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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_611_Библиотеки_им_академика_М_И_Перельмана
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Fig. 27.21 Preoperative and 1year postoperative photo
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Fig. 27.21 (continued)
although patients were satised. With the advent
of these technologies, application of 10–20 sessions has visually improved the nal result, both
in the surgeon and the patient’s eyes. We believe
it is a must for adjuvant therapy after circumferential liposuction of 360°. Also, we recommend
between 10 and 20 sessions of lymphatic drainage especially in the rst 2weeks after surgery
(Fig.27.24). We also provide the patient with a
chart of food that cause and ght inammation,
encouraging them to have more of the later
(Fig.27.25) [19].
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Fig. 27.22 Preoperative and 1year postoperative photo
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Fig. 27.22 (continued)
I. Fakih-Gomez et al.
Fig. 27.23 External ultrasound is done to favor skin
retraction and reduce inammation
Fig. 27.24 Pressotherapy device helps lymphatic drainage thus reducing inammation
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Fig. 27.25
foods- that- ght- inammation
Food that ght and cause inammation. Source: https://www.health.harvard.edu/staying- healthy/
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I. Fakih-Gomez et al.
27.8 Complications
Complications include organ or rib cage damage,
as some undetected hernias may be present and
inadvertently perforated. Although this is a major
complication, it is very uncommon. Control over
the cannula, continuous palpation of tissue being
aspirated, and tangential movements may help
decrease this complication.
Deep venous trombosis may be present in the
postoperative period due to venous stasis during
surgery, immobilization in the postoperative
period and individual factors discussed previously. Virchow’s triad should be suspected and
treated accordingly with heparine.
Sudden desaturation, non-responding to oxygen support, with or without chest pain, will
point out pulmonary embolism. This can be a
life-threatening complication and may require
intensive care support. If suspected, undergoing a
CT scan to ensure diagnosis is mandatory, and
we advise to consider consultation with intensive
care unit to prevent a fatal outcome.
As for typical liposuction consequences,
bruising will be present in almost every case.
Patient should be advised that it will resolve
within a month. Discoloration may appear, especially with early sun exposure, but will improve
with time.
Weakness is also common, usually if large
volume liposuction was performed. Iron supplementation, blood transfusion, or autotransfusion
may be helpful. We recommend early deambulation, iron, and vitamin supplements and high protein diet to all our patients to accelerate recovery
time.
27.9 Conclusion
Liposuction still remains one of the most performed cosmetic surgical procedures worldwide.
360° liposuction addresses the front and back
part in a holistic approach to achieve a more aesthetic gure. Liposuction technologies have signicantly advanced over the last generation. The
appearance of new devices allows us easier sur-
geries, safer techniques, and more consistent and
improved results with better skin retraction. Postmaternity liposuction is a tricky procedure due to
skin laxity after pregnancy. Preoperative assessment of skin quality and use of enhancing skinretraction machines is mandatory.
Disclosure The authors received no funding support and
declared no potential conicts of interest with respect to
the research, authorship, and/or publication.
References
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Harv Health Lett. 2015;40(4):5.
Umbilicoplasty
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ValderiVieirada SilvaJúnior, JoséFrota,
andCésarCals
28
28.1 Introduction
The navel is an important scar for abdominal aesthetics [1]. It is described as an aesthetic subunit
in itself, a mark that is essential to the overall aesthetics of the abdomen [2]. Your appearance and
position are important to the end result of a
tummy tuck. However, its reconstruction and
appearance improvement are always difcult for
the plastic surgeon [1].
It is the body’s rst natural scar and has its
position described between the third and fourth
lumbar vertebrae. It measures between 1.5 and
2cm deep, rests on the midline between the upper
iliac crests and changes with age and is inuenced by the thickness of abdominal fat, weight
changes, pregnancy, hernias, and scars. It has
four brous cords, which are reminiscent of the
umbilical vein, the uracus, and the two umbilical
arteries and exert deep traction to x and deepen
it. It helps to dene the middle portion of the
abdomen, demarcates its lower portion, and its
absence and mispositioning dene an unnatural
aspect of the abdomen [1, 3].
V. V. da SilvaJúnior (*)
Plastic Surgery of Stetic Class Clinic, Plastic Surgery
of Instituto, Fortaleza, Ceará, Brazil
J. Frota
Plastic Surgery of Hospital, Fortaleza, Ceará, Brazil
C. Cals
Fortaleza, Ceará, Brazil
The navel shape can be described based on six
forms described by Delpierre etal.: T-shape, vertical oval, horizontal oval, round, distorted, or
protruding. In general, the most common shapes
are round and vertical. However, in older or overweight patients, the horizontal shape becomes
more common [4].
28.2 Surgical Techniques
28.2.1 Procedures Step by Step:
Umbilicoplasty
andAbdominoplasty
Postpregnancy changes are very undesirable for
some women, and abdominoplasty appears to be
a high satisfaction option for the patient because
of the great improvement in body contouring [5].
A badly made belly button may even be acceptable, but its absence becomes noticeable and a
cause for extreme stress. Important factors for
good navel reconstruction are the position, depth,
shape, and location of the scar. Thus, for a good
completion of surgery, the navel should be well
located and nished [1]. Although the midline is
considered a pleasing navel position, a 2003
study by Rohrich noted that most navels do not
rest on the midline [6], which may be acceptable
but slightly lateralized midline positions.
Tummy tuck evolved in terms of technique,
safety, aesthetic outcome, and decreased compli-
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_28
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cations. This made the results more natural.
However, the navel is still a major challenge
because it presents many healing and shape variables, thus the success of the surgery is based on
the result of a reconstructed navel [4].
Umbilicoplasty (or omphaloplasty) is the
method to give a more anatomical and natural
appearance to the abdomen, and there are several
techniques [4]. Since Vernon rst described it in
1957, almost every abdominoplasty technique
has described a custom omphaloplasty method,
resulting in a wide variety of different incision
patterns used to relocate the umbilical scar [7–
19]. Over the years, there have been many studies
in the literature focusing on the positioning of the
navel in the abdomen, as well as its ideal anatomical shape, size, and depth. Although these
studies share some commonalities in determining
what is ideal, there are still differences [20].
The denitions of high or low navel position
are left to the surgeon’s personal judgment.
These are probably the reasons why there is no
standardization regarding its repositioning during abdominoplasty, as well as there is no consensus on the ideal umbilicoplasty technique
[21]. Its main purpose is to create a natural,
deep, and scarring navel. Some techniques use
attachment points or local aps. However, some
may be shallow or wide and unnatural [3]. In
addition, the scar formed around the navel is the
most noticeable that the panties or pants cannot
cover. Therefore, the best aesthetic result is targeted [20].
Classical umbilicoplasty consists of the vertical elliptical incision of the treated navel, the
xation of the stump on the abdominal wall, and
the subsequent steriorization of the abdominal
ap by a vertical elliptical incision. However,
despite the similarity of various techniques of
this particular approach, surgeons have continually modied this umbilicoplasty pattern in the
hope of obtaining a more aesthetically pleasing
form, better scar appearance, and adequate
umbilical depth [20].
Many techniques have emerged to try to simulate a more natural navel, but many leave the
navel stigmatized as it was operated, which
frustrates the surgeon, especially the patient.
They vary widely, but most have some result
limitation, whether in shape or contour, depth,
level of complications such as wound dehiscence, stenosis, broad, or small. However, all of
them aim to make the navel as natural as possible [20].
28.2.2 Technical Tips toImprove
Outcomes andAvoid
Complications
28.2.2.1 Tactics foraGood
Umbilicoplasty
For successful umbilicoplasty, the nal incision
design on the remaining umbilical stump is a
very important variable. There are a variety of
stump incision forms, and the round or oval shape
accounts for 90% of the studies [20].
Incision in the abdominal ap is also another
decisive factor in the outcome. As the circular
scar is associated with a higher rate of navel stenosis, there was a constant attempt to create noncircular incisions [22]. It was believed that
complications with umbilical opening stenosis
could be the way the abdominal ap is incised.
Variations in abdominal ap incision design have
been described to give better aesthetic results and
more discrete scars, such as inverted U described
by Malic. In addition, many designs of the
abdominal ap incision have been described,
such as round, vertical ellipse, Y or U shape,
inverted V, vertical line and vertical oval.
However, the incision in the abdominal ap does
not always coincide with the incised shape in the
navel [18].
Other authors have described a variation of
inverted U and the xation of the abdominal ap
through the dermis to the abdominal fascia to
give a periumbilical depression effect [23, 24]
and Castillo describes the Y incision [25].
The xation of the umbilical stump to the rectus muscle or not, the degreasing or not of the
abdominal ap in the region where the remaining
stump will be xed to create the periumbilical
concavity (80% of the studies) are maneuvers
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that can inuence the nal aesthetic result of the
navel [20]. Hazani suggests an incision in the
inverted U-shaped abdominal ap with xation
of this ap portion in the aponeurosis and skin
grafting in the defect region [26].
Some authors advocate the xation of the
stump to the deep plane of the rectus abdominis
fascia [20]. Dogan does not nd it necessary [27].
This maneuver may cause greater tension in the
nal suture of the stump to the abdominal ap,
resulting in hypertrophic scars, especially in
obese patients, where the ap thickness is greater.
For this, it is suggested the xation of de-epidermal portion of the abdominal ap in the rectal
fascia to decrease this tension and have satisfactory aesthetic result of the scar [28].
Additionally, the measurement of this incision
design is also an important factor in obtaining the
best aesthetic result and reducing stenosis. Some
studies determine the exact measurement of the
incision to be 1.8–2cm. However, they have not
been able to avoid the articial aspect of the operated navels but have reduced the complication of
large navel-like navels, as a measure that can
avoid this situation has been standardized [28].
The position of the navel in the abdominal
wall is also very important. In the work of
Abhyankar et al., study was conducted with a
group of 75 women, a distance of 25.69 cm
between the xiphoid and the pubis was observed.
From the navel, the pubic symphysis was
16.18 cm. And the average navel depth was
1.16cm [1].
In 2013, an observational study of the navel
anatomical surface was developed. Studies have
shown that besides being midline, the most
attractive position is the divine ratio or golden
ratio. That is, the ratio of measurement from the
lower portion of the xiphoid appendix to the
navel to the lower abdominal portion is 1.62.
Bone pelvic marks are not considered reliable as
a reference for umbilical positioning [29].
Rodriguez et al. concluded that the pubic
umbilical distance may vary depending on the
patient’s weight, and 15cm distance may be a
good parameter to dene the new navel position
in abdominoplasty [30].
The discussion to dene the shape, the ideal
position, and the best surgical reconstruction of
the navel is ongoing. Studies that propose to elucidate and standardize the ideal navel position in
the abdomen have failed to dene this.
Anthropometric measurements involve different
navels among women of different ethnicities,
ages, and body mass index. Therefore, the navel
reinsertion only by measurement makes this
technique unreliable and reproducible in umbilicoplasty [20].
The type of surgical thread used can also be a
deciding factor for a good end result. Although
more data are needed to have an objective conclusion on the type of suture around the navel,
77.8% of the studies concluded with nonabsorbable sutures. Given the high incidence of poorlooking or hypertrophic scars in the umbilical
incision, it has been suggested that suturing with
nonabsorbable threads may reduce these complications following umbilicoplasty [20].
28.2.2.2 New Stage: Navels without
Scars
In a quest to achieve more natural navels, techniques were developed that included the amputation of the original navel to perform a
complete umbilical reconstruction [31].
Clo and Nogueira propose an X-incision and
the making of four V-aps, which are xed in the
aponeurosis of the musculature, leaving a deep
and scar-free navel [32].
In another technique, stitches are given in the
abdominal ap dermis where it was calculated to
be the new navel, and they are attached to the
abdominal aponeurosis just below. However, a
shallow navel index was observed between 20
and 30% of cases, which may be high incidence
in the technique to reduce complications [31].
To reduce this shallow aspect, there are some
tactics, such as using the decorticated umbilical
remnant to x the skin of the abdominal ap
where the new belly button will be made. This
xation with stitches is made around and in the
center of the remaining navel stump. That is,
instead of amputating, it is partially used to
secure the background of the new one. This tactic
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