Long Umbilical Stalk: Strategies for Shortening and Preservation during Abdominoplasty
The umbilicus is a very important anatomical and aesthetic landmark of the abdomen. The preservation and creation of a natural looking umbilicus is crucial for obtaining an aesthetically appealing abdomen during abdominoplasty or abdominal wall reconstruction. One of the most daunting challenges during these procedures is the management of a large umbilical pedicle, termed umbilicus with a long stalk. This finding is common in obese or previously obese patients. This long pedicle can become a conundrum for the plastic surgeon who wishes to still preserve the patient’s natural umbilicus. In some cases it is impossible to perform the proper closure without appropriate reduction in the length of the umbilical pedicle with standard techniques – the long umbilical stalk is telescoped with sutures applied from subdermis to fascial layer of the rectus. We propose an algorithm with a stepwise technique to safely and effectively shorten the length of the umbilicus.
There are two maneuvers to shorten a long umbilical stalk: (i) Cut the portion of skin enveloping the stalk; or (ii) Bury the skin in the abdominal wall musculature. Skin resection is limited because you need the skin component of the navel to create a natural looking structure. You cannot cut the stalk unless you are prepared to create a neo-umbilicus. Telescoping along without pushing the stalk backward is limited because this structure is too rigid to be compressed on itself. Thus, the only option is to hide the stalk in the abdominal wall muscle plane.
The concepts of this technique were described and published in “Abdominoplasty and Abdominal Wall Rehabilitation,” in the Journal of the American Society of Plastic Surgeons, and in an article entitled “Umbilical Reconstruction with the Heart Shaped Incision,” published in the book Adult Umbilical Reconstruction. However, these works did not provide systematic organization, details, operative approach or algorithmic description for execution and specific focus on the technique. This approach has allowed predictable, reproducible and aesthetically pleasing results.
Methods/Technique:
The technique aims to reduce the distance between the base of the pedicle and the external umbilicus, in cases where the pedicle is >2 cm and <4 cm and the standard muscle plication will not reduce it to 1cm of length, or in cases where the pedicle is ³4 cm. It is based on the creation of a tunnel (in a cranio-caudal direction) through the union between the lateral edge of the sheath of rectus abdominis muscle from one side with the contralateral edge of the same fascia along the entire length of the muscle, through their respective raphe, which had been previously released. The first step involves incision of the anterior fascia of the rectus abdominis sheath – when performing the fasciotomy, a classification of 4 proportions made between the medial edge of the sheath and its lateral edge must be done to identify the point of the fascia incision. The proportion used for the fasciotomy determines the depth of the tunnel, so it is directly related to the size of the “long umbilicus stalk” – the longer it is, the deeper the tunnel will be needed and the fasciotomy further away from the medial edge of the sheath. The size of the pedicle is proportionally related to the advancement in the previously published ARFR classifications: incision at n/5 – classification n (where n = 1,2,3,4 or 5). After fasciotomy, the lateral edge of one sheath is sutured with nylon thread and separate stitches, to the lateral edge of the one corresponding contralateral sheath, forming a tunnel. The approach should always be initiated proximal to the umbilicus. The third and final step involves performing the same approximation of the lateral edges of the sheath to the full extension of the rectus abdominus.
Results/Complications:
From 1990 to 2022, 628 abdominoplasties were performed. For this study, secondary abdominoplasties, patients undergoing neo-umbilicoplasty or immediate umbilical hernia repair, and patients with prior liposuction were excluded. This makes 316 patients to whom the described algorithm was applied. However only 184 patients were available for a meaningful follow-up above 6 months. The BMI ranged from 22 to 36 with an average of 30.2. Age were from 19 to 62 with an average of 38.4 years old. 4 patients had up to 1 centimeters long, 10 patients between 1-2 centimeters, 92 patients between 2-4 centimeters and 78 patients above 4 centimeters.
Conclusion:
Naval reconstruction after abdominoplasty is not as simply as may be perceived. The technique described is an effective, fast and safe way to reduce the length of the umbilicus with a long stalk. This enables the plastic surgeon, whenever faced with a long pedicle in abdominoplasty, to create a tunnel that will give way to a pedicle with adequate size for the continuity and completion of the abdominoplasty while preserving the beauty of a natural umbilicus.