I have also
observed that in most abdomens with large amounts of fat, the umbilicus
is ptotic, with a long stalk pulled down by gravity. In the youthful,
muscular abdomen, the umbilicus appears to be much higher than in the
obese abdomen.
To encourage
the idea of placing the umbilicus in a higher position, I published my
previous experience with the umbilicus with hidden scars.' In this procedure
I suggest moving the scar around the umbilicus posteriorly to the level
close to the linea alba, with a natural-looking umbilicus. In some cases
with an umbilicus with a long stalk, even after most of the excess stalk
was excised, the remaining umbilicus bulged out anteriorly and looked
unsightly. A simple solution to the problem is to move the umbilicus slightly
upward, which produces better results (Fig 1).
Anatomy
The umbilicus
is a distinct landmark of beauty of in the abdominal region. In patients
in whom the umbilicus is removed because of surgical procedures, the abdomen
looks abnormal and shapeless. The location of the umbilicus is determined
to be at a level that corresponds to the disk between the third and fourth
lumbar vertebrae.' This is its location site in a healthy young patient.
However, as the person ages and osteoporosis shortens the vertebral column,
and as the torso shortens, the umbilicus moves inferiorly. If we assume
a triangle base by connecting two points on the anterior superior iliac
spine to a point corresponding to the disk between the third and fourth
lumbar vertebrae, this triangle is approximately 3 cm high (Fig 3). I
suggest that as a person ages, this triangle flattens and may even become
inverted downward. This downward migration is in addition to the inferior
movement of the umbilical opening as a result of gravity. I suggest restoring
the umbilicus to its normal position or just slightly higher.
Fig 1. (A) The umbilical
stalk is fixed to the abdominal wall so that its opening ends up at a
higher position. (B) Defatting around new umbilical site is necessary
to create a depressed area so that the scar around the umbilicus is hidden
in the bottom of this depression. Notice also the sculpting effect in
the upper abdomen that could be achieved by defatting the midline and,
in some cases, even suturing the midline to the rectus sheath.
Fig 2. (A)
Preoperative view of a patient with a ptotic umbilical opening (downward
tilt of the umbilical stalk). (B) Postoperative view with the elevated
umbilical opening. Notice the result by comparing the umbilical site to
the curvature of the waistline and also the underwear markings in the
preoperative and postoperative views.
Fig 3. (A) Normal
relationship of umbilicus to third and fourth intervertebral space and
triangle formed by connecting this point to right and left anterior superior
iliac spine. (B) With osteoporosis as a result of aging, especially in
female patients, the vertebral column shortens. Thus, the upper body migrates
down. Notice how the distance from A to D is reduced.
Materials
and Methods
During the repair
phase of an abdominoplasty or a TRAM flap reconstruction, after placement
of guide sutures in the lower abdomen, the site of the umbilicus is marked
as usual on the midabdominal flap. At this point, it usually looks like
the umbilicus site is too close to the incision line. If this is the case,
a decision is made to place the umbilicus at a higher position. The amount
of elevation of the new umbilicus depends on the severity of the ptosis
of the umbilicus, and the length of the stalk and its degree of mobility.
The operating surgeon's judg ment is a determining factor. The technique
of umbilicoplasty with hidden scars that has been described previously'
is used to fix the umbilicus to the linea alba and the rectus sheath,
but in a higher position (Fig 1A). One should note that some tension in
the flap from the umbilical incision site to the xiphoid region is necessary.
After fixation of the umbilicus to the linea alba, the flap is pulled
down and incisions are made, and defatting around the new umbilical incision
is performed (Fig 1B).' At times, defatting of the midline sections of
the superior abdominal flap up to the xiphoid is done to create a midline
recess that resembles anatomically and aesthetically strong abdominal
muscles. Sutures are placed at the location of the new umbilical depression
in the level of the linea alba/rectus sheath. The operation is then concluded
as usual, with the exception that lesser tension on the lower abdominal
flap may now be feasible. This technique helps to remove the site of the
previous umbilicus safely and still provides a relaxed lower abdominal
flap with a good blood supply.
Results
This technique had
helped remedy the unsightly, too-low umbilicus. Also, it is my impression
that it has helped lower abdominal flap circulation. I believe that a
higher position of the umbilicus is aesthetically more pleasing and renders
a more youthful look (Fig 2).
Discussion
Youthful abdominal
surface anatomy portrays a muscular underlying structure with definition
of the upper abdominal muscles (even in the modern female figure). The
umbilicus appears to be higher in these individuals compared with their
obese counterparts, although admittedly this could be visual perception.
In older individuals with a longstanding panniculus, this is definitely
not a visual perception, but a true anatomic ptosis of the umbilicus signified
by a long stalk. Actually, I believe
any stalk that has turned from posterior-anterior to an inferior direction
is considered ptotic. This operation helps to create an overall more youthful
appearance by: 1) placing the umbilicus in a higher position; 2) creating
a depression from the xiphoid to the umbilicus, which is especially important
when reduction of fat in the midline upper abdomen is performed; and 3)
by increasing the distance from the umbilicus to the incision line in
the lower abdomen, it enhances further the aesthetics of this key anatomic
site in the human figure. In addition to its aesthetic considerations,
this procedure is beneficial in: 1) protecting lower abdominal flap circulation
by transferring most of the tension from the lower abdomen to the upper
abdomen; and 2) in some cases more tissue is available for a safe resection
in the lower abdomen.
Presented at the Southeastern
Society of Plastic and Reconstructive Surgeons; Orlando, FL; June 2001.
References
1 Massiha
H, Montegut W, Phillips R. A method of reconstructing a natural-looking
umbilicus in abdominoplasty. Ann Plast Surg 1997;38:228
2 Basmajian JV. Grant method of anatomy. 1971;8:200
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