Introduction

The umbilicus is our first scar, the last remnant of our life in utero [1, 2]. There are many instances in which sacrificing the umbilicus is unavoidable: abdominoplasty performed simultaneously with umbilical or ventral hernia repair, transverse rectus abdominus myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) breast reconstruction [3], surgical removal of cutaneous mole or cancer localized to the navel and congenital conditions, such as bladder exstrophy or omphalocele. In particular, Ricci et al. [3] observed umbilical stalk necrosis to occur in 3.2% of patients after abdominal-based microsurgical breast reconstruction. The importance of the umbilicus in abdominal harmony leads plastic surgeons to place particular attention on its anatomic features during reconstruction. It is appropriate to clarify the terminology, as follows. The terms umbiliconeoplasty, neo-omphaloplasty, and neoumbilicoplasty refer to the creation of a navel (umbilical reconstruction) where it does not exist, whereas the terms umbilicoplasty, omphaloplasty, and umbilicaplasty refer to the transposition of the umbilicus (umbilical reinsertion) during abdominoplasty or other abdominal surgeries [4,5,6]. The aim of this review is to provide a complete overview of all existing surgical umbiliconeoplasty techniques.

Methods

PubMed database was queried using ‘umbilical and reconstruction’, ‘umbilicus and reconstruction’, ‘navel and reconstruction’, ‘umbiliconeoplasty’, ‘neo-omphaloplasty’ or ‘neoumbilicoplasty’ to select the papers dealing with the reconstruction of the umbilicus. Only the studies in which the performed surgical technique was clearly described were included. Studies on umbilical reinsertion in abdominoplasty or during other surgeries were excluded. The database search was conducted from January 2019 to March 2019 by the first author (A.S.).

Results

We found 77 papers from 1955 to 2018 (Tables 1 and 2). Sixty different techniques for the reconstruction of a missing umbilicus were described: 56 flap [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78], 2 graft [52, 79], and 2 combined flap and graft techniques were described [80, 81]. Eight representative techniques out of them have been selected by the first author (A.S.) based on frequency of description in the literature and clinical significance and have been illustrated in Figs. 1, 2, 3, 4, 5, 6, 7, and 8. Local skin flap was the most frequently performed technique. Three flaps technique (Fig. 1) was described in 7 papers [14,15,16,17,18,19, 82], and purse-string suture technique (Fig. 2) in 7 [8,9,10,11,12, 21, 73].

Table 1 Studies describing umbilicus reconstruction techniques
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Table 2 Umbilicus reconstruction techniques
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Fig. 1
figure 1

Three triangular flaps technique, also called tricuspid or diamond shape, Y to V, or Mercedes-Benz [14,15,16, 18, 19]. a Preoperative drawing. b Subcutaneous tissue removal. c Skin flaps are sutured to the abdominal fascia. d Postoperative aspect

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Fig. 2
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Purse string technique, as described by Bartisch et al. [9]. The use of purse string technique for umbilical reconstruction was reported by other authors as well [7, 8, 10,11,12,13]

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Fig. 3
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Neo-omphaloplasty during inverted T abdominoplasty using the 2 lateral rectangular pedicle flaps technique [27, 28, 37, 57]. a Preoperative drawing. b Movement of the flaps. The opposing skin flaps are sutured to each other and to the abdominal fascia to create a depression (green arrows). c Postoperative ‘inverted T’ scar

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Fig. 4
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Four flaps technique, as described by Lee et al. [74]. A cone-shaped portion of the adipose tissue underlying the X-shaped incision is removed to create the depression (C, shaded area). The use of the same technique was reported by other authors as well [3, 40, 54, 70]

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Fig. 5
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Inverted C–V flap, as described by Shinohara et al. [49]. a preoperative drawing. b skin incision. c flap rising and initial sutures. d immediate post-operative aspect

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Fig. 6
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Rabbit head–shaped scar flap, as described by Watanabe et al. [66]

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Fig. 7
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Spiral rotational flap, as described by Featherstone and Cuckow [75]

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Fig. 8
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Dome procedure, as described by Senturk et al. [76]. a Preoperative drawing. b Rising of c flap. c Island flaps b and c are moved downward. d Final sutures

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Neo-omphaloplasty during inverted T abdominoplasty using the 2 lateral rectangular pedicle flaps technique was described in 4 papers (Fig. 3) [27, 28, 37, 57].

The Four flaps technique was described in 5 papers [3, 40, 54, 70, 74] (Fig. 4), while the Island flap technique was described in 4 [20,21,22,23]. Seven articles described the use of more than 1 surgical technique [24, 29, 31, 39, 41, 52, 64].

Figure 5 illustrates the Inverted C–V flap, as described by Shinohara et al. [49] Fig. 6 illustrates the Rabbit head–shaped scar flap, as described by Watanabe et al. [66] Fig. 7 illustrates the Spiral rotational flap, as described by Featherstone and Cuckow [75]. Figure 8 shows the Dome procedure, as described by Senturk et al. [76] Figs. 9 and 10 show 2 representative cases of neo-omphaloplasty during inverted T abdominoplasty using the 2 lateral rectangular pedicle flaps technique.

Fig. 9
figure 9

A 43-year-old female patient. Neo-omphaloplasty during inverted T abdominoplasty using the 2 lateral rectangular pedicle flaps technique [27, 28, 37, 57]. a: Preoperative drawing. b: The 2 lateral skin flaps (green arrows) are raised and defatted. c: The 2 lateral skin flaps are sutured to the abdominal fascia and to each other. d: Two prolene stitches (blue arrows) are used to approximate the cranial and caudal ends of the neo-umbilicus. E: A small tampon is inserted inside the neo-umbilicus

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Fig. 10
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A 36-year-old patient. Umbilicus reconstruction using the 2 lateral flaps technique, as described by Sabatier et al. [37], Vallim et al. [28], Mendes et al. [27] and Franco et al. [57] Preoperative picture (on the left) and postoperative picture (on the right). The original umbilicus was intentionally amputated and reconstructed during an abdominoplasty, using the two lateral rectangular pedicle flaps technique

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The types of umbilicus reconstruction were classified according to the cause of reconstruction: congenital umbilicus malformations, exomphalos repair, omphalocele or gastroschisis, urinary malformations, umbilical hernia repair, umbilical endometriosis, abdominoplasty, resection of cutaneous tumors, absent or destroyed umbilicus, abdominal wall surgeries, intra-abdominal surgeries, and multiple causes (Table 3).

Table 3 Type of umbilicus reconstruction due to a specific cause
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The most frequent indication for umbilical reconstruction was after the correction of umbilical hernia, as described in 16 papers [7, 14, 15, 18, 22, 23, 30, 35, 36, 38, 47, 51,52,53, 68, 76].

Twelve different techniques [27,28,29, 37, 39, 55, 57, 59, 60, 64, 70, 80] were described for the immediate reconstruction of the umbilicus during abdominoplasty (Fig. 3 illustrates the Neo-omphaloplasty during inverted T abdominoplasty using the 2 lateral rectangular pedicle flaps technique [27, 28, 37, 57]). Scarless umbilicoplasty techniques were described in 2 articles [29, 53].

Regarding umbilicus reconstruction in children, 37 articles described surgical techniques with congenital defects such as umbilical hypogenesis, umbilicus agenesia, exomphalos, urinary malformations, omphalocele, gastroschisis, and umbilical hernia (Table 3) [9, 12, 17,18,19, 22, 30,31,32,33,34, 40, 41, 43,44,45, 47,48,49,50,51,52,53,54, 62, 63, 66, 71,72,73,74,75, 78, 81].

Ricci et al. [3] described umbilical reconstruction with four-flap technique after abdominal-based microsurgical breast reconstruction, using the technique previously described by Lee [74], Kaneko [54] and by Ricketts and Luck [40], while Hazani et al. [80] described the umbilicus reconstruction after TRAM (transverse rectus abdominis muscle) flap for breast reconstruction using a transposition flap and a skin graft.

Discussion

In umbiliconeoplasty, a perfect result is difficult to obtain [5, 72, 83, 84]. No real standards define the appearance of an aesthetically pleasing umbilicus; however, a vertically oriented umbilicus with the presence of superior hooding tends to be more attractive than a horizontal one [85,86,87,88] Furthermore, the position and dimension of a normal, good-looking umbilicus should be taken into consideration during surgical planning. Yu et al. [89] observed that the umbilicus is normally located at a mean height distance of −0.7 ± 1.3 cm in relation to the iliac crest (range, 5 cm below to 3 cm above) in young adults. Guerrerosantos et al. [90] proposed the location of neo-umbilicus 1 cm above the horizontal line that connects the 2 iliac crests.

Regarding the transverse position of the umbilicus, Rohrich et al. [91] demonstrated that the umbilicus is not a midline structure as generally thought. Fathi et al. [92] reported 15 mm as the largest dimension of a normal umbilical ring, examining 24 embalmed adult cadavers. Yu et al. [89] reported the mean height of the umbilicus as 2.1 ± 0.6 cm, with a range of 1.3 to 3.7 cm and the mean width as 2.3 ± 0.7 cm (range, 1.0–4.0 cm), in 80 volunteers of normal body habitus.

Reconstruction of the umbilicus can be performed after abdominal hernia repair. McMillan [35] first described an umbilical reconstruction in 1955 using a bilateral lateral advancement flap after the correction of an umbilical hernia. The closure of the skin was accomplished following the vertical laparotomy incision, and at the point where the umbilicus should be located, the skin was sutured to the underlying fascia. This resulted in the formation of a dimple, which makes an excellent substitute for an umbilicus. Borges [36] used a rotation of 2 small paramedian flaps to reconstruct the umbilicus after umbilical herniorrhaphy. Kirianoff [14] first described the 3 flaps technique in 1978 (Fig. 1), then Franco and Franco [16] modified this flap, leaving a central raw area for second-intention healing.

Reconstruction of the umbilicus during vertical or anchor abdominoplasty, when the navel is amputated, has been widely described (Figs. 3, 9, and 10) [27, 28, 37, 57]. Both surgeons and patients have been reported to prefer umbiliconeoplasty to the traditional omphaloplasty with reinsertion of the original navel in the vertical scar, in a study by Vallim et al. [28]. Nevertheless, umbilical transposition is currently more commonly used than umbilical reconstruction. The immediate reconstruction of the umbilicus during vertical or anchor abdominoplasty has been carried out using the 2 lateral pedicle flaps technique in 4 papers [27, 28, 37, 57]. Neo-omphaloplasty during inverted T abdominoplasty using the 2 lateral rectangular pedicle flaps technique is also our personal preference.

Reconstruction of the umbilicus can be performed after surgical correction of pediatric congenital conditions (e.g., bladder exstrophy, omphalocele, and umbilical hernia) as well. In 1969, Tange and Miyake [30] described the use of a transposition flap to reconstruct the umbilicus after surgical repair of umbilical hernia in a 3-year-old child. The 4 flaps technique was first described by Ricketts38 in 1983, then later by Kaneko and Tsuda in 2004 [54]. In 1999, Matsuo et al. [81] described the use of local flap with cartilage graft for umbilicus reconstruction. The posterior wall of the umbilicus was created by an advancement flap, and the anterior wall of the umbilicus was created by a conchal cartilage composite graft [81]. Since then, many other local flaps have been described to reconstruct the umbilicus in children with bladder exstrophy, omphalocele, or umbilical hernia [9, 12, 15, 17,18,19, 22, 31,32,33,34, 40, 41, 43,44,45, 47,48,49,50,51,52,53,54, 62, 63, 66, 72,73,74,75, 78, 81].

For the reconstruction of the umbilicus after surgical repair of bladder exstrophy, Hanna and Ansong [32] described the use of a V–Y flap and Sumfest and Mitchell [43] described using a tongue-like flap. Feyaerts et al. [33] described the kangaroo pouch technique, using a rectangular superior pedicled skin flap fashioned as a kangaroo pouch. Three flaps technique, originally described by Kirianoff [14] and later modified by Franco and Franco [16], can also be used. In 2015, Featherstone and Cuckow [75] described the use of spiral rotational flap after correction of bladder exstrophy; they used this technique for the creation of a new umbilicus in 47 patients with excellent cosmetic results and no adverse effects.

Some umbiliconeoplasty techniques were borrowed from nipple-areola reconstruction [93,94,95]. The reconstruction of the navel is very similar to the reconstruction of the nipple, both generally involving the use of a local flap and the creation of a 3-dimensional structure, but in the case of umbilical reconstruction, the flap will be projected inside. Shinohara et al. [49] were the first to describe the use of C–V flap for umbilicus reconstruction (Fig. 5), then Uraloglu et al. [60] and Lee et al. [72] described modified versions of this technique [49, 60, 72]. Ozbek and Ozcan [55] described the use of a Thomas flap for the reconstruction of umbilicus. Korachi et al. [53] and da Silva Júnior and de Sousa [29] described scarless umbilicoplasty techniques that included defatting a circular area of the abdominal flap, creating an umbilical depression with several transfixed attachment stitches to the underneath muscular fascia. Furthermore, DelMauro et al. reported using a pedicled deep inferior epigastric artery perforator (DIEP) island flap for umbilicus reconstruction [20]. Prior to this, three publications had described the use of an island flap employing otherwise redundant skin from the lateral margin of the defect [21,22,23].

Conclusion

This is a narrative and pictorial review that aims to make clarity on the currently available options for umbilicus reconstruction. While creating a universal algorithm comparing the various techniques goes beyond the scope of this study, in order to choose the surgical technique the surgeon might look at the previously reported type of umbilicus reconstruction due to a specific cause (Table 3) and decide accordingly. Illustrations of the most popular techniques (Figs. 1, 2, 3, 4, 5, 6, 7, and 8) may be useful as well.