Superior Positioning of the Ptotic Umbilicus in Abdominoplasties and TRAM Flaps
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- Published 14/06/10
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Superior Positioning of the Ptotic Umbilicus in Abdominoplasties and TRAM Flaps
By Hamid Massiha, MD, FACS
During the past several years, I have used a
higher position
for the umbilicus in cases of abdominoplasty and transverse rectus
abdominis
musculocutaneous (TRAM) flap reconstruction of the breast. This approach
has
multiple advantages: First, there is a transfer of tension from the
lower
abdominal distant part of the flap to the well-supplied upper part of
the
abdominal flap. Second, the reconstructed umbilicus is not too close to
the
incisions, which, in addition to compromising distal flap circulation,
is
highly unsightly and looks misplaced anatomically. And third, the high
position
of the umbilicus is a sign of a youthful abdomen. The higher location is
an
aesthetic advantage. In the case of true ptosis of the umbilicus, it is
necessary to recreate the normal position.
Studying flap necrosis in cases of
abdominoplasty and/or
abdominal closure in TRAM flap reconstruction often shows a triangular
area
starting at or below the umbilicus with the base at the lower abdominal
incision. Furthermore, these cases are usually the ones in which the
umbilicus
is too close to the incision line in the lower abdomen. In some cases,
although
the lower abdomen looked well, the upper abdomen seemed to have too much
fat
and, at times, even too much skin.
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.
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.
The author finds that higher positioning of the umbilicus in
cases of abdominoplasty and other similar operations such as
transverse
rectus abdominis musculocutaneous flap breast reconstruction is a useful
technique. The operation renders better aesthetic results and also
increases
the margin of safety in lower abdominal flap circulation because tension
is
transferred from the lower abdomen to the upper abdomen. Technically,
the
procedure is easy to do and teach. The umbilicus is fixed to a higher
point in
the abdominal wall and the new umbilicus is reconstructed in a
reasonably
higher position with a safe degree of tension at the upper abdominal
flap while
trying to decrease tension in the lower part of the abdominal flap.
Massiha H. Superior positioning of the ptotic
umbilicus in
abdominoplasties and TRAM flaps. Ann Plast Surg 2002;48:508-510
From the Department of Surgery, Louisiana State
University
School of Medicine, Metairie, LA.
Address correspondence and reprint requests to
Dr Massiha,
Department of Surgery, Louisiana State University School of Medicine,
3939
Houma Boulevard, Suite 216, Metairie, LA 70006.
