Massive weight loss abdominoplasty with novel technique of umbilicus reconstruction
Reviewed by Philip Geary

This paper provides a description of the authors’ technique and thoughts on fleur de lys abdominoplasty including a technique of fashioning of the neo-umbilicus within the vertical scar. It contains good operative and postoperative photographs. The authors starting with the pathophysiology: the combined effects of laxity in the superficial fascial system and fixation at the zones of adhesion. However, they suggest a constancy in these factors, though there appears to be variation in the degree of fixity in these zones between patients. There is often variation from one side to the other in the same patient, some presenting with a single lower abdominal festoon, others with a clear ‘mid-infraumbilical fold’ or supraumbilical fold, and some asymmetrically. The inframammary fold is also notoriously mobile in this patient group. The authors emphasise the importance of vectors of correction, more important in the massive weight loss (MWL) patients in whom there is less conversion of longitudinal tension into lateral tightening, and for this reason, it is rare that MWL patients be adequately corrected with a single anterior horizontal scar. The marking is mentioned in the text, though it would have been helpful to include some additional illustration (the buried midline technique, the posterior excision markings (it is essential to evaluate the posterior midline with the patient bending down towards their toes). The inner scar umbilicoplasty is well described. The flaps are initially cut wide, and later trimmed after the neo-umbilicus location is established after the lower wound closure. It is not clear why non-absorbable sutures are used in the umbilicus, though the authors do not mention any difficulty in their removal – especially after four weeks. There are elements of the technique which are not covered (concurrent liposuction, flap quilting to reduce seroma, though these are covered elsewhere in the volume). Whilst not comprehensive, this is a thought provoking account, and I will certainly incorporate the umbilicoplasty technique into my practice.

Fleur-de-lis abdominoplasty and neo-umbilicus.
Mendes FH, Donnabella A, Moreira ARF.
CLINICS IN PLASTIC SURGERY
2019;46(1):49-60.