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13 Abdominoplasty (The Umbilical Lozenge Technique)
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D’Assumpçāo EA. Técnica Para Umbilicoplastia, Evitando-se um dos Principais Estigmas das
Abdominoplastias. Rev Bras Cir Plást. 2005;20(3):160–6.
D’Assumpçāo EA.Complicações locais em abdominoplastias. Rev Bras Cir. 2002;92:21–8.
Schoeller T, Wechselberger G, Otto A, Rainer C, Schwabegger A, Lille S, etal. New technique for scarless
umbilical reinsertion in abdominoplasty procedures. Plast Reconstr Surg. 1998;102(5):1720–3.
PMID: 9774037 DOI:https://doi.org/10.1097/00006534- 199810000- 00064
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estigmas pósabdominoplastia. Rev Bras Cir Plást. 2009;24(4):525–9.
Dogan T.Umbilicoplasty in abdominoplasty: a new approach. Ann Plast Surg. 2010;64(6):718–21.
PMID: 20407366 DOI: https://doi.org/10.1097/SAP.b013e3181b02210
Lee MJ, Mustoe TA. Simplied technique for creating a youthful umbilicus in
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org/10.1097/00006534- 200205000- 00054
Del Toro, D.; Dedhia, R.; Tollefson, T.T.Advances in scar management: prevention and manage-
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24(4): 322–9.
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Chapter 14
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The Excision-Suture Tactic: AQuick
andLow Bleeding Option forTissue
Resection
IthamarNogueiraStocchero, GustavoFlosiStocchero,
GuilhermeFlosiStocchero, andAlexandreSiqueiraFrancoFonseca
Abstract This tactic, which has been used for years, is aimed toward patients who
present with skin laxity and, for various reasons, will greatly benet from shorter
surgical times. It is widely used in post-bariatric patients, being very useful for
patients who do not object to having their issues addressed in steps, one at a time,
often under local anesthesia.
Surgical technique: it involves precise marking of the skin, or skin/subcutaneous
fat, to be removed. It is an unusual tactic, since the surgeon who incises is not the
same who sutures, thus eliminating the step of changing positions. Both acts take
place sequentially, which makes the end of the excision step almost coinciding with
the end of the suture step.
Discussion: the greatest advantage offered by this option is to enable surgeries
which would otherwise be more invasive, with greater risks of major bleeding and
longer surgical time. Moreover, since this technique requires less complexity in
operating room infrastructure, it may increase the job market, thus being a good
alternative to be offered to patients.
Conclusion: when well-indicated, it is a great option for excess skin removal,
provided that patients be well aware of what is proposed. This tactic permits convenient, frequently outpatient procedures that may offer fast recovery.
Keywords Quick suture · Quick tissue resection · Hemostatic suture · Post-bariatric
surgery · Skin laxity correction
I. N. Stocchero (*) · G. F. Stocchero · G. F. Stocchero · A. S. F. Fonseca
Centro Médico Viver Melhor, São Paulo, Brazil
e-mail: dr.ithamar@vivermelhor.com.br; gustavo@vivermelhor.com.br;
guilherme@vivermelhor.com.br; dr.alexandre@vivermelhor.com.br
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_14
251© The Author(s), under exclusive license to Springer Nature
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I. N. Stocchero et al.
Introduction
The quest for excellence should guide all medical practice. However, in its own
essence, medical practice involves recognizing its limitations, which can be translated in the famous saying “to cure sometimes, to relieve often, and to comfort
always.” These words perfectly reect our incapacities, which become evident
according to the difculty levels that we all face before the adversities of a period
of time.
Sometimes, excellence lies within doing whatever is possible in the light of the
present situation, always respecting the limits of the surgeon, the patient’s conditions, and the feasible techniques.
What the tactic herein presented aims is to expand the range of treatment options
for patients whose health condition, lack of access to more complex care units, or
lack of time or nancial resources may all prevent them from getting more invasive
procedures.
Undergoing a series of smaller, quicker surgeries in order to achieve acceptable
results is better than having nothing at all.
The idea of this tactic rst appeared in hair follicle harvesting for hair transplantation (Stocchero 2003). Since the scalp is prone to copious bleeding, the double act of
resection and suture done by the same surgeon demands a counterproductive additional maneuver. If immediate suturing is performed right after incision, a precious
amount of time is saved, which leads to lesser bleeding and a shorter surgical time.
Current Concepts
Obesity has become a major public health issue in the modern era. Due to its implications in morbidity, in the well-being of the population, and also for aesthetic reasons, it became the target of several therapies, such as specic medications, diets,
exercise, and weight loss clinics, and, nowadays, with the great number of patients
undergoing various types of bariatric surgeries, results have frequently become
excellent.
The number of people who came to benet from massive weight loss has resulted
in patients who have recovered their health and their desire to live and to engage in
communal activities and to live a life that is full. These people come from different
levels, either related to their ambitions, their socioeconomic status, their moments
of life, and even their health condition.
These patients present with a wide range of skin laxity, which may be present all
over their bodies or only in certain areas, depending on their genetic characteristics,
their age group, the type of obesity treatment, history of pregnancy, degree of weight
loss, etc.—a myriad of possibilities.
Besides skin laxity, it is important to address the level of discomfort that each
patient is experiencing. It may range from the absence of complaints up to severe
14 The Excision-Suture Tactic: AQuick andLow Bleeding Option forTissue Resection
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depression. Within this array of situations, which sometimes is thin ice, it is the
plastic surgeon’s duty to perceive what is the best option for each patient. Success
will come as a result of the level of satisfaction achieved, and not necessarily from
the renement of the technique employed.
253
Indications
Every time that a shorter surgical time and low bleeding are more important factors
than technical renement
For example, patients with low hemoglobin levels are excellent candidates.
There are also those who want a “one morning surgery,” which may allow them
to keep with their usual routine without the need for work leaves.
The tactic presented herein is not intended to compete with the traditional,
renowned techniques used to address the well-known challenge of severe skin laxity, which results from massive weight loss. It is, in fact, an addition to those techniques, since it may be the necessary indication for the progressive correction of
large areas of redundant skin throughout a body, which has often lost half of its
weight and volume.
Its execution is reserved for linear resections, as this tactic is not adequate for
contouring procedures with curved incisions. However, linear resections comprise
most of the necessary surgical interventions for these patients, for example:
– Upper limbs: medial aspect of arms, dorsal aspect of wrists
– Dorsum: transverse torsoplasty, lateral excess skin
– Abdomen: vertical, transverse, or eur-de-lis abdominoplasty
– Lower limbs: medial and lateral aspect of thighs, excess skin over the knees
Surgical Technique
Skin marking deserves special attention, since it will dene the whole course of the
procedure. Special care should be taken when using bimanual grasp of excess skin,
since it will make all the difference in the result; in order to achieve the best aesthetically possible results, preoperative markings must be strictly followed during
surgery (Figs.14.1 and 14.2).
It is an unusual procedure, since the surgeon who incises is not the same who
sutures. Practicing team synchronism is very important to obtain the desired result,
because the excision-suture is a continuous act that requires full attention during the
whole procedure.
There are two options for its execution:
1. Using horizontal mattress sutures, with relatively long passes of the needle, and
placed close to the borders of the markings; a Reverdin needle may be useful in
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Fig. 14.1 Measuring the
dermal-fat fold
Fig. 14.2 Marking the
dermal-fat fold
I. N. Stocchero et al.
this step when the skin-subcutaneous fat fold is thicker (Fig.14.3). This type of
suture offers the advantage of lesser bleeding and tension during the excisionsuture. Sutures may occasionally be left for 2days, in cases where additional
skin tension was produced, so that sutures may aid cutaneous expansion
(Figs.14.4 and 14.5).
2. Resection and suture without approximation sutures, which is well-indicated in
cases with severe skin laxity (Figs.14.6 and 14.7). If there is concern about skin
tension, bolster sutures may be used in one of the wound edges, after anchoring
the sutures to the dermis of the opposite edge; these sutures will be removed on
the third postoperative day (Fig.14.8).
When the tissue to be removed is quite thin, we will perform an essentially cutaneous excision, which is easy to work with. However, there are occasions when the
14 The Excision-Suture Tactic: AQuick andLow Bleeding Option forTissue Resection
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Fig. 14.3 Passing the
horizontal mattress sutures
and nal aspect
Fig. 14.4 Cauterization
during the excision-suture
with the horizontal
mattress sutures
255
demarcated area of resection involves a certain amount of fat. It is advisable to use
approximation sutures and suction excess fat right above the sutures, within the area
to be incised and sutured (Fig.14.9). Time should not be wasted on suctioning the
entire ap, as it will be resected. It is enough to suction the base of the ap.
The sequence is the surgeon incises; if necessary, vessel cauterization is performed; and then the assistant surgeon sutures. In that manner, when the excision is
completed, the closure will be practically nished.
Regarding the suture, there are situations in which agility is especially important
(e.g., patients with hypertension, diabetes, or low hemoglobin levels). In such cases,
a running mattress suture may be used while planning a future aesthetic revision
when those health conditions are better controlled. This is a good option, especially
after larger resections. Whenever possible, performing a running subcuticular suture
will already yield a better result, combined with taping of the incisions, which will
promote greater approximation of wound edges. Deep dermal sutures and staples
are also an option (Figs.14.10 and 14.11).
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Fig. 14.5 Excision-suture
with the horizontal
mattress sutures
Fig. 14.6 Starting the
excision-suture without the
horizontal mattress sutures
I. N. Stocchero et al.
14 The Excision-Suture Tactic: AQuick andLow Bleeding Option forTissue Resection
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Fig. 14.7 Progression of
the excision-suture without
the horizontal mattress
sutures
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Fig. 14.8 Bolster sutures
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Fig. 14.9 Liposuction of
the base of the ap
Fig. 14.10 Final aspect of
the lower abdomen suture
I. N. Stocchero et al.
Fig. 14.11 Final aspect of
the eur-de-lis suture
(diagram)
14 The Excision-Suture Tactic: AQuick andLow Bleeding Option forTissue Resection
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259
Results
Usually, results are very well accepted by patients who were adequately oriented in
the preoperative consultations. In fact, results leave nothing to be desired when
surgical planning was careful.
Case presented: a 54-year-old woman with hypertension, diabetes, obesity,
breathing difculties, abnormal gait, and a history of blood transfusion due to an
ovarian tumor. She underwent oophorectomy combined with eur-de-lis abdominoplasty, in which the excision-suture tactic was employed. Total surgical time, including a 7-kg monoblock resection of the surgical specimen, was 1 h and 40 min
(Figs.14.12 and 14.13).
Fig. 14.12 Final aspect of the eur-de-lis suture
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