[Abdominoplasties. Personal technic for reconstruction of the umbilicus. Transfer of the scar to below the umbilicus].
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In search of the ideal female umbilicus.
The umbilicus is essential to the aesthetic appearance of the abdomen. However, little research exists on what characterizes an aesthetically pleasing umbilicus. Often, the plastic surgeon is called on to reconstruct the umbilicus. Although a variety of reconstructive methods are available, no real standards define the appearance of an aesthetically pleasing umbilicus. To ascertain the characteristics of an aesthetically pleasing umbilicus, a photographic analysis was undertaken using 147 female participants between the ages of 18 and 62 years. Each subject's age, height, and weight were recorded. Photographs of each participant's umbilicus were then taken from 30 cm and 50 cm away. The photographs were reviewed by the authors, and each umbilicus was categorized on the basis of size, shape, hooding, or protrusion. The photographs were then reviewed by a panel and given a score between 1 and 10 to rate attractiveness. Using linear regression analysis, the effects of body mass index, shape, hooding, and umbilical protrusion on attractiveness were assessed. The T- or vertically shaped umbilicus with superior hooding consistently scored the highest in aesthetic appeal, whereas the presence of any degree of protrusion and a horizontal orientation or distorted shape detracted from the score. Those with a large umbilicus tended to score consistently lower than those with a smaller configuration. A desirable goal in umbilical reconstruction is, thus, to create a small T or vertically oriented umbilicus with the addition of a superior hood or shelf.
Adolescent↗
Simplified technique for creating a youthful umbilicus in abdominoplasty.
Reimplantation of the umbilicus remains a critical aesthetic component in abdominoplasty and transverse rectus abdominis musculocutaneous breast reconstruction. Although the ideal shape of the umbilicus has been debated, recent studies have shown the young, thin female with an attractive abdomen tends to have a small, vertically oriented umbilicus. The aesthetic considerations for reimplantation include position, depth, shape, and location of scar. The authors present a technique that is expedient and reliable and that addresses each of these variables. The umbilicus is sutured to the rectus fascia and reimplanted through a vertical incision in the abdominal flap. Subdermal sutures are placed from the umbilicus to the linea alba superiorly and inferiorly. These sutures create a vertically oriented shape and place the umbilicus in the midline. Shortening the umbilical stalk establishes depth and hides the closure of the umbilicus and abdominal flap within the stalk. The stalk length is easily varied, depending on the thickness of the panniculus. Defatting is performed through the vertical incision to allow easy visualization of the umbilicus. This technique creates depth, ensures optimal position, pulls the scar deep in the umbilicus, and produces a vertically oriented, youthful umbilicus. More importantly, a questionnaire given to patients who have undergone abdominoplasty with this procedure (n = 21) confirms that patients have a high level of satisfaction with the resulting shape, position, and overall appearance.
Abdomen↗
Laparoscopic appraisal of the anatomic relationship of the umbilicus to the aortic bifurcation.
STUDY OBJECTIVE: To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measurement during laparoscopy. DESIGN: Prospective, consecutive study (Canadian Task Force classification II-1). SETTING: Tertiary referral center. PATIENTS: Ninety-seven women undergoing operative laparoscopy. INTERVENTIONS: The distance from the aortic bifurcation relative to the umbilicus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three groups based on body mass index (kg/m2). The anatomic location of the common iliac vessels and course of the left common iliac vein were identified in 68 women. MEASUREMENTS AND MAIN RESULTS: The position of the aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm caudal in the Trendelenburg position. In the supine position, the aortic bifurcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was statistically significant for the total study population (p <0.0001) and for the nonoverweight group (p <0.01). In both positions no significant correlation was found between the distance from the aortic bifurcation to the umbilicus and body mass index. Mean +/- SD distance of the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overweight group, and 1. 2 +/- 1.5 cm for the very overweight group. Respective values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at least partly occupied by the left common iliac vein, and was completely filled in 19 women (28%). CONCLUSIONS: The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of body mass index, the aortic bifurcation is more likely to be located caudal to the umbilicus in the Trendelenburg compared with the supine position. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.
Adolescent↗
A method of reconstructing a natural-looking umbilicus in abdominoplasty.
The umbilicus, in the opinion of the authors, is a significant aesthetic unit of the abdominal area. Restoration of this structure to its most natural form in abdominoplasty, breast reconstruction, or primary reconstruction of the umbilicus due to surgery or trauma has been the goal of plastic surgeons from the early times of modern plastic surgery. The authors present a technique of umbilicoplasty that transfers the incisions and suture line deep to the level of the rectus muscle. This procedure can result in the appearance of a normal umbilicus in many patients. Umbilicoplasty, done as part of an abdominoplasty, or to restore the umbilicus due to surgical loss, has progressed during time. However, the most significant disadvantage has been the incisions and scars around the new umbilicus, which detract from the aesthetic value of the newly constructed umbilicus. Any attempt to give a more natural look to it thus far has been less than satisfactory in our hands. In the last several years, we have concealed the scar deep in the bottom of the umbilicus, with good initial results.
Abdominal Muscles↗
The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique.
OBJECTIVE: We evaluated the location of the umbilicus relative to the aortic bifurcation and the left common iliac vein where it crosses the midline. METHODS: Abdominal computed tomography images from 35 reproductive-age women were retrospectively reviewed to determine the location of the umbilicus. The results were correlated with body mass index using Pearson correlation coefficient and a two-tailed paired t test. RESULTS: The location of the umbilicus, but not the aortic bifurcation, was more caudal in heavier women and negatively correlated with body mass index. In nonobese women, the mean location of the umbilicus was 0.4 cm caudal to the aortic bifurcation, and was at or cephalad to the bifurcation in eight of 15 (53%). In overweight women, the mean umbilical location was 2.4 cm caudal to the bifurcation, and in obese women, 2.9 cm caudal to the bifurcation. In the last two groups of subjects, the umbilicus was located at the level of the bifurcation in six of 20 (30%). In every case, the umbilicus was located cephalad to where the common iliac vein crossed the midline. CONCLUSIONS: The umbilicus is often located at or cephalad to the aortic bifurcation, and consistently located cephalad to where the left common iliac vein crosses the midline. The laparoscopic approach should take these relationships into account to minimize injuries to major retroperitoneal vessels.
Adult↗
The umbilicus in laparoscopic surgery.
BACKGROUND: This study examines the factors related to infection and incisional herniation after laparoscopy at the umbilicus, as compared with those at remote sites. METHODS: From a prospective database of 561 cholecystectomies, 190 inguinal hernia repairs, 71 Nissen fundoplications, and 51 ventral hernia repairs, 873 consecutive Hasson cannula sites, 748 umbilicus sites, and 125 remote sites were analyzed. RESULTS: The wound infection rate was found to be 6%: 7% at the umbilicus (9% after cholecystectomy and 2% after other operations [p < 0.05]) and 0% at remote sites (p < 0.05). Excluding cholecystectomy, the umbilical infection rate was 2%, similar to that at remote sites. The postoperative ventral hernia rate was at 0.8%, the same at the umbilicus as elsewhere. The rate was similar for gallbladder and nongallbladder operations and correlated with the postoperative wound infection rate, but not with the preexisting fascial defect rate. CONCLUSIONS: Wound infection at the umbilicus is similar to that at other sites, except after cholecystectomy. Postoperative ventral hernia at the umbilicus is similar to that at other sites and not related to preexisting fascial defects.
Adult↗
Location of the transverse colon in relationship to the umbilicus: implications for laparoscopic techniques.
STUDY OBJECTIVE: To establish the location of the transverse colon in relationship to the umbilicus, and determine if it varies as a function of patient height or weight. DESIGN: Retrospective review of computed tomograms (CT) of the abdomen (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Sixty-seven women with normal abdominal anatomy. INTERVENTION: Review of abdominal CT scans. MEASUREMENTS AND MAIN RESULTS: The relative relationships of the transverse colon and umbilicus were compared with age, height, weight, and body mass index (BMI = kg/m2) using multiple regression analysis. Average location of the superior margin of the transverse colon was 4.6 cm (95% CI 3.5-5.7 cm) above the umbilicus. In nine (13%) women it was below the umbilicus. The colon was below the umbilicus in 25% of nonobese women (BMI <25 kg/m2). CONCLUSION: Because the transverse colon lies below the umbilicus in more than 10% of women, injury to it may be an uncommon yet unavoidable complication of laparoscopy.
Colon↗
Primary melanoma of the umbilicus: report of a case and review of the relevant anatomy.
BACKGROUND: Malignant melanoma presenting on the umbilicus is rare. Treatment of melanoma on the umbilicus is difficult because of the unusual anatomy of the umbilicus. OBJECTIVE: To present the case of a patient with a primary malignant melanoma of the umbilicus and to discuss treatment concerns that are relevant to the umbilical anatomy. METHODS: This is a case report as well as a review of the pertinent anatomy. RESULTS: The initial excision was read as having clear deep and lateral margins on histopathologic examination. Postoperative complications led to a re-excision down to and including the umbilical attachment to the peritoneum. The re-excision revealed residual primary cutaneous malignant melanoma in a remnant umbilical cyst. CONCLUSION: When a malignant melanoma is located on the vertical sidewall or bottom of the umbilicus, one should consider surgical excision down to peritoneum, including the umbilical attachment to the peritoneum. Because this is beyond the scope of training for most dermatologic surgeons, it would be appropriate to refer these patients to a surgical oncologist or a plastic surgeon.
Aged↗
Transverse retubularized sigmoidovesicostomy continent urinary diversion to the umbilicus.
PURPOSE: The most widely used conduit when creating continent urinary diversion based on the Mitrofanoff principle has been appendicovesicostomy. However, appendix is not always available and it is increasingly used for the antegrade continence enema in situ appendix procedure. In 1993 the technique of transverse retubularization of the ileum to create a continent catheterizable conduit for an ileal reservoir was described and in 1997 this technique was studied in an animal model. Larger patients may need 2 ileal segments in series to bridge the distance between the umbilicus and bladder. To avoid using 2 segments we used transverse retubularized sigmoid colon to create a catheterizable sigmoidovesicostomy to the umbilicus. METHODS AND METHODS: In 5 children 6 to 19 years old (mean age 15) with neurogenic bladder secondary to spina bifida a transverse retubularized sigmoidovesicostomy to the umbilicus was performed. In all patients an antegrade continence enema procedure was done for refractory constipation and overflow fecal incontinence secondary to neurogenic bowel. Laparoscopy was performed to mobilize the appendix in patients who requested a low Pfannenstiel incision for better cosmesis. Additional procedures included the pubovaginal sling placement and sigmoid colocystoplasty. RESULTS: Mean length of the sigmoidovesicostomy, which was equal to the circumference of the sigmoid before retubularization, was 13 cm. (range 10 to 15). This sigmoid conduit reached the umbilicus easily in all cases. All sigmoidovesicostomies were easily catheterized and all were continent. One patient with morbid obesity (body mass index 40.4) had a mucocutaneous anastomotic breakdown 3 months postoperatively. Minimum followup was 1 year (mean 1.5). CONCLUSIONS: Transverse retubularized sigmoidovesicostomy is effective for creating a continent urinary diversion to the umbilicus in patients with neurogenic bladder secondary to spina bifida. Dilating the sigmoid colon from neurogenic bowel creates a long conduit based on the Yang-Monti principle and 2 ileal segments with an anastomosis are not required. Additional benefits are that the sigmoid colon is readily accessible via a low Pfannenstiel incision and may also be used for augmentation in select cases.
Adolescent↗
Arterial vascular anatomy of the umbilicus.
The rare occurrence of umbilical necrosis after performance of a transverse rectus abdominis muscle (TRAM) flap prompted this investigation into the specific arterial anatomy of the umbilicus using multiple anatomic techniques. Sixteen fresh cadavers were studied by using dissection of blue latex-injected specimens, radiography of barium latex-injected specimens, and selective ink injection of individual perforators. It was discovered that the umbilicus receives arterial inflow by means of three distinct deep sources in addition to the subdermal plexus. These deep sources are (1) the right and left deep inferior epigastric arteries that each give off several small branches, and a large ascending branch, which courses between the muscle and the posterior rectus sheath passing directly to the umbilicus; (2) the ligamentum teres hepaticum; and (3) the median umbilical ligament. The clinical implications of this study are that the umbilicus should have robust arterial inflow if only one rectus muscle is removed, such as during a unilateral TRAM flap, because the contralateral side should still provide large direct vessels from the deep inferior epigastric arteries to the umbilicus. During bilateral TRAM elevation, all of the large arterial sources are removed from the umbilical inflow and circulation must depend on small vessels from the ligamentum teres and median umbilical ligament. Care should be taken in this latter clinical situation to preserve these sources of blood flow during umbilical flap creation.
Abdominal Muscles↗
Is the umbilicus truly midline? Clinical and medicolegal implications.
A common misconception is that the umbilicus is a midline structure. To date, an anatomical survey examining whether the umbilicus is located at the midline has not been reported. This study measured the position of the umbilicus among 136 subjects, in two separate experiments. The results demonstrated that the umbilicus was not at the midline for nearly 100 percent of subjects and was more than 2 percent from the midline for more than 50 percent of subjects. This finding is of great importance for patient counseling in preoperative and postoperative settings. Because the discerning eye has repeatedly been demonstrated to be able to detect smaller asymmetries, these findings are significant and should be discussed with patients undergoing cosmetic abdominoplasty or reconstructive procedures, for preoperative informed consent. Education and preoperative demonstration can help prevent medicolegal ramifications. The umbilicus is rarely midline and, when critically analyzed, is located lateral to the midline axis more often than not.
Abdominal Wall↗
Imaging of the umbilicus and periumbilical region.
Umbilical disorders can be classified according to embryonic remnants contained in the umbilicus, including the urachus, omphalomesenteric duct, and round ligament of the liver; the extraperitoneal paravesical spaces; the umbilical ring; and the umbilicus itself. Only one of the five types of congenital urachal abnormalities (urachal cyst) is common. All anomalies associated with the omphalomesenteric duct are rare except the Meckel diverticulum, which is the most common congenital abnormality of the gastrointestinal tract. The round ligament contains the remnant of the umbilical vein, which in the presence of portal hypertension, may open, recanalize, and form a portosystemic collateral vessel. Extraperitoneal paravesical spaces that run from the umbilicus to the bladder may contain fluid collections. The umbilical ring and the umbilicus may give rise to many masses, including omphalocele, gastroschisis, various hernias, inflammatory and suppurative processes, and neoplasms. Clinical manifestations of umbilical disorders are usually nonspecific; use of cross-sectional imaging can help identify most of these entities because of their typical locations and distributions in continuity with the urinary bladder and the umbilicus and guide therapy. Understanding the anatomy and the differential diagnosis of umbilical disorders is key to arriving at a correct diagnosis and proper patient treatment.
Abscess↗
Reconstruction of a natural-looking umbilicus.
Based on the assumption that the umbilicus is a wound that has healed by second intention, we describe a method of reconstruction. The procedure consists of complete resection of the umbilical scar and its reconstruction by a linear incision at the site of the new umbilicus and inversion of the skin hedges, which are sutured to the linea alba leaving a 1 cm space between the skin borders to cause secondary wound healing. This procedure provides a natural-looking umbilicus. It is easy and quick to do, and can be used for reconstruction after abdominoplasty, excision of a naevus, or when the umbilicus has been removed during a previous xiphopubic incision.
Adult↗
Pilonidal sinus of the umbilicus.
Only 15 cases of pilonidal sinus of the umbilicus have so far been reported. A 16th case is described; it supports the theory of acquired origin of the disease. The case fulfilled the criterion for pilonidal sinus--the 36-year-old man had a hair in the infected umbilical cyst. The cyst and umbilicus were excised. The umbilicus was not reconstructed because of the danger of recurrence. It is recommended that a careful search be carried out for hair in all patients with an infected umbilicus.
Adult↗
Urine leakage from the umbilicus in a child with achondroplasia and tetraplegia (due to cervical stenosis): a safety vent for the obstructed neuropathic bladder.
Urine leakage from the umbilicus was observed while expressing urine by the Crede manoeuvre in a three-year-old tetraplegic girl with a chronically distended urinary bladder. Intravenous urography (IVU) revealed bilateral hydroureteronephrosis with markedly distended urinary bladder. Regular three hourly intermittent catheterization was advised, and the parents and carers of this child agreed to perform catheterization. There was cessation of urine leak within 48 hours of urethral drainage. Cystography performed two weeks later showed no vesicoureteric reflux; vesicoumbilical fistula was no longer demonstrable. Follow-up IVU, performed after eight and half months of regular intermittent catheterization, showed regression of hydroureteronephrosis. We believe that urine leakage from the umbilicus served two important protective functions in this child, viz. (1) it prevented possible vesical or renal rupture; (2) the striking clinical symptom of urine leak from the umbilicus focussed the attention of the carers to the underlying serious condition of the urinary tract. Further, this case demonstrates that regression of marked hydroureteronephrosis can be achieved by intermittent catheterization performed at regular intervals by devoted parents/carers, in selected cases of spinal cord injury with neuropathic bladder, and vesical outlet obstruction, thus obviating the need for any form of temporary or permanent urinary diversion.
Achondroplasia↗
Unusual presentation of patent vitello intestinal duct with round worms emerging from the umbilicus.
Patient vitello intestinal duct (VID) is not an uncommon anomaly in children. It usually presents with fecal discharge from the umbilicus. Round worm infestation is very common in Indian children, but an association of patent VID and ascariasis, presenting as round worms emerging from the umbilicus, is unique and has not been previously reported in the literature. We present such a case in a 2-year-old boy who presented with a history of round worms coming out through the umbilicus. It was provisionally diagnosed to be a case of patent VID, which was proven correct on laparotomy.
Ascariasis↗
The normal position of the umbilicus in the newborn: an aid to improving the cosmetic result in exomphalos major.
BACKGROUND/PURPOSE: The aim of this study was to determine the normal position of the umbilicus and hence improve the cosmetic result of exomphalos major repair. METHODS: The position of the umbilicus was determined in 50 neonates with respect to the xiphisternum and pubis. RESULTS: The normal umbilical position is 60% of the way from the inferior border of the xiphisternum to the superior border of the pubis in the midline. CONCLUSION: In the repair of exomphalos major, the most aesthetically pleasing result is obtained if the umbilicus is placed 60% of the way from the xiphisternum to the pubis.
Esthetics↗