New Method for Umbilicoplasty with Bilateral Square Flap and Caudal Deep Inferior Epigastric Artery Perforator Flap

       The navel is an aesthetic element of the abdomen. The size, shape, depth, location, and scar location are essential elements of an aesthetically pleasing navel.¹ However, the navel is often surgically damaged owing to its location. Over recent years, various umbilical procedures have been reported to cause umbilical defects, keloids, and abscesses. Due to the increase in using laparoscopic surgery, various techniques and flap methods have been developed to reproduce an aesthetically desirable umbilical morphology before surgery. These include horizontal and vertical incisions,^2,3 skin grafts,⁴ superiorly based triangular flaps,⁵ VY flaps,⁶ inverted V flaps,⁷ and inverted U flaps⁸. Despite these advances, current umbilicoplasty can lead to various complications, such as unsightly scarring, scarring ring formation, and umbilical cord stenosis. The ideal navel shape is circular, caudally recessed, and bag shaped or box shaped. Recently vertically long navels have been preferred, and methods using bilateral square advancement flaps have been reported.^9,10 This method requires wide vertical excision of the normal skin to ensure that flap length could form a deep umbilical fossa. Although the umbilical fossa created by simply suturing the left and right flaps may have a vertically elongated shape, it may form a slightly unnatural geometry. We devised a new umbilicoplasty that combines the bilateral square anterior flap with a caudal triangular deep inferior epigastric artery perforator flap. This method can reproduce the natural umbilical morphology with caudal depth without wasting excess skin that should be excised. This study aimed to evaluate whether this umbilicoplasty device resulted in a desirable navel.

A total of 23 patients with umbilical keloids after laparoscopic surgery underwent umbilical keloid resection and new umbilicoplasty between April 2018 and March 2020. The mean age of the patients was 48.2 (range: 36–68) years, and the mean body mass index was 23.1 (range: 18.5-33.4). One well-skilled plastic surgeon performed all surgeries. Satisfaction with umbilical morphology was assessed on a 5-point scale by self-interview at 1 year after surgery: 1, bad; 2, poor; 3, fair; 4, good; and 5, excellent.

Surgical Procedure

All surgeries were performed under general anesthesia. Preoperatively, the distance from the skin to the anterior sheath of the rectus abdominis muscle, which corresponded to the deepest part of the navel, was measured based on magnetic resonance imaging (MRI). In addition, one or more deep inferior abdominal artery perforating branches were identified and marked caudal to keloid by Doppler echocardiography.

Preoperative design

The resection line of keloid was marked circumferentially. A square advancement flap was designed on either side of the keloid at the same transverse longitude as the depth of the navel observed on MRI. On the caudal side, an inverted triangular flap was designed to include 1 or more previously identified deep inferior abdominal artery perforating branches. The base of the triangle was created by forming a continuous skin layer from a rectangular flap to ensure blood flow. The height of the caudal triangular flap was equal to the transverse longitude of the rectangular flap. To correct dog-ear deformity, resection of an isosceles triangle of excess skin was designed above and below keloid (Figure 1).

Surgical technique

The keloid was excised as designed. Right and left square flaps were harvested by dissecting in the adipose tissue in the layer below the superficial fascia, wider than the flaps. An inverted triangular flap was harvested as a subcutaneous pedicle flap containing the deep inferior epigastric artery perforator. Thick bilateral square flaps were advanced to the midline by anchoring the subcutaneous adipose tissue in several places using 3-0 Vicryl anchoring sutures, and the flaps tips were anchored to the anterior sheath of the rectus abdominis muscle. The caudal triangular flap was rotated 90° cephalad and perpendicular to the abdominal wall and advanced to form the caudal base of the umbilical fossa. The flap tip was sutured to the anterior sheath of the rectus abdominis muscle using 3-0 Vicryl sutures to form a pouch that would become the umbilical fossa. The subcutaneous tissue was sutured in 2 layers using 3-0 Vicryl sutures, the subcutaneous tissue using 4-0 PDS and superficial layer using 5-0 nylon sutures, and the wound was closed (Figure 2).

Postoperative management

The umbilical fossa was compressed with a silicone prosthesis, and thread was removed 1 week after surgery. Subsequently, a cotton ball was inserted into the umbilical fossa for approximately 2 months after surgery to stabilize the designed morphology. Abdominal binder was worn for approximately 1 month after surgery.

The average follow-up interval was 16 (range, 12 to 24) months. Typical cases are shown in Figure 3 and Figure 4.

After surgery, a partial loss of the caudal triangular flap was observed in a patient who had an umbilical keloid after breast reconstruction with a deep inferior epigastric artery perforator flap (Figure 5). In this patient, blood flow in the penetrating branch was not confirmed in the triangular flap before surgery. Secondary healing was achieved without needing revision surgery.

No complications such as umbilical stenosis, distortion, cranial hypertrophic scarring, infection, or hematoma were observed. All patients were satisfied with their umbilical morphology (mean score, 4.6).

Previous studies on the shape of the navel showed that the aesthetically pleasing navel is oval, recessed, and hooded.^11-13

In the method introduced by this study, inserting a triangular flap nourished by the deep inferior epigastric artery perforator on the caudal side reduced normal skin excision while obtaining a more natural umbilical morphology with a caudal depth. Gross anatomical studies have shown that the deep inferior epigastric artery perforator is the most abundant and thick around the umbilicus.^14-16 Therefore, this method applies to most patients with favorable results.

Based on our encountered cases, patients with keloids had a good scar course. Scars beyond the umbilical fossa were reportedly prone to hypertrophic scars.¹⁷ In our method, only 1 linear and inconspicuous scar was formed. Thus, umbilical surgery using left and right square flaps, as shown in this case, effectively reduced skin tension by dissecting the subcutaneous tissue widely beyond flaps.

This study has several limitations. The patient cohort was limited to Japanese patients only and did not include obese patients. In addition, this method may be inappropriate because other perforators can be amputated in the umbilical region after breast reconstruction surgery using the deep inferior epigastric artery perforator flap, and blood flow in the triangular flap could be unstable. Furthermore, this method does not resolve scarring above and below the umbilicus. This procedure is indicated only for cases that cannot be treated by an incision in the umbilicus alone. The overall patient satisfaction ranged from high to very high; nevertheless, the long-term course needs to be further monitored.

In umbilicoplasty after keloid resection, it is essential to reproduce a long, deep, and well-shaped umbilicus to maintain the aesthetic of the abdomen. Creating a stable flap on the caudal side using originally excised tissues restored the naturally visible depressed umbilicus. Further monitoring is needed to confirm the long-term course.

Affiliations: ¹Keio University Hospital, Keio Gijuku Daigaku Byoin, Shinjuku-ku, Tokyo Japan; ²Yamato Municipal Hospital, Yamato-shi, Kanagawa, Japan

Corresponding author: Kento Takaya, MD; kento-takaya312@keio.jp

Ethics: This study was conducted in accordance with the principles embodied in the Declaration of Helsinki. Written informed consent was obtained from the parents or guardians of patients prior to study participation, including consent for participation and publication of findings.

Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.