Tummy Tuck Abdominoplasty Mommy Makeover G. Gregory Gallico, MD

Tummy Tuck, Abdominoplasty, and 'Mommy Makeover'

 Low Scar Abdominoplasty with Inferior Positioning of the Umbilicus

 

Amy S. Colwell, M.D. and G. Gregory Gallico III, M.D.

Division of Plastic Surgery, Mass General Hospital,
Boston MA   02114

Correspondence:
Amy S. Colwell M.D.
15 Parkman Street WACC 435
Boston MA  02114
Phone: 617-643-5963
Fax: 617-643-5964
acolwell@partners.org

Abstract
Purpose: Mini-abdominoplasty with inferior positioning (‘free floating’) of the umbilicus has received little attention in the literature in 15 years.  We have extended the original mini-abdominoplasty to include low placement of a full transverse abdominal scar, abdominal flap undermining to the rib cage, and plication of the diastasis recti from xiphoid to pubis. This extended procedure is an excellent choice for the middle age, postpartum woman with excess abdominal tissue, but a normal body mass index who desires a low scar. 
Methods: A retrospective review from the authors’ practices identified women who had abdominoplasty with umbilical fascial transection and inferior repositioning.  The inferior skin incision was marked 5 to 6 cm above the vulvar commissure and carried laterally to terminate at the level chosen by the patient.  The superior incision is tentatively marked to give a scar to naval distance of at least 7 cm.  The superior abdominal flap was undermined superficial to the abdominal fascia to or above the rib margin and to the anterior axillary lines. The diastasis recti was plicated from xiphoid to pubis. The new position of the umbilicus was typically 2-6 cm lower than its original position. 

Results:  Sixty patients age 34-56 years old had abdominoplasty with inferior positioning of the umbilicus.  Patients had mild skin and fat excess and musculoaponeurotic laxity from xiphoid to pubis.  No umbilical or incisional skin necrosis occurred in patients with or without concomitant flank liposuction.

Conclusion:  A full abdominoplasty with floating of the umbilicus delivers a low horizontal scar without a vertical extension.  The umbilicus can be positioned 2-6 cm lower on the abdominal wall with reasonable aesthetic results.  This procedure should be considered for the woman who does not have sufficient excess skin to allow a peri-umbilical incision (traditional abdominoplasty) without high transverse scar placement or a vertical midline scar. The ideal candidate for this procedure is a middle-aged, postpartum woman without excess body fat but with abdominal skin laxity and full-length diastasis recti laxity.

Introduction

Abdominoplasty procedures are classically tailored to resect variable amounts of excess fat and skin and correct musculoaponeurotic laxity. Classification systems by Bozola and Psillakis and later Matarasso helped define different types of abdominal deformities and their respective treatments.1, 2  Techniques such as abdominoplasty, lipoabdominoplasty, and mini-abdominoplasty continue to generate much discussion in the literature and at national meetings.  Although abdominoplasty with floating of the umbilicus was the subject of articles by Gradel and Wilkinson about 15 years ago, recent reviews have  eliminated it from the algorithm suggesting it may compromise the end abdominoplasty result.3-5

We feel this technique is valuable for the middle-age, postpartum woman with diastasis recti from xiphoid to pubis and a normal body mass index.  In this group, the mini-abdominoplasty technique is inadequate to correct the excess supraumbilical skin and musculoaponeurotic laxity. However, there is not enough redundant skin to allow traditional abdominoplasty without leaving a high transverse scar.  With current fashion trends, a low transverse scar is often desirable and has the added advantage of a superior mons reduction and lift.  We describe our experience and modified technique in sixty patients.

Methods

Retrospective review was performed according to institutional guidelines.  Patients were identified from the authors’ practices that had resection of skin from the abdomen with umbilical fascial transection and repositioning. 

Marking
The inferior skin incision is marked 5 to 6 cm above the vulvar commissure with the skin on stretch and carried laterally in the inguinal crease (Figure 1).  The superior incision is tentatively marked to give a scar to naval distance of at least 7 cm.  The final superior incision is not determined until the abdominal flap is undermined. 

Procedure
Flank and posterior hip liposuction is performed in patients with excess fat in this region.  The lower transverse scar is incised and dissection proceeds superiorly taking care to leave some fat on the fascia to help prevent seroma formation.  To transect the umbilicus, one finger is placed externally into the umbilicus to ensure transection proceeds below the skin base and above properitoneal fat or hernia contents.  The umbilical fascial defect is then closed with one or two 0-Ethibond figure of eight sutures.  Abdominal undermining is performed to the rib cage and the diastasis recti is closed from xiphoid to pubis with interrupted figure-of-eight (??hyphenated) 0-Ethibond sutures.  The new position of the umbilicus is determined by flexing the patient and determining skin excision.  The umbilicus is typically lowered 2-6 cm by placing a figure of eight 0-Ethibond suture to the fascia.  The transverse incision is closed with 0-PDS sutures in Scarpa’s fascia followed by 3-0 monocryl deep dermal sutures and a running 3-0 monocryl subcuticular stitch.  Two to four 19 ?French Blake drains are brought out through the incision 2 cm from each end.
 
Post-operative care
Incisions are dressed with either steri-strips or Dermabond and tegaderm.  An abdominal binder is kept in place for 6 weeks.  If liposuction was performed with the procedure, Reston foam is used to decrease flank swelling and bruising.  Drains are removed when the output is less than 30mL per day for 2 days.

Results
Sixty patients age 34-56 year old had abdominoplasty with floating of the umbilicus (Figure 2-4) with or without flank liposuction Typical characteristics were mild skin and fat excess in the supraumbilical as well as infraumbilical regions, laxity of the overall musculoaponeurotic layer, and a relatively long distance between the umbilicus and the vulvar commissure.  The skin excess was not enough to allow traditional abdominoplasty or lipoabdominoplasty without leaving a high transverse scar or an ‘anchor’ vertical midline incision with the vertical to close the remnant of the umbilical circumferential incision.  The excess supraumbilical skin and musculoaponeurotic deformity was greater than could be corrected by a mini-abdominoplasty.  No patient developed incisional or umbilical skin necrosis.   All patients expressed satisfaction with contour and umbilical position

Discussion

Truncal contouring is commonly performed to address skin and fat deformity secondary to aging, obesity, childbirth, and massive weight loss.  Optimizing outcomes in these patients depends upon selecting the appropriate surgical technique to address the deformity and deciding on scar placement with the patient.

Traditional abdominoplasty is designed for patients with excess skin and fat of the upper and lower abdomen with musculoaponeurotic laxity extending the length of their rectus muscle. Plication proceeds from xiphoid to pubis and the umbilicus is brought out through a new incision in the upper abdomen.  Although flank liposuction is commonly combined with abdominoplasty procedures, lipoabdominoplasty typically refers to liposuction of the entire upper abdomen with minimal direct undermining.6  Lipoabdominoplasty can be combined with umbilical transposition as in a traditional abdominoplasty or with a mini-abdominoplasty leaving the umbilicus in situ.  It is particularly useful for women with a higher than normal BMI with excess fatty tissue in the upper abdomen; however, some authors routinely perform the lipoabdominoplasty technique in most of their patients regardless of BMI.7 

With the growing trend toward more minimally invasive surgery, there has been increased enthusiasm toward the mini-abdominoplasty.  This technique allows for infraumbilical tightening of the diastasis recti and skin and is often performed on an outpatient basis in patients with an abdominal deformity limited to the infraumbilical abdomen.  However, supraumbilical skin excess and diastasis recti is not corrected.  To address the supraumbilical area, some authors have advocated midline dissection around the umbilicus to the xiphoid.  Although the diastasis can be corrected this way, the supraumbilical skin excess cannot.  Therefore, there remains a subgroup of patients with overall musculoaponeurotic laxity and supraumbilical skin excess for whom there remains three surgical options: traditional abdominoplasty with a high transverse scar, traditional abdominoplasty with an anchor scar, or abdominoplasty with floating of the umbilicus. 

Since the current fashion trends display low-riding jeans, shorts and swimwear, a high transverse scar or vertical extension may be visible and thus not desirable.  The technique of floating the umbilicus allows for a very low scar and we are now placing our scar about 5cm above the vulvar commissure and within the mons pubis.  A scar at this level is nearly always concealed, even with popular styles of clothing.  A low incision also has the benefit of a mons reduction and lift, which most women desire and appreciate.

Although the umbilical float procedure enjoyed some popularity in the early 1990s, enthusiasm seems to have waned. The reasons for this are unclear but some feel it gives an unnatural appearance and detracts from the overall aesthetic result.5  We tend to disagree.  When done correctly, resuturing of the umbilicus to the fascia gives a very natural, pleasing aesthetic appearance.  When we first starting using this technique, conservative movements of the umbilicus were performed suturing it 1-2cm lower than its original position as was described and recommended in the initial reports of the technique.  However, we were occasionally dissatisfied with the supraumbilical and infraumbilical skin correction with this short movement.  We therefore began moving the umbilicus 2-6 cm lower on the abdomen, depending upon the original umbilical to vulvar commissure distance. As would be expected, the skin correction improved at little cost to the overall cosmetic result.

Another potential reason for the decline in floating of the umbilicus is that original reports dissuaded plastic surgeons from using liposuction with the procedure.  We routinely perform flank, and sometimes central abdominal, liposuction, in these cases and have not seen any umbilical or incisional necrosis.  However, aggressive suctioning of the upper abdominal flap as in a lipoabdominoplasty with might result in an increased risk of skin necrosis because of the long distance from the costal margin to the incised flap edge.

In conclusion, we present sixty patients who had abdominoplasty with floating of the umbilicus.  Our modified technique includes lower repositioning of the umbilicus at 2-6 cm and concomitant flank liposuction.  The modifications improve the overall aesthetic result with no increase in complications.  Patient selection is the key to successful outcome for this technique, and the middle-aged postpartum woman with a normal body mass index is an ideal candidate.    

References

1.         Bozola AR, Psillakis JM. Abdominoplasty: a new concept and classification for treatment. Plast Reconstr Surg. Dec 1988;82(6):983-993.
2.         Matarasso A. Abdominolipoplasty: a system of classification and treatment for combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg. Spring 1991;15(2):111-121.
3.         Gradel J. Umbilical technical maneuvers to facilitate abdominoplasty with limited incisions. Aesthetic Plast Surg. Summer 1991;15(3):251-256.
4.         Wilkinson TS. Limited abdominoplasty techniques applied to complete abdominal repair. Aesthetic Plast Surg. Winter 1994;18(1):49-55.
5.         Sozer SO, Agullo FJ, Santillan AA, Wolf C. Decision making in abdominoplasty. Aesthetic Plast Surg. Mar-Apr 2007;31(2):117-127.
6.         Saldanha OR, De Souza Pinto EB, Mattos WN, Jr., et al. Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg. Jul-Aug 2003;27(4):322-327.
7.         Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty concept. Plast Reconstr Surg. Mar 1999;103(3):1020-1031; discussion 1032-1025.

Figure Legends

Figure 1: Marking of the technique.  The lower incision is marked 5 to 6 cm above the vulvar commissure on stretch.  The marks are extended laterally in the inguinal crease to a level requested by the patient.  A tentative upper limit to the excision is marked; however, the actual marking will be decided at the time of resection. 

Figure 2:  This (SA)_41__yo female had excess supraumbilical and infraumbilical skin following childbirth.  A 230 gm, 9 cm wide ellipse was resected leaving 14 cm from umbilicus to vulvar commissure and lowering the umbilicus by 4 cm. She is shown preoperatively and at her _4__month follow-up.

Figure 3: This (LC) 37 yo female patient is shown preoperatively and _6__months post-op from abdominoplasty with umbilical transection and repositioning. A 287 gm, 7 cm wide ellipse was resected leaving 14 cm from umbilicus to vulvar commissure and lowering the umbilicus by 3 cm.

Figure 4:  Preoperative and postoperative photos of a 38 yo female patient following abdominoplasty with umbilical transaction and repositioning. A 393 gm, 10 cm wide ellipse was resected leaving 11 cm from umbilicus to vulvar commissure and lowering the umbilicus by 5 cm. Although we could not remove all of her stretch marks they are greatly reduced.  13 month follow-up pic.

NORTHEASTERN SOCIETY OF PLASTIC SURGEONS
Low Scar Abdominoplasty with Inferior Positioning of the
Umbilicus
Amy S. Colwell, MD, Dzifa Kpodzo, MD, and G. Gregory Gallico III, MD
Abstract: Miniabdominoplasty with umbilical free float has received little
attention in the literature in 15 years and has been criticized for an abnormally
low umbilicus. We hypothesized the umbilicus in women presenting
for abdominal contouring is positioned higher than ideal and thus may benefit
from lowering. In addition, we felt modifications of the original umbilical
float technique would improve aesthetic results. A retrospective review
identified 60 patients aged 34 to 56 who had abdominoplasty with umbilical
fascial transection and inferior positioning. Technical modifications included
low placement of a full transverse abdominal scar, abdominal flap undermining
to the rib cage, more inferior umbilical repositioning, flank liposuction,
and plication of diastasis recti from xiphoid to pubis. Patients did not
have enough excess skin to allow traditional abdominoplasty without a
high-transverse or vertical midline scar. No umbilical or incisional skin
necrosis occurred. To assess optimal umbilical position, plastic surgeons
were asked to draw the ideal position on pre- and postoperative photographs
from 5 patients. The mean ideal umbilical position was 2.2 cm lower than the
actual position (P _ 0.01) in preoperative photographs and was close to the
true position in postoperative photographs. In conclusion, lower abdominoplasty
with inferior umbilical positioning is an excellent choice for the
middle age, postpartum woman with excess abdominal skin and full length
diastasis recti but a normal body mass index.
Key Words: abdominoplasty, umbilical float, body contouring
(Ann Plast Surg 2010;64: 639–644)
Abdominoplasty procedures are classically tailored to resect variable
amounts of excess fat and skin and correct musculoaponeurotic
laxity. Classification systems by Bozola and Psillakis and
later by Matarasso helped define different types of abdominal
deformities and their respective treatments.1,2 Techniques such as
abdominoplasty, lipoabdominoplasty, and miniabdominoplasty continue
to generate much discussion in the literature and at national
meetings. Although abdominoplasty with floating of the umbilicus
was the subject of articles by Gradel and Wilkinson about 15 years
ago, recent reviews have eliminated it from the algorithm suggesting
it may compromise the end abdominoplasty result with an abnormally
low umbilical position.3–5
The authors feel that many women presenting for abdominal
contouring benefit from lowering of their current umbilical position.
Furthermore, by modifying the originally described technique to
incorporate the principles of traditional abdominoplasty rather than
miniabdominoplasty, a more aesthetic result is achieved.
The umbilical float technique is valuable for the middle age,
postpartum woman with diastasis recti from xiphoid to pubis and a
normal body mass index (BMI). In this group, the miniabdominoplasty
technique is inadequate to correct the excess supraumbilical
skin and musculoaponeurotic laxity. However, there is not enough
redundant skin to allow traditional abdominoplasty without leaving
a high-transverse scar. With current fashion trends, a low-transverse
scar is often desirable and has the added advantage of a superior
mons reduction and lift. The authors describe their experience and
modified technique in 60 patients.
METHODS
Retrospective review was performed according to institutional
guidelines. The patients were identified from the authors’
practices that had resection of skin from the abdomen with umbilical
fascial transection and repositioning.
Marking
The inferior skin incision is marked 5 to 6 cm above the
vulvar commissure with the skin on stretch and carried laterally in
the inguinal crease. The superior incision is tentatively marked to
give a scar to naval distance of at least 7 cm. The final superior
incision is not determined until the abdominal flap is undermined.
Procedure
Flank and posterior hip liposuction is performed in patients
with excess fat in this region. The lower transverse scar is incised
and dissection proceeds superiorly taking care to leave some fat on
the fascia to help prevent seroma formation. To transect the umbilicus,
1 finger is placed externally into the umbilicus to ensure
transection proceeds below the skin base and above properitoneal fat
or hernia contents. The umbilical fascial defect is then closed with
a 0-ethibond figure of eight suture. Abdominal undermining is
performed to the rib cage and the diastasis recti is closed from
xiphoid to pubis with interrupted figure of eight 0-ethibond sutures.
The new position of the umbilicus is determined by flexing the
patient and determining skin excision. The umbilicus is typically
lowered 2 to 6 cm by placing a figure of eight 0-ethibond suture. The
transverse incision is closed with 0-polydioxanone sutures in Scarpa’s
fascia followed by 3-0 monocryl deep dermal sutures and a
running 3-0 monocryl subcuticular stitch. Two 19 Blake drains are
placed prior to closure.
Postoperative Care
Incisions are dressed with either steristrips or dermabond and
tegaderm. An abdominal binder is kept in place for 6 weeks. If
liposuction was performed with the procedure, Reston foam is used
to decrease flank swelling and bruising. Drains are removed when
the output is _30 mL/day for 2 days.
Survey
Pre- and postoperative photographs were assembled from 5
patients who had the umbilical float procedure. A photograph editing
program was used to remove the umbilicus in these 10 digital
photographs. Ten faculty plastic surgeons were asked to mark the
ideal umbilical position on each image. Measurements were then
Received February 22, 2010, and accepted for publication, after revision, February
28, 2010.
From the Division of Plastic Surgery, Mass General Hospital, Boston, MA.
Presented at the 26th Annual Meeting of the Northeastern Society of Plastic
Surgeons, Charleston, SC, September 2009.
Reprints: Amy S. Colwell, MD, Division of Plastic Surgery, Massachusetts General
Hospital, 15 Parkman St, WACC 435, Boston, MA 02114. E-mail:
acolwell@partners.org.
Copyright © 2010 by Lippincott Williams & Wilkins
ISSN: 0148-7043/10/6405-0639
DOI: 10.1097/SAP.0b013e3181db759c
Annals of Plastic Surgery • Volume 64, Number 5, May 2010 www.annalsplasticsurgery.com | 639
FIGURE 1. This 41-year-old woman
had excess supraumbilical and infraumbilical
skin after childbirth. A
230 g, 9-cm wide ellipse was resected
leaving 14 cm from umbilicus
to vulvar commissure and lowering
the umbilicus by 4 cm. She is
shown preoperatively and at her
made from the top of the photograph to the ideal marked position
and the actual position. The difference between actual and ideal
umbilical position was calculated for each surgeon for each photograph.
The mean difference for pre- and postoperative positions
were calculated and compared. A Student t test was used to determine
statistical significance.
RESULTS
Sixty patients aged 34- to 56-year-old had abdominoplasty
with floating of the umbilicus (Figs. 1–3) with or without flank
liposuction. Typical characteristics were mild skin and excess fat in
the supraumbilical as well as infraumbilical regions, laxity of the
overall musculoaponeurotic layer, and a relatively long distance
between the umbilicus and the vulvar commissure. The excess skin
was not enough to allow traditional abdominoplasty or lipoabdominoplasty
without leaving a high-transverse scar or an “anchor”
vertical midline incision to close the remnant of the umbilical
circumferential incision. The excess supraumbilical skin and
musculoaponeurotic deformity could not be fully corrected by
miniabdominoplasty. No patient developed incisional or umbilical
skin necrosis. All patients expressed satisfaction with contour
and umbilical position.
The mean difference between ideal and actual umbilical
position in the preoperative photographs was 2.2 cm (SD: 1.035)
(Fig. 4). The mean ideal umbilical position was significantly lower
than the actual position (P _ 0.01). The mean difference between
ideal and actual position in the postoperative photographs was 0.54
cm (SD: 0.456) and not statistically significant. The ideal umbilical
position markings were closer to the actual position in the postoperative
photographs compared with the preoperative photographs
(P _ 0.02).
DISCUSSION
Truncal contouring is commonly performed to address skin
and fat deformity secondary to aging, obesity, childbirth, and mas-
FIGURE 1. This 41-year-old woman
had excess supraumbilical and infraumbilical
skin after childbirth. A
230 g, 9-cm wide ellipse was resected
leaving 14 cm from umbilicus
to vulvar commissure and lowering
the umbilicus by 4 cm. She is
shown preoperatively and at her
4-month follow-up.
Colwell et al Annals of Plastic Surgery • Volume 64, Number 5, May 2010
640 | www.annalsplasticsurgery.com © 2010 Lippincott Williams & Wilkins
FIGURE 2. This 37-year-old woman
patient is shown preoperatively
and 6 months postoperative from
abdominoplasty with umbilical
transection and repositioning. A
287 g, 7-cm wide ellipse was resected
leaving 14 cm from umbilicus
to vulvar commissure and lowering
the umbilicus by 3 cm.
FIGURE 2. This 37-year-old woman
patient is shown preoperatively
and 6 months postoperative from
abdominoplasty with umbilical
transection and repositioning. A
287 g, 7-cm wide ellipse was resected
leaving 14 cm from umbilicus
to vulvar commissure and lowering
the umbilicus by 3 cm.
sive weight loss. Optimizing outcomes in these patients depends on
selecting the appropriate surgical technique to address the deformity
and deciding on scar placement with the patient.
Traditional abdominoplasty is designed for patients with
excess skin and fat of the upper and lower abdomen with
musculoaponeurotic laxity extending the length of their rectus
muscle. Plication proceeds from xiphoid to pubis and the umbilicus
is brought out through a new incision in the upper abdomen.
Although flank liposuction is commonly combined with abdominoplasty
procedures, lipoabdominoplasty typically refers to liposuction
of the entire upper abdomen with minimal direct undermining.
6 Lipoabdominoplasty can be combined with umbilical
transposition as in a traditional abdominoplasty or with a miniabdominoplasty
leaving the umbilicus in situ. It is particularly
useful for women with a higher than normal BMI with excess
fatty tissue in the upper abdomen; however, some authors routinely
perform the lipoabdominoplasty technique in most of their
patients regardless of BMI.7
With the growing trend toward more minimally invasive
surgery, there has been increased enthusiasm toward the miniabdominoplasty.
This technique allows for infraumbilical tightening of
the diastasis recti and skin and is often performed on an outpatient
basis in patients with an abdominal deformity limited to the infraumbilical
abdomen. However, excess supraumbilical skin and diastasis
recti are not corrected. To address the supraumbilical area, some
authors have advocated midline dissection around the umbilicus to
the xiphoid. Although the diastasis can be corrected this way, the
excess supraumbilical skin cannot. Therefore, there remains a subgroup
of patients with overall musculoaponeurotic laxity and excess
supraumbilical skin for whom there remains 3 surgical options:
traditional abdominoplasty with a high-transverse scar, traditional
abdominoplasty with an anchor scar, or abdominoplasty with floating
of the umbilicus.
Because the current fashion trends display low-riding jeans,
shorts, and swimwear, a high-transverse scar or vertical extension
may be visible and thus not desirable. The technique of floating the
umbilicus allows for a low scar and we are now placing our scar
about 5 cm above the vulvar commissure and within the mons pubis.
A scar at this level is nearly always concealed, even with popular
FIGURE 2. This 37-year-old woman
patient is shown preoperatively
and 6 months postoperative from
abdominoplasty with umbilical
transection and repositioning. A
287 g, 7-cm wide ellipse was resected
leaving 14 cm from umbilicus
to vulvar commissure and lowering
the umbilicus by 3 cm.
Annals of Plastic Surgery • Volume 64, Number 5, May 2010 Abdominoplasty With Umbilical Float
© 2010 Lippincott Williams & Wilkins www.annalsplasticsurgery.com | 641
styles of clothing. A low incision also has the benefit of a mons
reduction and lift, which most women desire and appreciate.
Although the umbilical float procedure enjoyed some popularity
in the early 1990s, enthusiasm seems to have waned. The
reasons for this are unclear but some feel the umbilicus is positioned
low, which detracts from the overall aesthetic result.5 The results
from our survey suggest that patients presenting for abdominal
contouring may have an umbilicus that is positioned high and thus
would benefit from lowering. Furthermore, plastic surgeons marked
the ideal position of the umbilicus in postoperative photographs very
close to the actual position. When done correctly, resuturing of the
umbilicus to the fascia gives a very natural, pleasing aesthetic
appearance. When we first used this technique, conservative movements
of the umbilicus were performed suturing it 1 to 2 cm lower
than its original position as was described and recommended in the
initial reports of the technique. However, we were occasionally
dissatisfied with the supraumbilical and infraumbilical skin correction
with this short movement. We therefore began moving the
umbilicus 2 to 6 cm lower on the abdomen, depending on the
original umbilical to vulvar commissure distance and the patient’s
height. As would be expected, the skin correction improved and at
little cost to the overall cosmetic result.
Another potential reason for the decline in floating of the
umbilicus is that original reports dissuaded plastic surgeons from
using liposuction with the procedure. We routinely perform flank
and sometimes central abdominal liposuction in these cases and
have not seen any umbilical or incisional necrosis. However,
aggressive suctioning of the upper abdominal flap as in a lipoabdominoplasty
might result in an increased risk of skin necrosis
because of the long distance from the costal margin to the incised
flap edge.
In conclusion, we present 60 patients who had abdominoplasty
with floating of the umbilicus. Our modified technique includes
lower repositioning of the umbilicus at 2 to 6 cm and
concomitant flank liposuction. The modifications improve the overall
aesthetic result with no increase in complications. The patient
FIGURE 3. Pre- and postoperative
photographs of a 38-year-old
woman after abdominoplasty with
umbilical transaction and repositioning.
A 393 g, 10-cm wide ellipse
was resected leaving 11 cm
from umbilicus to vulvar commissure
and lowering the umbilicus by
5 cm. Although we could not remove
all of her stretch marks they
are greatly reduced as is shown in
her 13-month follow-up photograph.
Colwell et al Annals of Plastic Surgery • Volume 64, Number 5, May 2010
642 | www.annalsplasticsurgery.com © 2010 Lippincott Williams & Wilkins
FIGURE 4. Graphic representation of the survey results. A, The x-axis represents each preoperative patient photograph. The y-axis is
shown in centimeters. The actual umbilical position was set at 0 for each patient. The mean ideal position chosen by plastic surgeons
was plotted for each patient with standard deviation bars. The ideal position was significantly lower than the actual position.
B, The x-axis represents each postoperative patient photograph. The y-axis is shown in centimeters. The actual umbilical position
was set at 0 for each patient. The ideal position was slightly higher than the actual umbilical position in 3 patients. However, the
ideal position more closely resembles the actual position in the postoperative compared with the preoperative photographs.
Annals of Plastic Surgery • Volume 64, Number 5, May 2010 Abdominoplasty With Umbilical Float
© 2010 Lippincott Williams & Wilkins www.annalsplasticsurgery.com | 643
selection is the key to successful outcome for this technique, and the
middle-aged postpartum woman with a normal BMI is an ideal
candidate.
REFERENCES
1. Bozola AR, Psillakis JM. Abdominoplasty: a new concept and classification
for treatment. Plast Reconstr Surg. 1988;82:983–993.
2. Matarasso A. Abdominolipoplasty: a system of classification and treatment for
combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast
Surg. 1991;15:111–121.
3. Gradel J. Umbilical technical maneuvers to facilitate abdominoplasty with
limited incisions. Aesthetic Plast Surg. 1991;15:251–256.
4. Wilkinson TS. Limited abdominoplasty techniques applied to complete abdominal
repair. Aesthetic Plast Surg. 1994;18:49 –55.
5. Sozer SO, Agullo FJ, Santillan AA, et al. Decision making in abdominoplasty.
Aesthetic Plast Surg. 2007;31:117–127.
6. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al. Lipoabdominoplasty
with selective and safe undermining. Aesthetic Plast Surg. 2003;27:322–327.
7. Shestak KC. Marriage abdominoplasty expands the mini-abdominoplasty concept.
Plast Reconstr Surg. 1999;103:1020 –1031; discussion 1032–1025.
Colwell et al Annals of Plastic Surgery • Volume 64, Number 5, May 2010
644 | www.annalsplasticsurgery.com © 2010 Lippincott Williams & Wilkins

G. Gregory Gallico III, M.D. - Plastic, Cosmetic, and Aesthetic Surgery

If you would like to speak to me or a member of my staff to obtain additional information or to schedule a consultation, please contact my office either by

phone, fax, or e-mail:

Tel: (617) 267-5553
Fax: (617) 267-5507
E-Mail: ggallico@gallicomd.com

or write directly:
G. Gregory Gallico, III, M.D., F.A.C.S.

Assoc. Professor Plastic Surgery
Massachusetts General Hospital
Harvard Medical School and
Boston Center for Ambulatory Surgery
170 Commonwealth Avenue
Boston, MA 02116 USA