Lip Teh
December 2005
Umbilical Reconstruction
ANATOMY
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measures 1.5 to 2 cm in diameter and lies anatomically within the midline at the
level of the superior iliac crests.
umbilicus is formed as a result of contraction of four fibrous cords. These consist
of the obliterated left umbilical vein, which runs superiorly in the round ligament
of the liver; the obliterated urachus centrally, which runs inferiorly; and the two
obliterated umbilical arteries, which run laterally to their corresponding internal
iliac artery.
The resultant vector of these four cord contractures is usually directed inward and
upward, resulting in a characteristic skin overhang superiorly with a shelving of
the lower margin
A youthful and thin individual has a small and vertically oriented umbilicus
The older or more obese individual has a rounder, transversely oriented, and
hooded umbilicus superiorly
Arterial supply:
1. subdermal plexus
2. right and left deep inferior epigastric arteries that each give off several
small branches, and a large ascending branch, which courses between the
muscle and the posterior rectus sheath passing directly to the umbilicus
(dominant supply)
3. ligamentum teres hepaticum
4. median umbilical ligament.
A large perforator to the
umbilicus is shown (double
arrow), as are numerous
small perforators (single
arrows). The small
perforators approach the
umbilicus (circle) from
premuscular, intramuscular,
and postmuscular routes.
In unilateral TRAM, umbilicus mainly survives on contralateral DIEA perforators
In bilateral TRAM, depends on supply from ligamentum teres and median
umbilical ligament.
Lip Teh
December 2005
Umbilical Reconstruction
Options:
1) local flaps
2) local flaps + skin graft
3) conchal cartilage composite grafting
Local Flaps
PRS 1996 (Baack B; Anson G)
Position in midline at level of superior border of iliac crest
(Above, left) Skin markings for reconstruction of umbilicus. (Above, right) Lower flap
sutured to abdominal wall fascia. (Below, left) Points A and B brought together and
sutured to fascia at 12 o'clock position of the inner circle, creating the superior
umbilical hood. (Below, right) Appearance after closure of lateral edges.
Lip Teh
December 2005
Inverted CV flap: PRS 2000 (Shinohara H, Matsuo K, Kikuchi N)
Above, left) Marking of a C-V flap. (Above, right) The two V flaps are about to be
sewn to the C flap. (Below, left) The donor sites of the two V flaps are about to be
closed primarily. (Below, right) The inverted tubular flap is buried in the caudal
direction and fixed with bolsters.
Three flap: PRS 2003 (Iida N; Ohsumi N – Japan)
Lip Teh
December 2005
Purse String Method: PRS 2003 (Bartsich S.; Schwartz M)
Appropriate only for immediate reconstructions where there is a periumbilical defect.
Floor of umbilicus left to heal by secondary intention
Umbilical Stenosis
Double opposing Z plasty principle modified to go round curve