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R. Calderon
15. Isaac KV, Lista F, McIsaac MP, Ahmad J. Drainless abdominoplasty using barbed progressive tension sutures. Aesthet Surg J.
2017;37(4):428–39.
16. Austin RE, Sahaeb-Al-Zamani M, Lista F, Ahmad J.Periareolar
augmentation-mastopexy. Aesthet Surg J. 2019;39(9):953–65.
17. Wallach SG, Matarasso A.Chapter 6: Abdominoplasty: classication and patient selection. In: Aesthetic surgery of abdominal wall.
Berlin: Springer; 2007. p.70–86.
18. Hunsted JP, Schmidt A.Commentary on: Inuences of age, gender,
and body mass index on the thickness of the abdominal fatty layers
and its relevance for abdominal liposuction and abdominoplasty.
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20. Roseneld LK, Davis CR.Evidence-based abdominoplasty review
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Neoumbilicus
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MohanThomas andJamesD’silva
25
“Navel” is the rst scar that ever appears during our life time
and is also considered an epitome of beauty in many civilizations. It is a unique physiologic scar that reminds us of our
attachments to our mothers. The umbilicus is formed due to
scarring of the following four elements: the left umbilical
vein, which is connected to the round ligament of the liver;
the obliterated urachus, which directs inferiorly and is
attached to the dome of the urinary bladder; and the two
umbilical arteries, each of which runs laterally to the corresponding internal iliac artery.
Umbilicus usually presents as a round to oval depressed
structure. It has an average diameter of 1.5–2cm which to a
great extent contributes to the aesthetic appearance of the
abdomen. The umbilicus is the dening point of the median
abdominal sulcus and thereby contributes to the curvy shape
of the inferior abdomen. It is a natural reference point as anatomically it lies at the junction of the midline and the line
connecting the superior point of the iliac crests. Absence of
umbilicus leads to an unnatural appearance of the abdomen.
A misplaced or abnormally shaped umbilicus usually draws
unnecessary attention to the abdomen [1].
The abdominal wall at the umbilical region is composed
of
1. The skin
2. The supercial fascia and more or less fat
3. The supercial sheath of the abdominal muscle
4. The rectus abdominis muscle present on either side of the
umbilicus. In the midline layers 3, 4, and 5 form the Linea
Alba which may be 1cm wide
5. The deep layer of the sheath
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_25].
M. Thomas (*) · J. D’silva
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil
University, Mumbai, Maharashtra, India
6. The subperitoneal connective tissue
7. The peritoneum
25.1 Blood Supply, Lymphatic Drainage,
andNerve Supply oftheUmbilicus
The central area of the anterior abdominal wall, including the
umbilicus, is supplied by the branches of the superior and
inferior epigastric arteries. These anastomose with each
other on either side of the umbilicus and form an important
alternative channel for blood ow in case of aortic coarctation. A venous network is formed from supercial veins radiating from the umbilicus along the arteries. Paraumbilical
veins connect this network with the portal vein through the
umbilicus and along the ligamentum teres. A very important
portosystemic venous anastomosis is formed by this
connection.
The lymphatic drainage of the abdominal wall above the
umbilicus is to the anterior axillary lymph nodes while
lymph from the lower abdominal wall is drained to the inguinal lymph nodes. The drainage of the deeper tissues including the muscle and fascia is to the parasternal nodes
superiorly and para-aortic nodes inferiorly [2].
25.2 The umbilicus is classically composed
of four distinct anatomic structures
(Fig.25.1)
• Mamelon: Area of central hump.
• Cicatrix: Dense scar, which marks the intersection of
intra- and extra-embryonic mesoderm of the fetus.
• Cushion: Comprises of a slightly raised skin margin
around the cicatrix and mamelon. Cushion forms promi-
nent skin folds or ridges.
• Furrows: The depression inside the cushion and surround-
ing the mamelon.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_25
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Cicatrix
Mamelo
Furrows
Cushion
Fig. 25.1 Anatomical structures of the umbilicus
An umbilicus is dened according to its cosmetic appear-
ance [3].
Loss of the umbilicus can lead to an embarrassing deformity and it leaves the patient devastated. This can occur due
to various factors like, when older techniques of umbilical
hernia or incisional hernia repair are employed. It can also
occur after procedures like abdominoplasty involving
umbilical repair, urachal cyst repair, omphalocele repair,
gastroschisis repair, some tumor excisions. Mobilization of
bipedicled or bilateral TRAM/DIEP aps for breast reconstruction also can cause a deformity of the umbilicus.
25.3 Ideal Umbilicus
The ideal umbilicus as a general consensus must have a natural contour, adequate depth, minimal scarring, and most
importantly a proper superior hooding. Shinohara etal. [4]
emphasized that an umbilicus with a natural appearance consists of a ring, a tubular wall, a sulcus, and a bottom, without
any excess skin that would lead to interference with the aesthetic aspect of the ideal umbilicus.
Lee etal. [5] suggested that an aesthetically optimal female
umbilicus must possess the following properties: a vertical
ratio of 46:54 (with respect to the xiphoid process and the
lower limit of the vulvar cleft), a midline horizontal position,
and an oval shape with superior hooding or no hooding.
Abnormally shaped umbilicus that is small, which doesn’t contain any cushions or mamelons, is not considered aesthetic.
M. Thomas and J. D’silva
cal surgery, it is of paramount importance to undertake an
ultrasound examination of the umbilicus to rule out any
umbilical hernia.
1. Ideal position—The umbilicus should be positioned on
the midline intersecting with a line joining the superior
iliac crest on either sides or a couple of inches higher. It is
ideal to maintain the previous position of the umbilicus.
2. Size—The ideal circumference of the umbilicus should
be about 4–5cm and can be round, oval, or triangular.
3. Depth—The nal depth of the umbilicus should be less
than the thickness of the skin ap. The depth can be modied by either reducing the length of the umbilicus tube
or suturing the edges of the tube to the rectus sheath.
4. If possible, provide hooding on the superior aspect.
5. Excise subcutaneous tissue around the neo-umbilicus so
that a smooth depression leading to the umbilicus is
visible.
25.5 Umbilicoplasty during
abdominoplasty
1. Preservation of the natural umbilicus and its reposition—
In this technique the umbilicus remains anchored to the
deep abdominal fascia but is transposed through a newly
formed aperture in the upper abdominal skin ap. Most
surgeons prefer using a circum-umbilical incision in order
to preserve the xed umbilicus, passing it through a new
orice in the upper abdominal ap. Reinsertion of the
umbilicus into the abdominal wall is performed through a
circular, oval, vertical, or transverse incision. Surgical
techniques:
(a) Liposuction in the anterior abdominal wall in and
around the umbilicus should be aggressive as well as
uniform as seen in Fig.25.2.
(b) The position of the original umbilicus is marked using a
3-0 Silk/Nylon suture and a hemostat. The suture is xed
at a non-mobile point on the sternum (this is checked by
moving the abdominal pannus inferiorly). The hemostat
as shown in Fig. 25.3 now marks the position of the
25.4 Principles ofReconstruction
The reconstruction of the umbilicus depends on whether it
involves relocation of the umbilicus or a reconstruction of
the umbilicus due to scarring or absence. Before any umbili-
Fig. 25.2 Liposuction being undertaken of the anterior abdominal wall
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Fig. 25.3 The position of the original umbilicus is marked with a
hemostat along the midline
395
Fig. 25.4 The extent of inferior abdominal ap excision is marked by
assessing using Towel Clip
a
Fig. 25.5 (a) A 15 number blade is used to make an incision on the epidermis so as to have absolute control on the incision. A radio cautery can
also be used to make this incision. (b) The incision being deepened using an 11-number blade
umbilicus. This hemostat should not be released from
the suture as it will help in marking the neo-position of
the umbilicus as shown in later pictures.
(c) The extent of inferior ap laxity should be assessed
using a large Towel Clip after a complete uniform liposuction as seen in Fig.25.4.
(d) A circum-umbilical incision is made to release the umbi-
licus from the abdominal pannus. Figure 25.5a shows
the use of a 15-number blade to make an incision. This
can also be undertaken using a radio frequency and then
deepened using a cutting cautery or an 11 blade as shown
in Fig.25.5b.
(e) A thick vicryl 1 or PDS 1 suture is placed at 12 o’clock
position of the umbilical stump so as to orient the umbilical position during re-suturing as seen in Fig.25.6 and
marked by the arrow.
b
(f) The abdominal muscle is now tightened using nonab-
sorbable sutures Ethilon 1 or Ethibond 2 in a vertical,
oblique, or horizontal vector to correct the divarication
and/or reduce the inferior segment. Figure 25.7 shows
tightening in a vertical orientation taking care that no
suture passes through the umbilical stump and the vascularity is not compromised.
(g) Excess abdominal ap is now trimmed after placing the
patient in a jack knife position and a stay suture placed
between the abdominal ap and the inferior incision at
the midline suprapubic area. Once the tension on the ap
and the possible suture line have been checked then the
position of the neo-umbilicus is marked using the help
of the previously placed suture with a hemostat.
Figure 25.8 shows marking of the position of the
neo-umbilicus.
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M. Thomas and J. D’silva
Fig. 25.6 A thick PDS or vicryl suture being used at 12 o’clock position to help orient the umbilical position during re-suturing
a
Fig. 25.8 Marking of the neo-umbilicus position being carried out
using a suture
b
Fig. 25.7 (a) The weakness of the anterior abdominal wall is seen as a divarication. The marked parallel lines show the extent of tightening. (b)
Vertical abdominal wall tightening has been achieved using a Ethilon 1 or an Ethibond 2 suture
ab
cd
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397
(h) Once the position has been marked using a marking pen
on the abdominal ap in the midline, the position of the
umbilical stump conrmed below the abdominal ap,
plans are made to deliver the umbilicus through an incision. A round, vertically or horizontally oval, crisscross
or a round with a small ap incision is made as shown in
Fig.25.9a–d. The skin incision is deepened into the dermis and the soft tissue is cored out.
(i) As seen in Fig.25.10, the umbilicus is delivered through
the skin.
(j) Subcutaneous tissue in the neo periumbilical area is
reduced from the abdominal ap so as to get a beveled
edge as seen in Fig.25.11a. Key sutures in four quadrants
are done using Ethilon 4-0 which sutures the abdominal
ap edge to the rectus sheath and the umbilicus edge as
shown in Fig.25.11b. Figure25.11c shows the completed
reposition of the umbilicus. If required an absorbable
continuous suture can be used to future approximate the
umbilicus to ap edges.
(k) A parafn plug is nally placed in the umbilicus with an
overlying dressing to maintain the nal shape.
2. Excision of umbilicus and de-novo creation as mentioned
in the “TULUA” technique [6].
In the presence of an umbilical hernia or as part of the
“TULUA” technique as described by Villegas etal. the
umbilicus is completely sacked. New umbilicus is created
using a full thickness skin graft which is sutured to the
defect created as seen in Fig. 25.12a, b. The healing
3week after surgery is seen in Fig.25.12b.
Umbilicoplasty—immediate umbilicus reconstruction
(when previous umbilicus has been excised) without external
scars—not associated with abdominoplasty or after loss of
umbilicus.
(a) Purse-string suture techniques—One example of this
type of technique, described by Schoeller et al. [7], is
Fig. 25.10 Delivery of the umbilicus at the marked area
Fig. 25.9 Various types of incisions (a round, b oval incision, c round with V pattern, d star shaped incision) used to deliver the neo-umbilicus.
When well healed all these incisions give comparable results
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M. Thomas and J. D’silva
a
b
c
Fig. 25.11 (a) Beveling of the periumbilical skin edges being done to
reduce the subcutaneous tissue. (b) Key sutures xing the umbilical
skin edge, abdominal ap edge, and the rectus sheath. (c) The sutures
being tightened and the nal at umbilicus
used for immediate umbilical reconstruction. A 2-cm
wide ring is marked around the umbilical defect and skin
in the area defatted with scissors, preserving the subdermal vascular plexus. At the level of the deep face of the
dermis at the defatted ring’s outer circumference. A
purse-string suture using non-resorbable thread is placed
at the outer aspect of the de-fatted area. A second purse
string suture is made at the free dermal margin of the
ring. Before tightening the two sutures, a third thread is
passed that includes the skin margin at 3 and 9 o’clock
and is perpendicular to the drawn line. The outer purse
string suture is carefully tightened until the diameter of
the rim decreases from 6 to 2cm. This maneuver creates
skin folds and invaginates the skin ring. The second central suture is then completely tightened and xed to the
rectus sheath, imitating the bottom of the umbilical crater. The third thread is then knotted by taking a Vaseline
gauze and xing it as a bolster (Fig.25.13).
(b) C–V ap technique—Shinohara et al. [4] reported an
umbilical reconstruction technique in which there are
two V-aps and a C-shaped ap that are sutured in a
tubular manner. This technique allows for the deepening
of a non-invaginated adherent scar umbilicus. The depth
of the navel depends on the width of the base of the “V,”
and the diameter depends on the diameter of the “C.”
The V- and C-aps are sutured together to create an
a
Fig. 25.12 (a) Full thickness skin graft being used to recreate the umbilicus. (b) Neo-umbilicus after 3weeks
b
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399
a
invaginated tube. The donor sites of the V-aps are
closed primarily (Fig.25.14).
(c) There are various other techniques of neo umbilicus such
as V–Y ap technique by Jamra (23), twisted aps technique by Yotsuyanagi et al. (24), Triangular ap technique by Pfulg etal. (25), Iris technique by Miller (8).
Double circle technique by Baack etal. (4), etc. which
utilize local aps for reconstruction of umbilicus but are
beyond the scope of this discussion.
25.5.1 Complications
b
Complications such as umbilical stenosis, umbilical or skin
ap necrosis (34), scar hypertrophy, and transient skin erythema were observed. At times a deep neo-navel cannot be
achieved, resulting in a at and unaesthetic umbilicus. In
some instances, there could be sensory issues where patients
report hypo or insensitivity around the neo-umbilical scar.
There is also hyperpigmentation of the umbilical skin which
shows a marked demarcation between the previous umbilicus and the normal skin.
Fig. 25.13 (a, b) Showing the purse string technique of umbilical
reconstruction as published by Schoellar etal.
Umbilicus Intact
Vertically-
oriented
umbilical
excision
Obese abdominal
pannus?
Consider abdominal
stalk plication with 3-4
cm of circumferential
defatting
YES
Inverted-U
abdominal incision
High level Fitzpatrick Skin
Type or history or PMHx/FH of
Keloid or HSC?
NO
NO
Inverted-U
umbilical
excision
Consider anchoring
umbilical dermis to rectus
fascia, with 2-3cm
circumferential defatting
make semicircular
incision, remove
sub-q tissue,
invert flap and
suture to fascia
Consider non-dissolvable suture
(4-0 or 5-0 Prolene/Nylon)
Flow diagram—modied from—Creating the Perfect Umbilicus: A Systematic Review of Recent Literature Walter J. Joseph, Sammy
Sinno, Nicholas D.Brownstone, Joshua Mirrer, Vishal D.Thanik, Aesth Plast Surg. https://doi.org/10.1007/s00266-016-0633-x
YES
NO
Dissolvable sutures possible if
low tension closure
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Fig. 25.14 (Above, left)
Marking of a C–V ap.
(Above, right) The two V aps
are about to be sewn to the C
ap. (Below, left) The donor
sites of the two V aps are
about to be closed primarily.
(Below, right) The inverted
tubular ap is buried in the
caudal direction and xed
with bolsters. As published by
Sinohara etal.
M. Thomas and J. D’silva
References
1. Gardani M, Palli D, Simonacci F, Grieco MP, Bertozzi N, Raposio
E. Umbilical reconstruction: different techniques, a single aim.
Acta Biomed. 2019;90(4):504–9. https://doi.org/10.23750/abm.
v90i4.7539.
2. Fahmy M. Anatomy and physiology of the umbilicus. In:
Umbilicus and umbilical cord. Cham: Springer; 2018. https://doi.
org/10.1007/978- 3- 319- 62383- 2_20.
3. Ribeiro L, Muzy S, Accorsi A. Omphaloplasty. Ann Plast Surg.
1991;27:457.
4. Shinohara H, Matsuo K, Kikuchi N.Umbilical reconstruction with
an inverted C–V ap. Plast Reconstr Surg. 2000;105:703–5.
5. Lee SL, DuBois JJ, Greenholz SK, etal. Advancement ap umbilicoplasty after abdominal wall closure: postoperative results compared
with normal umbilical anatomy. J Pediatr Surg. 2001;36:1168–70.
6. Villegas FJ.A novel approach to abdominoplasty: TULUA modications. Aesthetic Plast Surg. 2014;38(3):511–20. https://doi.
org/10.1007/s00266- 014- 0304- 8.
7. Schoeller T, Rainer C, Wechselberger G, Piza-Katzer H.Immediate
navel reconstruction after total excision: a simple three-suture technique. Surgery. 2002;131:105–7.
Part VI
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Body Contouring After Massive Weight Loss
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