubic region; (b, d) after surgery showing improvement of abdominal
wall with sectioning of the umbilical pedicle with its xation
Соседние файлы в папке @xirurgi_2025