The technique presented
here has been successful in mimicking the natural appearance of the umbilicus
and hiding the scar deep down at the level of the linea alba. We achieve this
by tacking the skin on top of the umbilical column down to the linea alba and
rectus sheet. We then remove the fat from the abdominal skin around the new
umbilical site and suture the edges of skin of the abdomen to that of the umbilicus.
This will result in creating a depth (to which we refer as a crater) with a
scar at the bottom or the walls of the crater, well out of sight.
The actual steps
of the surgical process are as follows:
1. Attaching the
skin of the umbilicus to the rectus muscle fascia or linea alba is the first
step in creating this deep effect. To achieve these steps, a decision is made
at the beginning of each case as to the desired depth of the umbilical crater.
To achieve a deep-seated umbilical crater, the umbilical skin should be sutured
to the linea alba.
2. In patients
that have a thick abdominal flap with excess fat surrounding the new umbilical
orifice, the attachment of the umbilical skin to the rectus fascia may suffice.
3. During the actual
surgery, the umbilicus may start off with a very deep crater. In these cases,
we remove most of the crater and keep only the skin at the base to reconstruct
the new structure.
4. In patients
who have a long umbilical stalk, even after excess skin and the crater are removed
it may be necessary to suture the stalk down loosely out of the way and tack
the skin part of the umbilicus deep to the linea alba or rectus sheet.
5. In most patients
we recommend applying a trilateral incision on the abdominal skin for best results.
However, any preferred incision will work if designed well.
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| A |
B |
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| C |
D |
| Fig
1. (A) The skin of the umbilicus is being attached to the linea alba with
nonabsorbable sutures. (B) Skin incisions are made on the abdominal flap
(left) and defatted skin edges are sutured to the tacked down umbilical
base (right). (C) Detail of suturing the skin edges to the umbilical skin
(and linea alba, a variation). (D) Completion of the procedure with necessary
adjustments to create the desired effect. In the actual surgery the sutures
are in the crater and are not as visible as they are in this diagram. |
The
Procedure
After the abdominal
dissection has been completed, and before repair of the diastasis recti, the
structure of the umbilicus is examined for the choice of procedure to follow
(Fig 1).
If the umbilical
stalk is short and contains a small volume, the umbilicus is tacked down to
the linea alba with dermal-to-linea alba inverted sutures. This will result
in the umbilicus being attached to the linea alba in multiple areas. At least
six sutures are recommended to hold the umbilicus down. A 4/0 nylon suture has
been used in our patients. The diastasis recti is then repaired, with care not
to bury completely the tacked-down umbilicus. If this creates a problem and
the umbilicus has a tendency to be buried under the rectus muscles following
approximation of the two rectus sheets at the midline, some of these sutures
are loosened, reapplied, or lengthened so that while the umbilicus is firmly
tacked down, its skin edges are accessible for further suturing. At this time,
the excess panniculus is removed. After a guide suture is placed between the
abdominal flap and the pubic area, the decision is made where the new umbilicus
is going to be placed on the skin flap. This spot is marked and an incision
is made with three wings, like a trilateral star. One of the triangles of the
flap is placed at the upper part, and the two other flaps are placed at the
lower right lateral and lower left lateral aspects.
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B |
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D |
| Fig
2. A 36-year-old female patient. (A, B) Preoperative views. (C, D) Postoperative
views. Notice the depth created with no visible scars. |
After the incision
is deepened, the fibrofatty tissue from under the skin is removed, permitting
these flaps to be moved downward. This results in a dimpled look for the umbilical
structure. The tips of these flaps are then sutured down to the umbilical base
as a dermis-to-dermis suture or skin-to-skin suture. After the tips are sutured
down, the limbs of the triangle are also sutured down in different distances
as determined by the surgeon. This results in a structure with a base of the
umbilical skin at the bottom of the crater. After the final suturing is completed,
there should be no visible incision or suture at the rim or orifice of the new
umbilicus. Following this, repair of the abdominal flap is done as usual.
For patients in
whom the umbilicus has a long stalk, one choice for the surgeon may be to bring
the umbilicus downward or upward and tack down on the linea alba to a new position.
The effect will be that the umbilical stalk is practically eliminated from underneath
the umbilical skin. This transfer of the umbilical site, to either an upper
or lower position, can prevent the umbilical skin from bulging outward after
it is tacked down to the linea alba. After this, the procedure is continued
with the trilateral star incision and follows the procedure outlined earlier.
This procedure
is also applicable to primary reconstruction of the umbilicus due to trauma
or previous surgery. In these types of patients a completely new umbilicus can
be reconstructed. A trilateral star-shaped incision is applied and the flaps
are tacked down and sutured to the linea alba.
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B |
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D |
| Fig
3. A 60-year-old female patient. (A, B) Preoperative views. (C, D) Postoperative
views. |
When the skin edges
are tacked down to the linea alba and the depression of the umbilicus is created,
obviously there is not a flat base at the bottom of the umbilical depression
and the resulting umbilicoplasty will have a conical shape, as opposed to the
cylindrical shape that was described earlier. However, if done carefully, this
can produce satisfactory results, especially if some flatness at the bottom
of the umbilical crater can be created by using additional dermis-to-linea alba/rectus
sheet sutures.
Discussion
Utilization of
this technique of hiding the umbilicoplasty scars and incision line deep in
the base of the crater of the umbilicus has several advantages:
1. It hides the
umbilical incision and makes it more natural looking (Figs 2 and 3).
2. It could be
applied to obese or nonobese people, and different depths of umbilicus can be
created as desired. This technique can be applied to any patient, of any build
or size.
Additionally, the
technique is very versatile and can be used easily in primary reconstruction
of the umbilicus, as well as in abdominoplasty cases. Different shapes of umbilicus
can be achieved according to the skin incision. For example, instead of making
a trilateral star, the surgeon can achieve a different shape by applying any
appropriate incision. Any size umbilicus can be created with this method, and
the flexibility of this procedure allows the bottom flap of the umbilical crater
to be visible without the scar at the bottom of the umbilical crater being visible.
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