Natural-Looking Umbilicus as an Important Part of Abdominoplasty

Aesth. Plast. Surg. 27:139–142, 2003 DOI: 10.1007/s00266-003-0109-7 Natural-Looking Umbilicus as an Important Part of Abdominoplasty Hayati Akba+,1 Ethem Güneren,1 Lütfi Eroğlu,1 and O. Ata Uysal2 1 2 Samsun, Turkey Istanbul, Turkey Abstract. The umbilicus is an important and essential aesthetic component of the abdomen. Many surgeons use different methods to relocate umbilicus during abdominoplasties. We prefer to use a simple combination of different well-known principles to form the neo-umbilicus. The main steps of the procedure are to make an elliptical vertical incision, to do vertical abdominal fascial plication, to embed the umbilical stalk in this plication by suturing the umbilical skin and the rectus fascia together to maintain the umbilical dimple, to place it at the vertical incision made in the abdominal skin at a predetermined point. Silk sutures are used for the abdominal fascial plication and neo-umbilical fixation. Liposuction from the neo-umbilicus to xiphoid along the midline of the upper abdomen creates a minimal superior sulcus. In each patient, a three-dimensional umbilicus with sufficient depression was obtained. All patients, including one case with complications, were pleased by the final aesthetic results. Key words: Umbilicoplasty—Abdominoplasty—Umbilicus The shape of the umbilicus varies with age and the parity of the patients. It is flat and vertical in young, nulliparus patients, and hooded with a transverse appearance in multiparus patients [1–4,7,9,10,12]. Proper reposition and natural shape of neo-umbilicus on the abdomen are key factors of the successful umbilicoplasty. Nice aesthetic results are often limited by umbilical scaring caused by the reinsertion of This study has been presented at the XVI Congress of ISAPS held in Istanbul, Turkey, May 26–29, 2002 Correspondence to Hayati Akba+, Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Ondokuz Mayıs University, Kurupelit, Samsun 55139, Turkey; email: drhayati@hotmail.com the original umbilicus into the abdominal flap. Furthermore, contracture of the ring-shaped scar or a visibly hypertrophic scar might deform the neo-umbilicus. A deformed neo-umbilicus can significantly detract from the aesthetic value of the newly contoured abdomen and can be a source of undue psychological distress to the patient. Despite the many techniques described to address this problem, umbilical deformities and visible scaring continue to be common occurrences. In this study we have presented our experiences in obtaining a natural-looking neo-umbilicus in abdominoplasties. Material and Methods Between September 1998 and April 2002, fifteen female patients were operated on at Ondokuz Mayıs University, Division of Plastic and Reconstructive Surgery, Samsun, Turkey by a single surgeon (Dr. Akba+) who used this technique. The first step of neo-umbilicoplasty is to make a vertical elliptical incision of umbilicus. The abdominal skin is then undermined. After vertical fascial plication of the abdominal musculofascial structure, using an interrupted silk suture from the xiphoid to the pubis, midline we attach the umbilicus to the abdominal rectus fascia. The umbilical stalk is embedded during the plication of the abdomen. Elliptical umbilical island is tightened against the tensed abdominal fascia in its normal position, without distortion. The abdominal skin flap is tailored and the midline of this flap is sutured to the midline of pubic area to establish the new umbilicus location on the remaining abdominal skin. Marking is made first from the xiphoid to the pubic midline area. With one hand under the abdominal flap on the tightened umbilicus and the other hand on the abdominal flap, the correct place on the abdominal flap is found. A 3cm long vertical incision is made in the skin of the 140 Umbilicoplasty Fig. 1. Illustrations of the operative technique: (A) planning of incisions, (B) undermining of abdominal skin and plications of abdominal fascial laxity with silk sutures, (C) insetting of neoumbilicus and suturing of abdominal skin incisions, (D) liposuction. Results There was one complication with wound healing in a diabetic patient. Suture dehiscence and local infection occurred on the suprapubic suture line, eight days after surgery. We treated this case with a second operation. When the granulation tissue was ready at the base of the wound we placed a split-thickness skin graft on it and it healed uneventfully. Minimal umbilical prolabsus was another complication, with partial patient satisfaction. In all patients, a three-dimensional umbilicus with a sufficient depression was created. All patients, including the one with complications, were pleased by the final aesthetic results (Table 1; Figs. 3 and 4). Discussion Fig. 2. Close-up illustrations of umbilicus and the surrounding flap. They are sutured to the abdominal fascia to create the umbilical dimple. abdominal flap. After excess abdominal tissues are tailored and sutured in a normal, tension-free position on the inferior abdominal line, the abdominal skin is sutured to the rectus fascia around the base of the umbilical stalk at three, six, nine, and twelve o’clock to create a dimpled umbilicus. A second-layer suture between the abdominal skin and the umbilical skin is then made. Furthermore, liposuction is performed from the neo-umbilicus to the xiphoid on the midline of the upper abdomen in order to minimize the superior sulcus (Figs. 1 and 2). The age of patients ranged between 21 and 63 years and postoperative followup ranged from two months to 3 years. The umbilicus is the major aesthetic component of the abdominal wall and, from a cosmetic standpoint, it requires optimal reconstruction during abdominoplasty. The umbilicus is the only normal scar on the body; its absence or grotesque shape may be distressing [3]. The umbilicus was routinely discarded during abdominoplasties until the 1950s, when Vernon [14] and others advocated its preservation. Umbilical stenosis is one complication of abdominoplasties that are combined with umbilicus relocation, especially if the umbilicus is inset with a circular scar. Various methods have been advocated to prevent a circular scar [1,2,4,7,9,10,12]. An anatomic umbilicus should have a normal slant superiorly, a superior hood, a normal shape (cylindrical with a wide attachment to the abdominal wall fascia and a central mamelon), and it should not have any external scars, especially not scars concentric to the umbilical ring, which could result in stenosis [2]. Many techniques have been used for reinsertion of the umbilicus after abdominoplasty [5,11,13]. Scholler et al. [11] have described a scarless reinsertion technique during abdominoplasty, but they recommend using the old umbilicus only as a guide for the H. Akba+ et al. 141 Table 1. Patients demographics and results Patients Age/Sex Months of followup Complication Patient satisfaction Comorbid disease 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 43/F 37/F 22/F 63/F 53/F 41/F 27/F 35/F 56/F 32/F 34/F 54/F 60/F 45/F 36/F 12 28 36 14 9 5 17 4 6 24 31 2 3 6 11 – – – – – – – Umbilical prolapsus – – – – Wound dehiscence – – S S S S S S S MS S S S S S S S Hypertension – – – – – Asthma – Hypertension – – Umbilical hernia Diabetes – – MS, minimal satisfaction; S, satisfactory. Fig. 3. (A) Preoperative frontal view. (B) Postoperative frontal view at nine months. (C) Preoperative oblique view. (D) Postoperative oblique view at nine months. new umbilicus that will be created from central abdominal skin. This technique requires the sacrifice of old umbilicus skin and a complex surgical procedure. If it is not too deformed or ugly, we believe that old umbilicus is best one for most attractive neo-umbilicus after abdominoplasty. In addition, the umbilicus is an important aesthetic component of the abdomen, and it is essential for an attractive abdomen. Many surgeons use different methods to establish its correct anatomic position and to relocate it [6,8]. We prefer a highly simple and easy way to establish new umbilicus location. Important steps are elliptical vertical incision, vertical abdominal fascial plication from the xiphoid to the midline pubic area, embedding the umbilical stalk while excluding the umbilical skin in this plication, and suturing the umbilical skin and rectus fascia to maintain the umbilical dimple. Then a 3-cm vertical incision was made at the predetermined point and the old umbilicus is sutured to its new location. These sutures firmly fix the umbilicus and superficial liposuction of the abdomenal midline, from umbilicus to xiphoid, creates a sulcus that mimics the linea alba. Our technique is not totally new but combines different well-known principles. We excise the old umbilicus as an elliptical shape and firmly suture it to the abdominal fascia to prevent prolapsus or distortion after surgery. This creates natural umbilical 142 Umbilicoplasty Fig. 4. (A) Preoperative frontal view. (B) Postoperative frontal view at three years. (C) Preoperative oblique view. (D) Postoperative oblique view at three years. dimpling, preventing stenosis. There is no visible scar in this situation because the scar has been placed deep within the abdominal fascia. We have used only 2-0 silk sutures for fascial and subdermal suturing of the abdominal fascial plication and tightening of the neoumbilicus. No change in the projection of the umbilicus was observed over a median followup period of 14 months. We prefer silk sutures for both abdominal musculofascial plication and neo-umbilical tightening to rectus fascia, and to fix old umbilicus to its new place. Silk sutures are absorbed slowly enough to prevent the abdominal musculofascial system from relaxation. It is not a foreign body to tissue and is absorbed as a result. In three years, we have newer seen complications related to silk sutures during or after abdominoplasty. The other advantages of using silk are that it is inexpensive, secure, and time saving. We also use binding for about two months to prevent any recurrences of abdominal laxity after abdominoplasty. In conclusion, we obtained a high degree of patient satisfaction with natural-looking results by using this technique. References 1. Avelar JM: Abdominoplasty: Technical refinement and analysis of 130 cases in 8 years’ follow-up. Aesth Plastic Surg 7:205–212, 1983 2. Baack BR, Anson G, Nachbar JM, White DJ: Umbilicoplasty: The construction of a new umbilicus and correction of umbilical stenosis without external scars. Plast Reconst Surg 97:227–232, 1996 3. Baroudi R: Umbilicoplasty. Clin Plast Surg 2:43l–438, 1975 4. Delerm A: Refinements in abdominoplasty with emphasis on reimplantation of the umbilicus. Plast Reconst Surg 70:632–637, 1982 5. Grozer FM: Abdominoplasty. In: McCarthy JG (ed). Plastic surgery. WB Saunders, London, pp 3929–3964, 1990 6. Hoffman S: A simple technique for locating the umbilicus in abdominoplasty. Plast Reconst Surgery 83: 537–538, 1989 7. Juri J, Juri C, Raiden G: Reconstruction of the umbilicus in abdominoplasty. Plast Reconst Surg 63:580– 582, 1979 8. Kurul S, Uzunismail A: A simple technique to determine the future location of the umbilicus in abdominoplasty. Plast Reconstr Surg 100:753–754, 1997 9. Matsuo K, Kondoh S, Hirose T: A simple technique for reconstruction of the umbilicus, using a conchal cartilage composite graft. Plast Reconst Surg 86:149–151, 1990 10. Ribiero L, Muzy S, Accorsi A: Omphaloplasty. Ann Plast Surg 27:457–475, 1991 11. Schoeller T, Wechselberger G, Otto A, Rainer C, Schwabegger A, Lille S, Ninkovic M: New technique for scarless umbilical reinsertion in abdominoplasty procedures. Plast Reconst Surg 102:1720–1723, 1998 12. Sugawara Y, Hirabayashi S, Asato H, Yoshimura K: Reconstruction of the umbilicus using a single Triangular flap. Ann Plast Surg 34:78–80, 1995 13. Teimovian B, Marefat S: Body contouring with suction-assisted lipectomy. In: Cohen M (ed). Mastery of plastic and reconstructive surgery. Little Brown, London, pp 753–779, 1994 14. Vernon S: Umbilical Transplantation upward and abdominal contouring in lipectomy. Am J Surg 96:490– 499, 1957