Secondary omphaloplasty: description of a new proposal

Introduction: The navel is an essential component of abdominal aesthetics. Omphaloplasty sequelae can compromise the result of an abdominal abdominoplasty. The purpose of this article was to propose an alternative procedure that is simple to perform and well accepted by patients, with favorable cosmetic results. Methods: We surveyed cases of abdominal dermolipectomy in teaching hospitals and in private practice in the last 5 years (433 cases). Results: We found 30 cases (6.9%) of sequelae distributed as follows: 14 cases (3.2%) in the hypogastric scar and 16 cases in the umbilicus (3.8%). They are characterized as follows: 7 cases (1.6%) of constriction of the navel and 9 cases (2.07%) of scar hypertrophy. Conclusion: We analyzed the results of the proposed technique of secondary omphaloplasty in the immediate (up to 30 days) and late (1-year) postoperative periods.

Within the secondary surgeries, from our own statistics and those of other services, we found cases of vicious A number of different techniques have been used for cosmetic reconstruction to improve the appearance of a cicatrix of the navel 2,6 .The subject is still under discussion, as an ideal solution is yet to be found.This paper proposed a new procedure that is simple to perform and offers acceptable cosmetic results.
The immediate postoperative results (up to 30 days) were the following:  Constriction of the navel: improvement of 90% compared with that in the preoperative period.
Navel scar hypertrophy: improvement of 80% compared with that in the preoperative period.
Late postoperative results (1 year) showed the following: Constriction of the navel: persistence of 70% of the immediate result compared with that in the preoperative period.
Navel scar hypertrophy: greater than 50% improvement compared with that in the preoperative period (Figure 3).
For these reasons, this paper aims to propose an al- ternative procedure, easily performed and well accepted by patients, with favorable cosmetic results.

Surgical Technique
In the classic abdominoplasty or lipo-abdominoplasty, scars result in the upper pubic and periumbilical regions 5 .If an unfavorable evolution of the navel scarring occurs (stenosis, keloids, and hypertrophic scars), the intention is to improve its appearance for better abdominal harmony 3,4,5 .
With the goal of minimizing the problem of circular scars, we sought to distribute the centrifugal force of the scar, widening the area of contact of the skin on the abdomen with the umbilical stump, delimiting two semicircles (variant 1) or making a triangle with a larger base (variant 2 as shown in Figure 4A and B).
Based on variant 2, the delimited area is decorticated with the isolation of the navel and slimming of the periumbi-  With retro-umbilical defatting, postoperative aesthetic sinking of that region can be achieved, which enhances the result.
In variants 1 and 2, fixation of the decorticated area follows.The internal part of the semicircle is attached in the abdominal aponeurosis, with simple cardinal stitches by using a mononylon 3.0 suture.The umbilical stump skin is then enmeshed with the skin of the abdominal wall, with Perseu Lemos stitches by using a mononylon 4.0 suture (Figure 6A and B).In this way, all the tension of the umbilical scar will be distributed between the aponeurosis fascia and the navel skin plane in the abdominal wall.This fixation is performed with simple, separated stiches of nylon 3.0.Through this procedure, the tension on the superior skin fascia is minimized to achieve a final aesthetic result in the late postoperative period (Figure 4A and B).
This type of overlapping in the dermis of the umbilical stump brings a wider area of cicatrix contact to minimize umbilical stenosis, which occurs in traditional omphaloplasty techniques with circular scars (Figure 8).

RESULTS
Figure 8. Distribution of forces of the umbilical stump in the surrounding skin.
The results were evaluated and compared between the immediate (up to 30 days) and late postoperative periods (after 1 year) in patients who had undergone classic techniques of dermolipectomy and lipoabdominoplasty.The evaluations considered the percentiles of improvement and relapses.
We illustrate the results of this study in Figure 1, comparing the preoperative aspects with the immediate and late results in two patients (scar hypertrophy and umbilical constriction).Patient 2: Umbilical constriction.Figure 10: A, B, and C.

DISCUSSION
Although abdominoplasty is a technique that aims to produce a great degree of acceptability, an unsightly umbilical scar can compromise the result of the surgery 1 .The idea of broken incisions, which was proposed by Avelar (incision in the umbilical skin in the shape of a "Y"), reduced the incidence of stenosis that resulted from the circular incisions 1,3 The application of other techniques that avoid that unpleasant aspect is still a challenge for most plastic surgeons.
That assumption, far from offering a final solution to that problem, is based on the principle of the distribution of forces in two directions, one horizontal and one vertical, minimizing the risk of relapses and complications.
The distal result of the suture of the decorticated area in the abdominal aponeurosis will tend to unite the medial edge of the decorticated tissue to the abdominal aponeurosis, whereas the proximal result will tend to push the abdominal skin against the umbilical stump skin (Figure 8).Those resulting from the liberated umbilical stump will also undergo the action of this distribution, where its vertical component pushes the same up, allowing for a looser stump, with no tension and with its horizontal component bringing even closer the abdominal skin, which is already almost completely overlapped (dotted arrow; Figure 7 A and B).
Thus, tension distribution of the scar to the aponeurosis fascia of the umbilical stump can be achieved, allowing a more favorable aesthetic result.

CONCLUSION
Our evaluation compared immediate (up to 30 days) and late postoperative results (after 1 year; Figure 3).
Even today, achieving excellent results in abdominal abdominoplasty continues to be a challenge for plastic surgeons.This led us to the current proposition based on the principle of force distribution.We selected 16 cases, among a universe of 433 surgery cases, for this comparative study.

Figure 1 .
Figure 1.Distribution chart of the techniques used in the 433 cases

Figure 2 .
Figure 2. Chart of the sequelae found

Figure 3 .
Figure 3. Evolution of results in 1 year

Figure 6 (
Figure 6(A): Deep fixation of the internal edge.Overlapping of the proximal pole.

Figure 6 (
Figure 6(B): Deep fixation of the internal edge.Overlapping of the distal pole.

Figure 7 (
Figure 7(A) and (B): Distribution of tension in the resulting scar.
Figure9: A, B, and C

Figure 9 (
Figure 9(A): Preoperative picture of a patient with umbilical scar hypertrophy.

Figure 10 (
Figure 10(A): Preoperative picture of a patient with umbilical constriction.