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J. M. Avelar
Conclusion
Creating the new umbilical region during full lipoabdominoplasty is a mandatory
procedure, and it is a constant challenge because it is located in the central area of
the abdomen and always leaves scars around the umbilicus. By using my technique,
good aesthetical results that avoid scar retraction and contracture can be achieved
(Figs.12.5, 12.6, and 12.7) (Avelar 1976a, b, 1979, 1983). Such unfavorable postoperative stigmata were reported by Grazer and Goldwyn (1977). According to previous evaluation, planning, and demarcation, the whole area of the cutaneous
covering of the infraumbilical region is always resected. Cutaneous incisions into
the umbilicus are made before skin resection (Fig.12.9) (Avelar 2000a, b, c, d, e, f,
g, 2001a, b, 2002a, b). When lower and upper lipoabdominoplasty is performed, the
umbilicus is not transplanted, because the skin resection is limited to the suprapubic
area or on submammary folds. The surgical principles of my method are new ones
in that the nal scar is not a circular one but rather are similar to those left after an
atypical Z-plasty around the new umbilicus, creating a natural depression in the
surface of the region in the center of the abdominal wall (Figs.12.7 and 12.8).
References
Avelar JM (1976a) Umbilicoplasty– a technique without external scar (Umbilicoplastia– uma téc-
nica sem cicatriz externa). 13rd Bras Cong of Plast Surg and First Brazilian Cong of Aesthetic
Surgery. (13° Congresso Brasileiro de Cirurgia Plástica e 1° Congr Bras Cir Estética), Porto
Alegre– RS (Brazil) 81–82
Avelar JM (1976b) Umbilicoplasty - A technique without external scar. Cahiers de Chirurgie
Esthétique. Journees internationals de Chirurgie Esthetique. Vendredi 21 Paris (France) mai.
Avelar JM (1978) Abdominoplasty: Systematization of a technique without external umbilical
scar. Aest Plast Surg 2:141
Avelar JM (1979) Umbilical scar– importance and technique for creating during abdominoplasty
(Cicatriz umbilical– da sua importância e da técnica de confecção nas abdominoplastias) Rev
Bras Cir 1(2):41–52
Avelar JM (1983) (Abdominoplasty: Technical Renements and Analysis of 130 cases in 8 Years
Follow-up). Aesth Plast Surg 7: 205–212
Avelar JM (1985a) Combined liposuction with traditional surgery in abdomen Lipodystrophy.
XXIV Instructional Course of Aesth Plast Surg of ISAPS, Madrid.
Avelar JM (1985b) Fat-suction versus abdominoplasty. Aesthetic Plast Surg 9:265–276
Avelar JM (1985c)– Fat-Suction of the Submental and Submandibular Regions. Aesth Plast Surg
9:257–263
Avelar JM (1999a) A new technique for abdominoplasty– Closed vascular system of subdermal
ap folded over itself combined to liposuction (Uma nova técnica de abdominoplastia– sistema
vascular fechado de retalho subdérmico dobrado sobre si mesmo combinado com lipoaspira-
ção). Rev Bras Cir 88/89, (1/6), 3–20. Nov–Dec
Avelar JM (1999b) New concepts for abdominoplasty (Novos conceitos para abdominoplastia).
Paper presented at the 36th Congress of the Brazilian Society of Plastic Surgery. Rio de Janeiro
Avelar JM (1999c) Abdominoplasty: New concepts for a new technique (Abdominoplastia: Nuevos
conceptos para una nueva técnica). XXVI Annual International Symposium of Aesthetic Plastic
Surgery, Chairman: Prof. Jose Guerrerosantos- Puerto Vallarta, Jalisco- México. 10-13
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Avelar JM (2000a) Abdominoplasty without detachment (Abdominoplastia sem descolamento).
XX Jorn Paulista Cir Plast, São Paulo, Jun.
Avelar JM (2000b) Abdominoplasty with preservation of the Deep Vascular Sistem.
(Abdominoplastia com preservação do sistema vascular profundo). Personal Comunication
(Comunicação Pessoal). Monthly Meeting of the Brazilian Society of Plastic Surgery– Section
of Rio Grande do Sul (Reunião Mensal da Sociedade Brasileira de Cirurgia Plástica do Rio
Grande do Sul). May.
Avelar JM(2000c) Abdominoplasty: a new technique without undermining and fat layer removal
(Abdominoplastia: uma nova técnica sem prejudicar e remoção da camada de gordura) Arq.
Catarinense de Med 29: 147–9
Avelar JM (2000d) First Course of abdominoplasty (I Curso de abdominoplastia). Chairman: Prof.
Willian Callia. Invited Professor: Dr. Juarez M.Avelar. Municipal Hospital. São Paulo, march
Avelar JM (2000e) Second Course of abdominoplasty (II Curso de abdominoplastia). Chairman:
Prof. Juarez M.Avelar. Heart Hospital (Hospital do Coração). São Paulo, October
Avelar JM (2000f) A New Technique for Abdominoplasty Subdermal Flap Folded over Itself. XV
ISAPS Congress, Tokyo
Avelar JM (2000g) Abdominoplasty: A New Technique Without Panniculus undermining and
Without panniculus resection. 57th Instructional Course of ISAPS, Chairman: Lloyd Carlsen
Montreal, Quebec, September.
Avelar JM (2001a) Abdominoplasty without lipectomy. Mini Course of ISAPS with Aesthetic
Plastic Surgery Congress of Spain. Valladolid September.
Avelar JM (2001b) The new Abdominoplasty And Derived Technique. ISAPS and ASERF Annual
Meeting. The Aesthetic Meeting. NewYork- September.
Avelar JM (2002a) Abdominoplasty Without Panniculus Undermining and Resection: Analysis
and 3-Year Follow-up of 97 Consecutive Cases. Aesth Plast Surg 16–25
Avelar JM (2002b) Abdominoplasty. The Aesthetic Meeting of ISAPS, Istambul, Turkey
September.
Avelar JM (2016) Creation of the New Umbilicus: My Technique on Abdominolipoplasty and
Further Applications In: Avelar JM New Concepts on Abdominoplasty and Further Applications
Springer, Heidelberg/New York, p107
Callia WEP (1965) Contribution to the study of surgical correction of the pendulum abdomen and
globus (Contribuição ao estudo de correção cirúrgica do abdomen pêndulo e globus). original
art. Doctoral Thesis Fac Med USP, São Paulo- Brazil
Grazer FM, Goldwyn RM (1977) Abdominoplasty Assessed by Survey with Emphasis on
Complications. Plast Recont Surg 59(4): 513–7
Pitanguy I (1967) Abdominal lipectomy: an approach to it through an analysis of 300 consecutive
cases. Plast Reconstr Surg (40) 4:384–391
Pitanguy I (1977) Dermolipectomy of the Abdominal Wall, Thighs, Buttocks, and Upper Extremity.
In: Converse JM, ed. Reconstructive Plast Surgery 2nd edition. Philadelphia: Saundrs, 3800–23
Sinder R (1975) Plastic Surgery of the abdomen - Técnica pessoal de abdominoplastia, com
prévio deslocamento de retalho supraumbilical (antes da resseccão infraumbilical) e uso de
retalho dermoadiposo,– VI International Congress of Plastic and Reconstructive Surgery, Paris
(France) August
Vernon S (1957) Umbilical transplantation upward and abdominal contouring in lipectomy. Am
J.Surg., 94: 490–492.
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Chapter 13
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Abdominoplasty (The Umbilical Lozenge
Technique)
Marcelode OliveiraeSilva
Abstract Obesity is a pandemic. The exponential increase in abdominal correction
surgeries after important weight losses resulting from bariatric surgeries is a logical
consequence. The umbilical scar reconstruction surgical time has a fundamental
importance, and a lozenge- shaped navel contributes to the abdominal aesthetics.
However, the literature shows that the neo-navel is something challenging in these
surgeries, compromising the results and, sometimes, generating dissatisfaction on
the surgeon’s and the patient’s perspective. Unaesthetic healing and stenosis due to
scar contracture are common complaints when circular techniques are used and can
be avoided using the lozenge technique. The most frequent complications related to
omphaloplasty are post-necrosis effacement, stenosis due to circular retraction,
enlargement of the circumference, lack of anatomical contours, and a rayed appearance due to the external suture marks.
Keywords Abdominoplasty · Bariatric surgery · Navel reconstruction ·
Dermolipectomy · Neo-omphaloplasty
Introduction
Obesity is a pandemic. The exponential increase in abdominal correction surgeries
after important weight losses resulting from bariatric surgeries is a logical consequence. The umbilical scar reconstruction surgical time has a fundamental importance, and a lozenge-shaped navel contributes to the abdominal aesthetics. However,
the literature shows that the neo-navel is something challenging in these surgeries,
compromising the results and, sometimes, generating dissatisfaction on the surgeon’s and the patient’s perspective. Unaesthetic healing and stenosis due to scar
contracture are common complaints when circular techniques are used and can be
M. de OliveiraeSilva (*)
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_13
231
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avoided using the lozenge technique. The most frequent complications related to
omphaloplasty are post-necrosis effacement, stenosis due to circular retraction,
enlargement of the circumference, lack of anatomical contours, and a rayed appearance due to the external suture marks.
To avoid a stigmatizing appearance, the neo-navel should have the most natural
and pleasant shape possible. The correct shape and positioning of the neo-navel are
crucial to a satisfactory result. Above these aspects, among the most relevant points
to a good aesthetic standard result are the navel size and the non-visible scars. There
are several omphaloplasty techniques described in the literature, but there is no
consensus as to the best technique for its execution.
The systematization of this surgical stage avoids excessive manipulation of the
umbilical pedicle and reduces the surgical time spent in this step, minimizing the
risk of necrosis by ischemia and improving the neo-navel’s nal aesthetic appearance, resulting in a patient’s high satisfaction rate. The aim of this chapter is to
describe omphaloplasty by the lozenge technique in abdominal dermolipectomy,
demonstrating its technical details.
M. de OliveiraeSilva
Prof. Ivo Pitanguy Abdominoplasty Surgical Technique
The classic technique described by Pitanguy simultaneously approaches the aesthetic
and functional correction of the patient’s abdomen, always obeying the same principles: the abdominal wall reinforcement, repair of eventration and herniations, excision of adipose tissue excess, and correction of skin deformities (scars or stretch marks).
After preparation of the anesthetic team and placement of surgical drapes, the
midline of the abdomen is marked with a wire xed to the xiphoid process and
another 7cm above the vaginal sternal notch. The incision is drawn keeping it low
and following the inguinal pleat, curving upward on the sides. With the two long
wires, the symmetry of the marking is veried, which must extend to a point located
on an imaginary vertical line that passes over the anterosuperior iliac spines.
The navel is demarcated with a circular incision.
The transverse incision is performed by deepening the subcutaneous plane in a
beveled manner, creating a discreet fat pad in the pubis. The detachment proceeds
above the muscular fascia, meticulously performing hemostasis. The detachment
will continue until the umbilical scar, where a circumferential incision allows to
isolate the navel, leaving it inserted in the abdominal wall. The detachment continues superiorly until it reaches the xiphoid process, creating a tunnel to expose the
sheaths of the rectus abdominis muscles. The lateral limits of the detachment are the
costal margins (avoiding unnecessary lateral detachment).
The aponeurosis is reinforced from top to bottom, starting high enough to avoid
prominence in the epigastrium. Two strong hooks are used to test the desired tension
on the aponeurotic edges at the level of the navel. This anchorage must be performed
checking the degree of diastasis, without excessive tension, with non- absorbable
sutures and with inverted mattress stitches, that is, in X with the knot facing inward.
After diastasis correction, the anesthetist is asked to place the table slightly bent,
elevating the patient’s upper body by approximately 15°.
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The upper ap is xed to the suprapubic skin at the midline with a strong temporary suture. The lateral aps are then pulled inferiorly. Pitanguy marking tweezers
are used to determine the amount of tissue to be excised. The long sutures of the
xiphoid process and above the vaginal notch serve to verify the symmetry of the
marking and its position on the ap. With a rm countertraction of the auxiliary, the
ap is excised, beveling the subcutaneous tissue in order to better accommodate the
initial transverse incision.
The aps are distributed with temporary sutures, compensating medially so as
not to create “ears” (or “wrinkles”) and decrease the nal extension in the scar. The
Pitanguy tweezer is again used to determine the position of the umbilicus in the
midline.
The navel must be exteriorized through the appropriate circumferential incision.
A straight incision of about 1–1.5 cm is made, since in the ap traction, it will
become circular. A fat cone should be removed from the ap of this incision, allowing a better accommodation of the umbilical scar, thus creating a gentle periumbilical depression.
The nal closure of the incisions is performed by planes. It is of paramount
importance to redo the plan of Scarpa’s aponeurosis, ensuring a rm plan of approximation. Drains are routinely exteriorized on the pubic region.
A compressive curative is applied using a plaster shield wrapped with cotton and
bandage, allowing a rm and well-distributed compression. Umbilical curative must
be done with gauze and spherical objects (e.g., marbles) to avoid stenosis.
The abdominal strap is placed the next day, and the patient is recommended to
maintain a more curved posture, thus protecting the anchorage of the rectus abdominis muscles.
233
The Omphaloplasty Lozenge Technique inAbdominoplasty
In this technique, the preoperative marking of the suprapubic horizontal scar is
made between 6 and 8cm from the vaginal notch, during a superior traction maneuver of the prepubic region (Fig. 13.1). The marking is performed in bed, with the
patient in an orthostatic position, and checked with the patient in the supine position, already in the operating room.
As prophylactic measures, cefazolin 2g is administered, 30min before the start of
surgery, as directed by the hospital’s infection control commission, and the pneumatic
compression system is placed on the lower limbs over the previously worn compression stockings. The stockings are kept until the seventh postoperative day (Fig.13.1).
Midline marking is performed with the patient in the supine position, connecting the
xiphoid process to the vaginal notch. A uniform traction of the prepubic region into
cranial direction, with the open hand in the region of the lower abdomen, gives the
distance from the previously marked vaginal notch. At this point, starting from the
midline, a horizontal marking of 6cm is made on each side, with the aid of a compass.
The horizontal and bilateral marking extends in an arcuate fashion, with the superior
concavity toward the lower transverse fold of the abdomen, with the lateral limits of the
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Fig. 13.1 The height
incision’s marking in
abdominoplasty
M. de OliveiraeSilva
Fig. 13.2 (a) Vertical marking of umbilical incision’s measure. (b) Horizontal marking of the
umbilical incision’s measure
anterosuperior iliac crests. Such marking can be extended later after compensation of
the skin-fat ap, if necessary. The lozenge-shaped marking for the incision and release
of the navel is made with the assistant surgeon distributing the skin in this region in an
eccentric manner with both hands opened. The lozenge measurements are 1.4cm, in
the craniocaudal direction, and 1.0cm, in the latero-lateral direction (Fig.13.2a, b).
The rst incision is made in the supercial lozenge-shaped marking in the periumbilical region, with a cold scalpel with blade no. 15. Then, in order to deepen the
incision, in the same place, we used the no. 11 blade, and to nish the dissection and
isolation of the umbilical shape, up to the aponeurotic plane, we used Metzenbaum
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235
scissors. Then, a horizontal suprapubic incision is made, and the skin-fat ap is
detached, in a tunnel, up to the xiphoid process, allowing the plication of the rectus
abdominis muscles. During this surgical stage, eventual ventral and umbilical hernias are corrected, without violating the umbilical stump skin.
The umbilical stump is xed to the aponeurosis with four cardinal points, with
3-0 mononylon thread, preserving a distance between the skin and the aponeurosis
of 0.5cm (Fig.13.3).
After resection of the excess skin-fat tissue from the detached ap, it is pulled
and anchored, with temporary sutures, to the suprapubic ap, with 2-0 or 3-0 mononylon. Under the xed ap, we digitally located the position of the umbilicus in the
aponeurosis and marked the center of the location of the neo-navel, using the digital
projection under the ap (Fig.13.4).
The lozenge-shaped marking of 1.4×1.0cm is repeated, and the lozenge center
is dened by the previous digital maneuver (Fig.13.5a, b).
A new incision, perpendicular into its full thickness, is made in the new lozengeshape marked on the ap, to expose the umbilical stump xed to the aponeurosis
(Fig.13.6).
Next, we mark the positioning of the upper ap in relation to the lower one, with
a dermographic pen, and the temporary suture was removed, allowing the ap eversion. With this maneuver, we performed a lipectomy in the region of the lozenge,
using Metzenbaum scissors, which contributes to reducing the tension in the umbilical scar, besides forming a depression in the peri-umbilical region, simulating the
umbilical groove and, consequently, giving appearance of naturalness to the abdomen (Fig.13.7).
Fig. 13.3 The height of
xation of umbilical stump
marking
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M. de OliveiraeSilva
Before the ap repositioning, we marked the upper and lower ends of the umbilical scar with two 4-0 mononylon threads. The two ends of the wires, with entry in
the epidermis and exit in the subdermis of each end, are repaired with Halstead
tweezers, at the lower end (straight), and curved, at the upper end (curve). Both are
passed through the lozenge-shaped hole made to expose the umbilicus (Fig.13.8a, b).
The wires repaired in the umbilical scar serve as a reference for the navel’s position, avoiding twisting and facilitating the xation of the umbilical stump in its
Fig. 13.4 The neo-navel
marking
Fig. 13.5 (a) The neo-navel vertical measure marking. (b) The neo-navel horizontal mea-
sure marking
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237
corresponding position in the ap. The four sides of the created lozenge-shaped
hole are xed with Gillies stitches, using 4-0 mononylon thread (Fig.13.9).
The ap is repositioned according to the previous marking, and the closure is
performed with sutures in layers, with absorbable thread 3.0in two subdermal layers and with non-absorbable thread 3.0in the intradermal layer. After closing the
Fig. 13.6 The umbilical
stump exposition
throughout the ap
Fig. 13.7 Hemostasis and
lipectomy to realize ap
eversion
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Fig. 13.8 (a) Mononylon 4-0 thread on the superior and inferior extremities of the umbilical
stump, with epidermis entry and subdermis exit. (b) The repaired threads are passed through the
ap hole
Fig. 13.9 The repaired
threads are the reference of
the navel’s position in
relation to the ap,
facilitating the xation of
the umbilical stump in
your corresponding
position in the ap
M. de OliveiraeSilva
suprapubic incision, incisional VAC therapy is installed over the neo-navel and over
the entire suture line (Figs.13.10 and 13.11).
Patients are discharged from hospital 48h after surgery. Incisional negative pressure therapy is withdrawn on the rst outpatient visit (4 to 6days after surgery). All
patients are instructed in the same way regarding postoperative care and return to
activities (Figs.13.12, 13.13, 13.14, 13.15, 13.16, 13.17, 13.18, 13.19, 13.20, 13.21,
13.22, 13.23, 13.24, 13.25, 13.26, and 13.27).
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