Omphaloplasty: Y/V technique
Onfaloplastia: técnica Y/V

INTRODUCTION

Abdominoplasty is a type of plastic surgery that is carried out for essentially aesthetic purposes. In recent years, it has become a common procedure among women who desire to improve their body image, self-esteem, mental health, sexual relations, and quality of life. One of the most important steps in this surgical procedure is the reconstruction of the umbilicus.

The characteristics of the umbilicus include a depressed scar surrounded by skin folds, located in the anterior abdominal wall, approximately 18-23 cm from the vulvar commissure, 4 cm above and 2 cm below the horizontal line that passes by the two anterior superior iliac spines¹. The umbilicus has an elliptical shape in the vertical direction, or T-shape with a longitudinal axis that passes vertically in the midline. The mean diameter of the umbilical cord ranges from 1.5 to 2 cm, with a conical depression whose vertex is attached to the anterior muscular wall of the abdomen².

Anatomical studies performed by Dick in 1970³ showed four fibrous cords connected to the umbilical surface, which are responsible for the displacement of the umbilicus in the posterior direction. These fibrous structures originate from traces of the umbilical vein, the urachus, and the two umbilical arteries.

The umbilicus is the only natural scar on the body, and is therefore an important and essential aesthetic component of the abdomen. Given that customs and fashion increasingly stimulate the exposure of the abdomen, the secondary umbilical scar of dermolipectomy is a frequent concern of surgeons and patients.

The concern with aesthetics, however, does not coincide with the development of abdominoplasty. In the 19th century in France, some techniques removed the umbilicus alongwith the abdominal flap⁴. Weinhold Zentralb, in 1909, was the first to retain the umbilicus during abdominal dermolipectomy⁵.

In 1924, First performed the first umbilical transposition. Since then, many geometric shapes were attempted to obtain a scar that was close to the natural shape of the umbilicus. In 1931, Flesch-Thebesius and Weisheimer preserved a skin triangle in the umbilicus^6,7. Prudente, in 1943⁸, and Andrews, in 1956⁹, performed a transposition through circular incisions, leaving it in a skin cylinder. In 1957, Vernon¹⁰, also using a transposition of circular forms observed many stenoses at the umbilicus, which became challenging.

In 1979, Avelar¹¹ presented his technique wherein multiple “Vs” shaped incisions were made on the inner face of the umbilicus, breaking the scar into three flaps. In this sense, other Brazilian authors, such as López-Tallaj & Gervais, in 2001, Saldanha et al., in 2003, D’Assumpção, in 2005, and Mello & Yoshino in 2009^12-15, also proposed the use of various geometric shapes in search of the “ideal umbilicus”.

Since the introduction of classic abdominoplasty, the umbilicus is preserved in its original position and is refixed through a hole in the abdominal flap. Even with the advancement of many techniques, the umbilicus continues to be fixed in the same manner.

In modern abdominoplasty, several forms have been created, with respect to both the umbilical scar and the cutaneous flap opening, with the sole objective of obtaining a result that resembles the natural umbilicus. Round, oval, drop-shaped, triangular forms with upper or lower base, and lozenges have been proposed. However, they all have a scar that surrounds the entire perimeter of the umbilicus^16,17.

OBJECTIVE

To minimize the unsightly scarring effects associated with omphaloplasty, we propose the use of a technique that has demonstrated positive operative results and results in a more natural scar and with a lower rate of postoperative complications.

METHOD

In this study, 88 female patients between 27 and 62 years of age, with a mean age of 43 years, underwent surgery using the “Y”/“V” technique between June 2012 and May 2015.

Our marking was performed with the patient in an upright position, the midline being marked in the preoperative period and reinforced after asepsis of the patient and the operative region to prevent possible lateral displacement of the neoumbilicus (Figure 1).

Figure 1 - Surgical marking.

Figure 1 - Surgical marking.

All procedures were performed after epidural and intravenous sedation administered by the team anesthesiologist. After asepsis, the surgery began with the use of a no. 15 scalpel blade on the skin and was followed by the detachment of the abdominal flap with an electric scalpel. The detachment extends up to the umbilicus, with the umbilicus being isolated with a round-shaped scalpel blade no. 15 (Figure 2).

Figure 2 - Isolation of the umbilicus.

Figure 2 - Isolation of the umbilicus.

After isolation of the umbilicus, we continue with the elevation above the umbilicus up to the xiphoid appendix, forming a tunnel without extending this detachment laterally to prevent vascularization problems of the flap. After completing the detachment, we raise the head of the patient and evaluate the amount of the flap that will be resected based on the previous marking. Once the flap is removed, and plication of the rectus abdominis is performed, we specifically perform the proposed technique.

The fixation of the umbilical stump is performed with separate sutures in the aponeurosis of the rectus abdominis muscles, being evaluated based on its mobility based on the thickness of the panniculus resulting from the definitive abdominal flap (Figure 3). The rounded resected umbilical island is modeled with curved scissors to attain a “Y” shape, with the removal of a skin triangle in the cephalic portion and rectified on its right and left sides to form a “Y” (Figures 4 and 5).

Figure 3 - Fixed umbilical stump.

Figure 3 - Fixed umbilical stump.

Figure 4 - Umbilical island in the shape of a “Y”.

Figure 4 - Umbilical island in the shape of a “Y”.

Figure 5 - Modeled umbilical island.

Figure 5 - Modeled umbilical island.

After fixing the abdominal flap in the lower scar, marking the location of the neoumbilicus in the abdominal skin flap is held in the form of “Y,” by using a maneuver that introduces the hand by the lateral opening of the flap, where, by contiguity, the umbilicus is palpated, and this is projected into the skin after the introduction of a 25 × 7 needle in the direction of the index finger of the surgeon, which is on the umbilical island fixed to the aponeurosis, without which the surgeon can be injured (Figure 6).

Figure 6 - Maneuver that enables the location of the umbilicus.

Figure 6 - Maneuver that enables the location of the umbilicus.

This point is marked on the lower portion of the surgeon’s finger. After this first point, a new marking is made with methylene blue at a distance of 1.0 to 1.5 cm in the middle line above point 1 (depending on the thickness of the panniculus and the width of the patient to avoid large or small neoumbilicus on the patient’s abdomen). Thereafter, two lateral and superior points are marked between 0.5 and 1.0 cm of point 2, thus forming the “Y” proposed in this technique (Figure 7).

Figure 7 - Marking with methylene blue.

Figure 7 - Marking with methylene blue.

At this point, the skin is incised on top of the “Y” marking (Figure 8), and a fat cylinder is removed from the already fixed abdominal flap (Figure 9). To prevent umbilical stenosis, two “slivers” of the lateral flaps of the Y are removed to accommodate the umbilical suture better (Figure 10).

Figure 8 - Incision on top of the “Y” marking.

Figure 8 - Incision on top of the “Y” marking.

Figure 9 - Withdrawal of a fat cylinder from the previously fixed abdominal flap.

Figure 9 - Withdrawal of a fat cylinder from the previously fixed abdominal flap.

Figure 10 - Withdrawal of “slivers” of the lateral skin flaps of the “Y” incision.

Figure 10 - Withdrawal of “slivers” of the lateral skin flaps of the “Y” incision.

The umbilical suture begins with the triangular skin flap, formed by the incision in “Y” next to the vertex of the “V” removed on the umbilical island, allowing the descent of this flap and upper intraumbilical accommodation, which provides the concealment of the scar at this level (Figure 11). Subsequently, the bottom vertex of the umbilical island is fixed to the bottom vertex of the “Y” incised in the abdominal flap. Two lateral sutures are held next to the upper lateral vertices of the umbilical island and the lateral sides of the “Y” incised in the skin (Figure 12).

Figure 11 - Umbilical sutures.

Figure 11 - Umbilical sutures.

Figure 12 - Sutured umbilicus.

Figure 12 - Sutured umbilicus.

After these four pillars of fixation, the suture is completed with two more sutures at each side and two sutures between the initial triangular flap and the lateral vertices of the Y. 4-0 colorless nylon sutures are used.

Finally, with respect to the neoumbilicus, there is an open Y-shape, with its triangular caudal part and the cephalic part embedded within the panniculus of the abdominal flap, which provides more aesthetics to the neoumbilicus and a reduction in abdominoplasty stigma with a more apparent and sutured umbilicus (Figure 13).

Figure 13 - Immediate postoperative aspect.

Figure 13 - Immediate postoperative aspect.

Finally, wound dressing was performed using neomycin and the introduction of a ball-shaped gauze, which was replaced by a silicone umbilical mold after 48 h after surgery. The umbilical sutures are removed after 7 days, and the condition of scar is observed at this time.

RESULTS

A significant decrease in cases of umbilical stenosis was demonstrated in patients who underwent surgery in our study compared to the incidence noted with circular, oval, and other techniques. Additionally, a more natural shape is observed compared to an abdomen without a scar(Figures 14 to 19).

Figure 14 - Pre-operative aspect.

Figure 14 - Pre-operative aspect.

Figure 15 - Immediate postoperative aspect.

Figure 15 - Immediate postoperative aspect.

Figure 16 - 15 day postoperative aspect.

Figure 16 - 15 day postoperative aspect.

Figure 17 - 30 day postoperative aspect.

Figure 17 - 30 day postoperative aspect.

Figure 18 - 60 day postoperative aspect.

Figure 18 - 60 day postoperative aspect.

Figure 19 - One-year postoperative aspect.

Figure 19 - One-year postoperative aspect.

Complications include suture dehiscence in three cases, wherein we observed that, in these patients, the panniculus was denser (3.4%), umbilical stenosis developed in 1 patient (1.13%), color changes in the scar occurred in 4 patients (4.54%), keloid scars developed in 2 patients (2.27%), which were surgically corrected after 6 months.

Altogether, 11.34% of patients experienced complications; thus, we conclude that the technique was efficient and reduced umbilical scarring, requiring constant studies and adaptations to prevent the complications noted above.

It is important to note that a thorough physical examination and a good indication for surgery will lead to better results, considering all the factors involved during surgery.

DISCUSSION

There are several techniques for the construction of the neoumbilicus. The main techniques used are a circular shape, “V” shape and other designs proposed by several authors. To date, in our experience, the more harmonious and natural results, from the aesthetic point of view, are obtained with non-circular designs because they result in less stenosis of the umbilical scar.

Our proposed technique is easy to perform, with good aesthetic results, and a more natural postoperative abdomen after dermolipectomy with regard to the acceptance by patients of the resulting umbilical scar.

The final open Y format is closer to the natural aspect of an abdomen that has not been operated on.

Other authors perform neo-omphaloplasties in non-circular forms, with satisfactory results in relation to the aesthetic natural look of the neoumbilicus.

CONCLUSION

The technique reported in this study is a good alternative to other techniques used in the treatment of the neoumbilicus. Long-term monitoring and increasing the number of cases will be important in evaluating the technique and defining its use.

This proposed technique is simple to implement, providing a better long-term aspect of the umbilicus, with improved natural results and prevents frequent stenoses of the umbilicus that occurs with techniques that attempt to achieve a round-shape. It was called “Y” due to the shape of the incision on the skin of the abdominal flap for the formation of the neoumbilicus.

We suggest its use after the analysis of these cases, which proved to be satisfactory for both the surgeon and the patients who submitted to abdominal dermolipectomy, thus increasing the technical and tactical arsenal of the clinical surgeon.