International Journal of Gynecology and Obstetrics (2006) 94, 37 — 40

www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Reconstruction technique for

umbilical endometriosis
E.M. Kokuba a,*, N.M. Sabino a, H. Sato b, A.Y. Aihara c,
E. Schor b, L.M. Ferreira a

a
Division of Plastic Surgery, Escola Paulista de Medicina/Federal University of São Paulo, São Paulo, Brazil
b
Department of Gynecology and Obstetrics, Escola Paulista de Medicina/Federal University of São Paulo,
São Paulo, Brazil
c
Department of Radiology, Escola Paulista de Medicina/Federal University of São Paulo, São Paulo, Brazil

Received 10 November 2005; received in revised form 2 April 2006; accepted 4 April 2006

KEYWORDS Abstract
Umbilical
reconstruction; Objective: To present a technique for immediate umbilical reconstruction in women
Endometriosis; undergoing resection of umbilical endometriosis. Methods: Umbilical reconstruction
Neo-omphaloplasty; using 2 semicircular defatted skin flaps was performed in 7 patients surgically treated
Neo-umbilicoplasty for umbilical endometriosis from October 2000 to June 2004. The patients were
followed up for at least 6 months. Results: Anatomical aspect, depression, and abdo-
minal wall scar were considered satisfactory, although hypertrophic umbilical scars
developed in 2 patients. Conclusion: This technique using 2 semicircular defatted
flaps is efficient in creating a new umbilicus with a natural appearance while leaving a
minimal scar. Moreover, it allows for laparoscopic inspection of the abdominal cavity.
D 2006 International Federation of Gynecology and Obstetrics. Published by
Elsevier Ireland Ltd. All rights reserved.

1. Introduction The ideal umbilicus stems from a rounded

The umbilicus is an expected anatomical structure
of the abdominal wall, and its loss can be the source
of much anxiety. Accordingly, whenever possible, its
reconstruction should be performed immediately
following the main surgical procedure [1,2].
* Corresponding author. Tel.: +55 11 5584 9373, 8473 9165; fax:
+55 11 5584 9373, 3849 9301.
E-mail address: emkokuba@uol.com.br (E.M. Kokuba).
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
All rights reserved.
doi:10.1016/j.ijgo.2006.04.034
depression 1.5 cm to 2 cm deep, and has an overall
vertical orientation and a superior hood [3].
The surgical approach described in this report is
useful to reconstruct a new umbilicus after surgical
treatment of umbilical endometriosis (Fig. 1).
2. Materials and methods
To assess the extension and depth of the lesion, an
ultrasonographic examination of the umbilical re-
38 E.M. Kokuba et al.

Figure 1 Umbilical endometriosis: painful, purple Figure 3 Resected area.

tumor.
(Figs. 7—9). There were no recurrences of umbilical
gion is performed before the surgical procedure. endometriosis.
Two semicircular skin flaps are then shaped into in
an ellipse with a vertical orientation, taking into
account the margins for tumor resection. The
outer base of each semicircular flap usually
4. Discussion
measures 1.5 cm and its inner extremity 1.0 cm,
The aim of umbilical reconstruction is to create a
but these dimensions can vary according to the
natural-looking umbilicus with a permanent de-
subcutaneous fat layer of the patient (Fig. 2).
pression, leaving the smallest scar possible [2,4—
Skin and tumor are first excised according to
8]. When reconstructing the umbilicus, plastic
preoperative marking (Fig. 3); then, the skin flaps
surgeons should strive to attain attractive charac-
are defatted (Fig. 4) and fixed to the aponeurosis of
teristics, i.e., a modest size, a T or vertical shape,
the rectus abdominis muscles with 3 4—0 mono-
and a superior shelf or hood [3].
nylon sutures (Fig. 5). Finally, closure of the
In 1975, Borges [9] described a new technique
remaining soft tissues is carried out following a
with local flap that left an extensive transverse
standard procedure, using 4—0 monocryl sutures for
scar in the abdominal wall. Kirianoff and Jamra in
subdermal and intradermal sutures (Fig. 6).
1979 [10], Matsuo et al. in 1990 [4], Itoh and Arai in
1992 [11], Sugawara and colleagues in 1997 [12],
Mateu and Chamorro in 1997 [13], Shinohara et al.
3. Results in 2000 [13] all reported cases of late umbilical
reconstruction without tissue loss in the periumbil-
The 7 patients treated using this technique since ical region. The techniques used by these authors
October 2000 received a minimum follow-up of 6 were designed for delayed reconstruction on an
months. Although hypertrophic scars developed in 2 intact abdominal surface and cannot be applied to
patients, anatomical aspect, depression, and ab- patients with extensive tissue loss in the umbilical
dominal wall scar were considered satisfactory region.

Figure 2 Marking: an ellipse with 2 semicircular flaps. Figure 4 Defatted semicircular flap.
Reconstruction technique for umbilical endometriosis 39

Figure 5 Flaps fixation to aponeurosis: 3 4—0 mono- Figure 7 Immediate results.

nylon sutures.
scar is hidden within the umbilicus, as described in
In 1992, Miller and Balch [5] presented an birisQ 1990 by Illouz [14].
technique for tumor resection and immediate Many techniques have been proposed for umbil-
umbilical reconstruction. Since scar tension is ical reconstruction. However, it is difficult to
distributed among 4 flaps, this is a useful tech- obtain a good result when umbilical tissue loss has
nique in patients with great tissue loss in the occurred and immediate neo-onphaloplasty is re-
umbilical region. Immediate reconstruction pre- quired. Considering this hurdle, it is important to
sents 2 problems slightly different from those know many different ways of reconstructing the
encountered in delayed reconstruction. First, umbilicus, including those using local flaps, skin or
more tissue is required, which must be retrieved cartilage grafts, or other materials. The knowledge
from a greater distance [5]. Second, the umbilicus
is 3-dimensional; therefore, if it is to retain its
depth over a long time, the umbilical lateral walls
must be reconstructed with flaps [11]. Reconstruc-
tion with aponeurosis fixation of 2 semicircular
defatted flaps creates a small umbilicus with
sufficient depth, a good morphology, and a
vertical orientation. Flaps with no fat in the part
of the dermis sutured to the aponeurosis form a
depression simulating the anatomical conditions of
a natural umbilicus [13,14]. Besides, part of the

Figure 8 Ten months postoperatively, anterior view.

Figure 6 Skin margin closure with intradermal sutures. Figure 9 Ten months postoperatively, lateral view.
40
of many techniques will allow for the best result in
each case.
The size of the vertical scar depends on the size
of the semicircular flaps that form the ellipse. The
length of the scar is the result of the bdog earsQ
compensation. If the ellipse constructed with the
flaps is too short, dog ears form at the ends of the
closed wound. By adjusting the outer and inner
base of each semicircular flap to the thickness of
the patient’s abdominal panniculus, the surgeon
will reduce the size of the scar.
This technique allows creating a small umbilicus
with a vertical orientation inside a depression—
which is considered attractive. More important, it
can be used following resection, with wide
surgical margins, of umbilical endometriosis pre-
viously evaluated by ultrasonographic examination
[14,15]. Low recurrence rates have been noted
following tumor resection and umbilical reconstruc-
tion via this technique, and there were no recur-
rences at 6 months in the present study [14,15].
Moreover, laparoscopic exploration remains possible
in patients who underwent the procedure.
5. Conclusion
Abdominal cavity exploration, tumor resection, and
umbilical reconstruction can be performed in the
operative procedure, with no extra risks for the
patient. The described technique creates a new
umbilicus with a natural location and appearance
while leaving minimal scar and permitting further
laparoscopic exploration.
E.M. Kokuba et al.
References
[1] Baroudi R. Umbilicoplasty. Clin Plast Surg 1975;2:431 – 48.
[2] Franco T, Franco D. Neoomphaloplasty: an old and new
technique. Aesthet Plast Surg 1991;23:151 – 4.
[3] Craig SB, Faller MS, Puckett CL. In search of the ideal
umbilicus. Plast Reconstr Surg 2000;105:389 – 92.
[4] Matsuo K, Kondoh S, Hirose T. A simple technique for
reconstruction of the umbilicus, using a conchal cartilage
composite graft. Plast Reconstr Surg 1990;86(149):149 – 51.
[5] Miller MJ, Balch CM. bIrisQ technique for immediate
umbilical reconstruction. Plast Reconstr Surg 1993;
92:754 – 6.
[6] Onishi K, Yang YL, Maruyama Y. A new lunch box-type
method in umbilical reconstruction. Ann Plast Surg
1995;35:654 – 6.
[7] Pinto PA, Stock JA, Hanna MK. Results of umbilicoplasty for
bladder exstrophy. J Urol 2000;164(6):2055 – 7.
[8] Lacerda DJ, Martins DM, Marques A, Brenda E, Andrews JM.
Umbilicoplasty for the abdomen with a thin adipose layer.
Br J Plast Surg 1994;47(5):386 – 7.
[9] Borges AF. Reconstruction of the umbilicus. Br J Plast Surg
1975;28:75 – 6.
[10] Kirianoff TG. Making a new umbilicus when none exists:
case report. Plast Reconstr Surg 1978;61:603 – 4.
[11] Itoh Y, Arai K. Umbilical reconstruction using a cone-shaped
flap. Ann Plast Surg 1992;28:335 – 8.
[12] Sugawara Y, Hirabayashi S, Asato H, Yoshimura K. Recon-
struction of the umbilicus using a single triangular flap. Ann
Plast Surg 1995;34:78 – 80.
[13] Mateu LP, Chamorro JJH. Neoumbilicoplasty trough a purse-
string suture of three defatted flaps. Aesthet Plast Surg
1997;21:349 – 51.
[14] Illouz YG. A new, safe and aesthetic approach to section
abdominoplasty. Ann Chir Plast Esthet 1990;35(3):233 – 42.
[15] Toledo Jr CS. Abdominal wall deformity reconstruction
using vertical abdominoplasty and neoomphaloplasty. São
Paulo, Brazil7 Federal University of São Paulo; 1996.