Techniques inCosmetic Surgery

Simplified Technique for Creating a YouthfulUmbilicus in AbdominoplastyMichael J. Lee, M.D., and Thomas A. Mustoe, M.D.Chicago, Ill.

Reimplantation of the umbilicus remains a critical aes-thetic component in abdominoplasty and transverse rec-tus abdominis musculocutaneous breast reconstruction.Although the ideal shape of the umbilicus has been de-bated, recent studies have shown the young, thin femalewith an attractive abdomen tends to have a small, verticallyoriented umbilicus. The aesthetic considerations for re-implantation include position, depth, shape, and locationof scar. The authors present a technique that is expedientand reliable and that addresses each of these variables.The umbilicus is sutured to the rectus fascia and reim-planted through a vertical incision in the abdominal flap.Subdermal sutures are placed from the umbilicus to thelinea alba superiorly and inferiorly. These sutures createa vertically oriented shape and place the umbilicus in themidline. Shortening the umbilical stalk establishes depthand hides the closure of the umbilicus and abdominal flapwithin the stalk. The stalk length is easily varied, depend-ing on the thickness of the panniculus. Defatting is per-formed through the vertical incision to allow easy visual-ization of the umbilicus. This technique creates depth,ensures optimal position, pulls the scar deep in the um-bilicus, and produces a vertically oriented, youthful um-bilicus. More importantly, a questionnaire given to pa-tients who have undergone abdominoplasty with thisprocedure (n � 21) confirms that patients have a highlevel of satisfaction with the resulting shape, position, andoverall appearance. (Plast. Reconstr. Surg. 109: 2136,2002.)

The umbilicus is a prominent structure andaesthetic unit of the abdomen. Many tech-niques have been devised to create an aesthet-ically pleasing reimplanted umbilicus after ab-dominoplasty or transverse rectus abdominismusculocutaneous flap breast reconstruction.

These techniques have attempted to addresscomplications associated with reimplantation,which include unsightly scars, cicatricial ring

formation, and umbilical stenosis, malposition-ing, or aesthetically unpleasing shapes. Themost appealing shape of the umbilicus hasbeen debated. Pitanguy1 used a transverse in-cision for reimplantation to create a large,transversely oriented umbilicus. Many haveused circular incisions that have led to roundumbilical reconstructions.2,3 Others have fo-cused on recreating a naturally occurring su-perior hood with a variety of skin flaps rangingfrom simplistic to complicated.4–10

The aesthetic considerations for reimplanta-tion in abdominoplasty and breast reconstruc-tion are position, depth, shape, and location ofscar. Recent evaluation of the ideal umbilicushas shown that the youthful and thin individualhas a small and vertically oriented umbilicus,whereas the older or more obese individual hasa rounder, transversely oriented, and hoodedumbilicus.11,12 We present a technique of reim-plantation that emphasizes suturing the umbil-ical stalk to the linea alba and rectus sheathand utilizing a vertical incision in the abdomi-nal flap. This technique creates depth, ensuresoptimal position, pulls the scar deep in theumbilicus, and produces a small, vertically ori-ented umbilicus. This technique is simple, pre-dictable, and addresses all these aesthetic con-siderations to create a youthful appearancewithout visible scars. The senior author hasfound that the speed and simplicity of the pro-cedure, and its applicability to every abdomi-noplasty regardless of weight, have made it veryappealing.

From the Division of Plastic and Reconstructive Surgery, Northwestern University. Received for publication October 30, 2000; revised October4, 2001.

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SURGICAL TECHNIQUE

The skin is sharply incised in a vertical el-lipse, taking care to keep the skin island small.Minimal fat is included with the umbilicus topreserve the adventitial blood supply. Once theabdominal flap is elevated, and the muscle isplicated, the umbilical stalk is sutured subder-mally to the linea alba superiorly and inferiorlywith 3-0 Vicryl stitches (Fig. 1). These suturesensure a midline placement of the umbilicus,pull the scar deep within the umbilicus, andcreate depth and a vertically oriented shape.The distance of the suture from the dermis ofthe umbilicus to the linea alba is dependent onthe thickness of the panniculus and is easilyvaried. It is important to plicate the periumbil-ical fascia sufficiently on a thin patient to cre-ate an inverted umbilicus. The site of reimplan-tation in the abdominal flap is determined bywhere the original umbilicus projects in thecaudally pulled flap as previously described.7 Inthe abdominal flap, a small vertical incision ismade approximately the vertical size of theoriginal umbilicus. It is then extended to theexact length once the umbilicus is exposed.This vertical incision accentuates the verticalshape of the umbilicus. It is not necessary toremove any skin; a vertical incision keeps theumbilicus from widening.

Defatting is performed through the verticalincision, which allows easy visualization of theumbilicus (Fig. 2). It is important to defat anarea 2 to 3 cm surrounding the umbilicus. Thiscan be done through the vertical incision with-out the need for additional hemostasis. Wehave seen no incidence of necrosis secondaryto defatting. Subdermal 3-0 Vicryl sutures an-chor the abdominal flap to the umbilicus infour corners to pull the skin edges of the ab-

dominal flap down to the umbilicus and taketension off the skin closure (Fig. 3). The skin isclosed with a running suture of choice. Nopostoperative bolster or stents are applied, andthey have not been found to be necessary.

QUESTIONNAIRE

A questionnaire was randomly given to pa-tients who underwent elective abdominoplastyby means of this procedure for umbilical reim-plantation by the senior author. Twenty-oneresponses were obtained. Patients were askedto rate the shape of their new umbilicus, theposition and symmetry, and the overall appear-ance, which specifically included scar forma-tion. The rating scale was from 1 to 10, inwhich a score of 1 was unsatisfactory, 5 wassatisfactory, and 10 was ideal. The average rat-ing for shape was 8.0. The average rating forposition was 9.2; the average rating for overallappearance was 8.1. Seventy percent (15 out of21) of the patients were extremely satisfiedwith their umbilical shape and overall appear-ance, with scores of 8 and above. Only 1 out of21 patients was less than satisfied with the um-bilical shape, giving it a score of 4. This patientrated the overall appearance a score of 6. Ac-cording to the senior author, none of the pa-tients had any negative comments about theumbilicus on follow-up visits.

FIG. 1. The umbilical stalk is sutured superiorly and in-feriorly to the linea alba.

FIG. 2. An area 2 to 3 cm around the umbilicus (outerdotted line) is defatted through the vertical incision.

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DISCUSSION

The aesthetic considerations for reimplant-ing the umbilicus are position, depth, shape,and scar location. Suturing the umbilical stalkto the rectus fascia and linea alba createsdepth, pulls the scar deep within the umbili-cus, and helps maintain a vertical shape (Figs.4 and 5). Although other methods have been

developed to decrease the visibility of scars,3,9

the majority of these methods ultimately createa round, larger umbilicus. Others have de-scribed suturing the umbilicus to the fascia todecrease the visibility of scars; however, theyuse a sequence of triangular incisions in theabdominal flap that ultimately creates arounder and larger umbilicus.9 Some tech-niques place no incisions into the abdominalflap, which prevents scars, but use a purse-string suture to recreate the pattern of theumbilicus. This umbilicus pattern is circularand measures 6 to 7 cm in diameter.3

The vertical incision in the abdominal flap,as opposed to a circular, half-circular, or trian-gular incision, reinforces the vertical shapeand decreases the overall number of incisionsand the possibility of scar visibility. It also min-imizes the possibility of interrupting the bloodsupply to the skin compared with multiple skinflaps or a circular incision. The incision can beextended superiorly or inferiorly to fit the um-bilicus and provides a greater level of flexibilitythan other types of incisions. After the incisionis made, defatting from outside the flap allowseasy visualization of the umbilicus, which elim-inates the often time-consuming and frustrat-

FIG. 3. Four subdermal sutures anchor the abdominalflap to the umbilicus.

FIG. 4. Anteroposterior and oblique photographs of one patient before abdominoplasty.

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ing experience of trying to find the umbilicusafter the abdominal flap is closed.

A variety of techniques have been developedto create hooding of the umbilicus. This hood-ing may create a natural-looking umbilicus atthe expense of an increased number of super-ficial and highly visible incisions. The unpre-dictable nature of the effect of skin, weightchanges, and gravity may change the ultimateposition of this artificially created superiorfold. Although it is considered natural, hood-ing is more associated with increased abdomi-nal girth and increased age.1,12 It may detractfrom the goal of the abdominoplasty to createa thinner and more youthful appearance of theabdomen.

Our technique effectively hides scars andproduces a vertically oriented, youthful umbi-licus. The placement of the umbilicus is accu-rate and predictable. The technique is fast andsimple and requires no complicated skin flaps,cartilage grafts, or complicated suture place-ment. The senior author notes a dramatic in-crease in satisfaction and positive commentsregarding the patient’s umbilicus after abdomi-

noplasty with this technique compared withother traditional approaches. The results ofthe questionnaire support that patients have ahigh level of satisfaction with the verticalshape, the position, and the scar formation.

One potential drawback is that it does noteliminate the possibility of formation of a cic-atricial ring or umbilical stenosis. This type ofproblem is unusual, and it can be minimized bycareful attention to the skin closure with pri-mary healing. Early stenosis can usually betreated with steroid injections. With largerwomen, the umbilical stalk length and thelength of the umbilicus is slightly increased,maintaining good aesthetic proportion withthe abdomen as a whole (Fig. 6).

CONCLUSION

We believe this approach is simple, predict-able, and fast. The umbilical stalk is sutured tothe rectus fascia and linea alba and reim-planted into the abdominal flap with a linearincision. This approach balances the aestheticissues of shape, depth, and scar locations to

FIG. 5. Anteroposterior and oblique photographs of one patient after abdominoplasty. Suturing the umbilical stalk pulls thescar deep within the umbilicus and creates depth. The vertical incision creates a vertically oriented umbilicus.

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help create a more youthful and thin appear-ance of the abdomen.

Thomas A. Mustoe, M.D.Division of Plastic Surgery19th Floor, Suite 250675 North St. Clair StreetChicago, Ill. 60611-2923Tmustoe@nmh.org

ACKNOWLEDGMENT

The authors thank Mark Cisco, M.D., for providing theillustrations in this article.

REFERENCES

1. Pitanguy, I. Abdominal lipectomy: An approach to itthrough an analysis of 300 consecutive cases. Plast.Reconstr. Surg. 40: 384, 1967.

2. Delerm, A. Refinements in abdominoplasty with em-phasis on reimplantation of the umbilicus. Plast. Re-constr. Surg. 70: 632, 1982.

3. Schoeller, T., Wechselberger, G., Otto, A., et al. Newtechnique for scarless umbilical reinsertion in ab-dominoplasty procedures. Plast. Reconstr. Surg. 102:1720, 1998.

4. Dubou, R., and Ousterhout, D. K. Placement of theumbilicus in an abdominoplasty. Plast. Reconstr. Surg.61: 291, 1978.

5. Hodgkinson, D. J. Umbilicoplasty: Conversion of“outie” to “innie.” Aesthetic Plast. Surg. 7: 221, 1983.

6. Juri, J., Juri, C., and Raiden, G. Reconstruction of theumbilicus in abdominoplasty. Plast. Reconstr. Surg. 63:580, 1979.

7. Kurul, S., and Uzunismail, A. A simple technique todetermine the future location of the umbilicus inabdominoplasty. Plast. Reconstr. Surg. 100: 753, 1997.

8. Lim, T. C., and Tan, W. T. Managing the umbilicusduring abdominoplasty. Plast. Reconstr. Surg. 98: 1113,1996.

9. Massiha, H., Montegut, W., and Phillips, R. A methodof reconstructing a natural-looking umbilicus in ab-dominoplasty. Ann. Plast. Surg. 38: 228, 1997.

10. Miller, M. J., and Balch, C. M. “Iris” technique for im-mediate umbilical reconstruction. Plast. Reconstr. Surg.92: 754, 1993.

11. Craig, S. B., Faller, M. S., and Puckett, C. L. In searchof the ideal female umbilicus. Plast. Reconstr. Surg. 105:389, 2000.

12. Psillakis, J. M., Appiani, E., and de la Plaza, R. Color Atlasof Aesthetic Surgery of the Abdomen. New York: ThiemeMedical Publishers, 1991. Pp. 6–7.

FIG. 6. Anteroposterior and oblique preoperative (above, left; below, left) and postoperative (above, right; below, right) photo-graphs of an obese patient who underwent abdominoplasty. The umbilical stalk and vertical incision are lengthened to createa natural-looking umbilicus.

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