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Aesth Plast Surg

DOI 10.1007/s00266-014-0434-z



Concepts in Navel Aesthetic: A Comprehensive Surface Anatomy

Giuseppe Visconti Emiliano Visconti
Lorenzo Bonomo Marzia Salgarello

Received: 17 September 2014 / Accepted: 18 November 2014

Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Introduction The navel contributes to abdominal surface
identity and beauty. In Western societies, the display of the
navel in womens fashion has grown and, nowadays,
women are much more concerned about its shape and
position. Despite this, few studies are available on navel
surface anatomy and there is no standardization regarding
its proper placement in cosmetic abdominoplasty.
Materials and Methods In this observational study, we
analyzed navel shape and position on 81 high quality pictures, having been chosen as top 2013 bikini models by
editors of mass media. An on-line survey on navel shape
and position has been made via, involving
1,682 people.
Results The analysis revealed that navel position is quite
variable based on the proportions analyzed with an acceptable narrow data spread of the xiphoidumbilicus:umbilicus-abdominal mean crease ratio of 1.62 0.16. The data
dispersion for the other three ratios was wider, making them
This work has been presented in part at the ASAPSThe Aesthetic
Meeting 2014, April 2429, 2014, San Francisco, CA, USA and at the
25th EURAPS Meeting, May 2931, 2014, Lacco Ameno, Isle of
Ischia, Italy.
G. Visconti  M. Salgarello
Department of Plastic and Reconstructive Surgery, Universita`
Cattolica del Sacro Cuore University Hospital A.
Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy
G. Visconti (&)
Via Pietro Adami, 22, 00168 Rome, Italy
E. Visconti  L. Bonomo
Department of Bioimages and Radiological Sciences, Universita`
Cattolica del Sacro Cuore University Hospital A.
Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy

less reliable as references. The most appreciated navel shape

was the vertical oval with superior hooding (82 %), and the
less appreciated ones were the horizontal oval (29 %) and the
protruding shape (47 %). When comparing navel position on
the same body, the majority of participants choose the one
with the navel relocated according to the golden ratio (i.e.,
Conclusion The most attractive navel position is located
at the xiphoidumbilicus:umbilicus-abdominal crease
golden ratio. Bony landmarks seem to be not reliable as
references for proper navel positioning. The use of the
Fibonacci (golden mean) caliper intraoperatively might aid
in proper positioning of the navel in abdominoplasty.
No Level Assigned This journal requires that authors
assign a level of evidence to each submission to which
Evidence-Based Medicine rankings are applicable. This
excludes Review Articles, Book Reviews, and manuscripts
that concern Basic Science, Animal Studies, Cadaver
Studies, and Experimental Studies. For a full description of
these Evidence-Based Medicine ratings, please refer to the
Table of Contents or the online Instructions to Authors
Keywords Umbilicus  Omphaloplasty 
Abdominoplasty  Lipoabdominoplasty  Umbilicoplasty 
Divine proportion  Golden ratio

At the time of birth, the umbilical cord is cut, leaving a
stump which dries, heals, and falls within the first
48 weeks. The resulting scar is the umbilicus, which
represents the first unique physiologic scar of human life.
This structure is usually depressed and measures between


Aesth Plast Surg

1.5 and 2 cm in diameter. Its appearance is influenced by

age, weight, pregnancies, and hernias. The umbilicus
contributes to abdominal surface identity and beauty. Since
the dawn of time, it has been considered an erogenous zone
across the world. Since the introduction of the bikini in
1946, as well as low-rise clothing and crop tops in the
1990s, the display of the navel in womens fashion has
grown in Western societies, with navel piercing and tattoos
becoming more common. The higher attention toward the
navel shape and position paid by women asks for a more
critical analysis by the plastic surgery community of this
peculiar skin structure.
Besides the fact that the concept of ideal navel may vary
among people and may be influenced by age, ethnicity, and
personal preference, few studies are available on navel
surface anatomy and there is no standardization regarding
its proper placement when performing omphaloplasty in
cosmetic abdominoplasty. The information available on
proper navel positioning is usually based on surgeons
experience or on analysis of ethnic groups of people
selected by researchers.

The aim of this study is to analyze the navel position and

shape of the worldwide top model/celebrities recognized as
top 2013 bikini models to determine references for ideal
navel shape and positioning and to find potential clinical

Fig. 1 Artwork depicting abdominal frame and lower trunk aesthetic

units in frontal view. The pelvis bony framework influences the shape
of the abdomen and gives surface bony landmarks that are usually
used for umbilicus position analysis such as the apex of the iliac
creasts, the anteriorsuperior iliac spine and the pubic symphysis. The
yellow line (inter apex of the iliac crest distance (interIC)), red line
(inter-anterior superior iliac spines distance (interASIS)), the red
dotted line (interASIS-center of umbilicus), and the yellow dotted line
(interIC-center of umbilicus distance) represent the bony framework
parameters analyzed in this study. The lower trunk aesthetic units in
frontal view are the flank (orange), upper abdomen (light pink

area upward the umbilicus), umbilicus, lower abdomen (pink

area downward the umbilicus), and mons pubis (violet). The black
dotted line identifies the abdominal crease, a watershed crease
extending from one ASIS to the other and separating two fleshy
prominences, the lower abdomen and the mons pubis. The blue
line (xiphoid-center of umbilicus distance (XU)) and the white line
(center of umbilicus-abdominal crease distance (UC)) represent the
parameters analyzed according to the abdominal aesthetic units.
These parameters were used to calculate the four proportions: XU:UC
ratio, interASIS:UC ratio, interASIS:interASIS-U ratio, and interICU:U-interASIS ratio


Materials and Methods

This observational study comprised three parts:

Quantitative study of the navel surface anatomy in 81

top 2013 bikini models by analyzing four proportions: xiphoid-center of umbilicus/center of umbilicus-abdominal crease (XU:UC) ratio; inter-anterior
superior iliac spine line (interASIS)/center of umbilicus-abdominal crease (UC) (InterASIS:UC) ratio;
interASIS/center of umbilicus-interASIS (interASIS:interASIS-U) ratio; center of umbilicus-interASIS/inter iliac crest line (interIC)-center of umbilicus
(interASIS-U:interIC-U) ratio (Fig. 1).

Aesth Plast Surg



Analysis of navel shapes in 81 top 2013 bikini

models was recorded and classified based on previous
study of Craig SB et al. The vertical to horizontal
umbilical (V:H) ratio has been calculated for each
navel (Fig. 2).
On-line survey via made of seven
multiple-choice questions, involving 1,682 invited
people unaware of our concepts in navel aesthetic
(Figs. 3, 4). Of these, 102 participants (67 women
and 35 men) effectively took part in the survey.

Part AAnalysis of the Navel Surface Anatomy in 81

Top 2013 Natural Bikini Models
Photographs of celebrities and top models were taken from
six open on-line gossip magazines (,,,,, and providing the list
of top bikini 2013. These are recognized among the
worldwide top 15 on-line gossip magazines. Moreover,
bikini pictures of nine current Victorias Secret Angels
have been analyzed as well.
Only front pictures of the entire body in a natural
orthostatic position with good light exposure were considered for analysis. Pictures with both arms elevated, with
unnatural poses, with trikini or other swim wear obscuring
the xiphoid, umbilicus, iliac crest, ASIS, and abdominal
crease, as well as celebrities/models who underwent
abdominoplasty, were excluded. Being not standardized as
clinical photographs would be, we took care to consider
only high-definition pictures to make the analysis as standardized as possible. As a result, 81 top bikini bodies of
2013 were included in this study. The mean celebrity/
model age was 35.1 (ranging from 22 to 58 years old). The

Fig. 3 Pictures submitted for a survey from which the

participants had to choose the navel position that looks the most
harmonious, natural looking, and aesthetically pleasant. Which one do
you prefer, a or b? a XU:UC ratio 1.618 (edited). b XU:UC ratio
1.4913 (original)

Fig. 4 Pictures submitted for the survey from which

participants had to choose the navel position that looks the most
harmonious, natural looking, and aesthetically pleasant. Which one do
you prefer, a or b? a XU:UC ratio 1.618 (edited). b XU:UC ratio
1.5206 (original)

Fig. 2 Navel shapes found in

the analysis of 81 top bikini
models have been classified
according to Craig et al. and
submitted for a
survey. a vertical lozenge
without superior hooding,
b oval vertical with superior
hooding, c round with
superior hooding, d t-shaped
with superior hooding, e oval
horizontal with superior
hooding, f protruded/outie
navel with superior hooding


Aesth Plast Surg

mean celebrity/model height was 169.4 cm (ranging from

155 to 177 cm).
A picture analysis of proportions described in Part A
(see also Figs. 1, 2) was performed using the ruler tool in
Adobe Photoshop CS7 (Abode Systems, San Jose, CA,
USA) and the proportions were evaluated by pixel
Statistical analysis of the collected data was made to
obtain mean values with standard deviations. The summarized results are provided in Fig. 5.

Part COn-Line Survey

The pictures included in this study (see Part A) have been

zoomed in at the level of the navel to classify the navel
shape based on a previous study of Craig et al. and to
obtain a V:H umbilical ratio. Proportions have been calculated using the ruler tool in Adobe Photoshop CS7.
Statistical analysis of the collected data was made to obtain
mean values with standard deviations. The mean V:H
umbilical ratio was 1.3 0.46 (minimum value 0.41,
maximum value 2.57).

After considering the result of the statistical analysis of the

data in Part A, an on-line survey consisting of seven
multiple-choice questions was conducted via
in English and Italian languages. In two questions, the
participants had to choose the most harmonious, naturallooking, and aesthetically pleasant navel and the less
harmonious, not natural-looking, and not aesthetically
pleasant navel among the 6 different navel shapes found
in Part A analysis. The navel pictures were obtained by
zooming in on the highest-definition pictures taken in Part
A (Fig. 2).
In each of the other 5 questions, we provided two
photographs of the same celebrity/model of which one was
the original photograph and the other one had the umbilicus
position relocated according to the ideal XU:UC ratio of
1.618. This editing was performed using the patch tool in
Adobe Photoshop CS7. The participant had to choose in
which of the two pictures the navel position looks more
harmonious, natural looking and aesthetically pleasant.
As the XU:UC ratio range found in Part A was from 1.11 to
2.31 (mean 1.62), the five pictures submitted to the on-line

Fig. 5 Dispersion graph of the proportion values found in each

picture analyzed. Xiphoid-center of umbilicus: center of umbilicusabdominal crease (XU:UC) ratio (mean 1.62 0.12, ranging from
2.31 to 1.11); inter-anterior superior iliac spine distance: center of
umbilicus-abdominal crease (interASIS:UC) ratio (mean 2.04 0.35,

ranging from 1.58 to 2.73); inter-anterior superior iliac spine-center of

umbilicus : inter-anterior superior iliac spine (interASIS-U:interASIS)
ratio (mean 3.07 0.74, ranging from 1.79 to 5.22); inter iliac crest
apex-center of umbilicus : inter-anterior superior iliac spine (interICU:U-interASIS) ratio (mean 2.87 1.92, ranging from 0.86 to 11.83)

Part BAnalysis of Navel Shapes in 81 Natural Top

Bikini Models of 2013


Aesth Plast Surg

survey were chosen based on the following XU:UC ratios,

1.111.4, 1.41.5, 1.51.59, 1.651.8, and over 1.8, to
better represent the entire sample. For each of these ratio
categories, the most appropriate pictures for editing were
selected and edited. (Figures 3, 4)
The aim of this survey was to investigate the impact of
our findings on spontaneous human perception of navel
position harmony and beauty.

Part AAnalysis of Navel Surface Anatomy in 81
Natural Top Bikini Models in 2013
Statistical analysis results (mean SD) of the four proportions measured in Part A are shown in Table 1.
The analysis revealed that navel position is quite variable based on the proportions analyzed. However, there is
an acceptable narrow data spread of the XC:UC ratio mean
(min 1.11, max 2.31, mean 1.62), with the standard deviation being 0.12. The mean value of 1.62 can be very
acceptably approximated to the golden ratio (i.e., 1.618).
The data dispersion for pelvic bony landmark ratios (i.e.,
interASIS:UC, interASIS:interASIS-U, and interASISU:interIC-U) is wider, with the standard deviation being
0.35, 0.74, and 1.92, respectively. Because of these wider
data spreads, these three ratios can be considered less
reliable than the XC:UC ratio as references (Fig. 5).
Part BAnalysis of Navel Shapes in 81 Natural Top
Bikini Models in 2013
The 81 navels analyzed can be classified into 6 different
shape categories, according to the classification of Craig
Table 1 Table showing results (mean standard deviation, minimum and maximum values) of the four proportions analyzed (navel
position) and of the vertical to horizontal navel ratio

Mean standard

Min and max



1.62 0.12

Min 2.31max 1.11


2.04 0.35

Min 1.58max 2.73


3.07 0.74

Min 1.79max 5.22


2.87 1.92

Min 0.86max 11.83

vertical to horizontal

1.30 0.46

Min 0.41max 2.57

XU:UC xiphoid-center of umbilicus:center of umbilicus-abdominal

crease ratio, interASIS:UC inter-anterior superior iliac spine
line:center of umbilicus-abdominal crease ratio, interASIS:interASISU interASIS : center of umbilicus-interASIS ratio, interASIS-U:interIC-U interASIS-center of umbilicus : inter iliac crest line -center of
umbilicus ratio)

et al. (Fig. 2). Five (6.2 %) navels were classified as

vertical lozenge without superior hooding (Shape a), 29
(36 %) umbilici were classified as oval vertical with
superior hooding (Shape b), 23 (28.4 %) round with
superior hooding, 18 (22 %) t-shaped with superior
hooding, 5 (6.2 %) oval horizontal with superior hooding, and 1 (1.2 %) protruded navel with superior hooding (Fig. 2).
The data spread of the V:H ratio is quite wide to draw
strong conclusions. However, this analysis reveals that the
navel shapes tend to be more vertical than horizontal.
Part COn-Line Survey
The mean age of participants was 32 years old (ranging
from 25 to 48 years old). Of these, 85 were European, 10
were from North America, 5 were from South America,
and 2 were from Asia.
Eighty-four participants (82 %) voted that Shape b (oval
vertical with superior hooding) as the most harmonious,
natural-looking, and aesthetically pleasant navel followed
by 13 people (13 %) preferring Shape c and 5 people
voting for Shape a. The remaining shapes were not chosen
by anyone.
Fifty participants (47 %) voted Shape f (protruded
navel) as the less harmonious, not natural-looking and not
aesthetically pleasant navel, followed by 29 people
(29 %) who disliked Shape e and 10 people (10 %) disliking Shape d. The remaining 13 participants (14 %) voted
Shapes b and c (6 % each) and, lastly, shape a (2 %)
(Fig. 2).
In all five questions, each including two pictures comparing navel position on the same body, the majority of
participants preferred the picture with the navel relocated
according to the golden ratio of 1.618, with variable

Since the first historically relevant report by Vernon in
1957 [1], almost every author reporting his/her abdominoplasty technique has usually provided a personal omphaloplasty technique. This resulted in a large number of
different incision patterns to relocate the navel. The aim of
the different omphaloplasty techniques is to obtain a
pleasant navel shape and to minimize scarring.
However, minimal attention has been focused on navel
positioning. Besides placing it along the abdominal midline, the omphaloplasty is usually performed on the navel
stalk projection in a neutral position on the abdominal
superior flap once this is advanced and temporarily fixed to
the pubic skin [2, 3]. Other authors, contrarily, prefer to use


Aesth Plast Surg

bony landmarks (i.e., fixed distanced from the waistline or

from the anterior iliac crest) to properly relocate the navel
[1, 4, 5].
So far, there is a lack of consensus on the proper navel
position in abdominoplasty, and this matter is left to the
artistry and sense of beauty of each surgeon.
In the literature, the very few works on navel surface anatomy have focused on two main topics: shape and position.
Navel shape has been extensively studied by Craig et al.
[6]. They classified the navel shape of 147 women and
submitted close-up views to 21 examiners who scored each
navel. According to their analysis, the most appealing
umbilicus is small in size, with a T or vertical shape and
superior hooding. Lack of the superior hooding, distorted
and horizontal shape, as well as protrusion (outie), have
been judged as signs of an unpleasant navel. The outie
navel, however, not only represents a different navel shape
with excess skin/scar-like tissue but it may be a clinical
sign of umbilical hernia. This condition has to be taken into
account when evaluating a patient seeking abdominoplasty.
The findings from our study are in line with those of Craig
et al. regarding the features of an aesthetically pleasing
navel. However, we found the pleasant navel to be oval or
round in shape with superior hooding. The T-shaped navel
did not catch participants attention. Sakamoto et al. analyzed 254 Japanese navel shapes with ages ranging from
1 month to 16 years old, concluding that the umbilical
shape is usually more horizontal during infancy and gradually changes into a length-wise and deeper shape with
growth [7]. Nevertheless, these observations may be
influenced by ethnicity, which are in line with our findings
(V:H ratio mean 1.30 0.46). Choundhary and Taams
analyzed the navel appearance in different positions, finding that superior hooding is a result of gravity on the given
navel when the subject is in a standing position. In the
supine position, the superior hooding disappears. In the
upside-down position, inferior hooding appears as a
counterpart of the superior hooding seen in the standing
position [8]. This demonstrates that hooding is the biomechanical result of the umbilical scar under the influence
of gravity and surrounding soft tissues.
Navel position on the abdominal wall is usually analyzed bi-dimensionally, on a transverse and median longitudinal axis. The only comprehensive analysis of navel
position on the transverse axis comes from Rohrich et al.,
who analyzed 116 female navels on the transverse body
axis, and found that the umbilicus is rarely midline. [9]
This work is considered very valuable for both clinical
analysis and for medicolegal implications. However, the
ideal umbilicus remains anatomically defined as a midline
structure of the linea alba.
On the median longitudinal axis, the anatomy books
locate the umbilicus between the third and fourth lumbar


vertebrae. However, this reference is not useful for plastic

surgeons when dealing with omphaloplasty intraoperatively. So far, Vernon suggested placing it around 4 cm
below the waistline, Baroudi and Pitanguy positioned it on
the projection of the umbilical stalk in a neutral position,
whereas Hinderer advised locating it 3 cm above the level
of the anterior iliac crest. [14]. Based on their study on
100 non-obese patients, Dubos and Osterhout concluded
that in 96 % of their cases, the umbilicus is located at the
topmost level of the iliac crest [5]. So far, all the authors
trying to find a method to locate the navel position on the
longitudinal axis used pelvic bony landmarks and fixed
values, and not ratios. Recently, Abhyankar et al. reported
their analysis of 75 Indian female volunteers in the supine
position, finding that the xiphisternumumbilicus distance/
umbilicuspubic symphysis distance ratio is approximately
1.6:1 and the ratio of the distance between the umbilicus
and ASIS and the interASIS distance is 0.6:1. [10] Another
ethnic study of 65 Iranian patients suggested using a
mathematical formula to properly locate the navel [11].
Nevertheless, the Indian study can be influenced by
ethnicity features and it has not been performed on
worldwide recognized beautiful abdomens. These findings
are in line with ours as we used the abdominal crease and
not the pubic symphysis (lower positioned) as the inferiormost limit. Using the xiphisternum and the abdominal
crease as superior and inferior abdominal surface limits, the
evaluation of the abdominal aesthetic units only can be
performed. [12] Our analysis reveals that the attractive
navel is located in the golden ratio (i.e., 1.618) within the
abdominal aesthetic unit (i.e., xiphoidumbilicus to umbilicus-abdominal crease ratio.). The other calculated ratios
based on pelvic bony landmarks showed a wider spread of
data that makes them less reliable as references for
appropriate navel positioning. This is very likely related to
the high variability of pelvic bone angulations and
dimensions in the female population, as we already know
from framework analysis in gluteal augmentation from
Mendieta [13].
The golden ratio has been studied since ancient Greek
times as it usually appears in geometry and Nature. It
influenced the ancient arts and architecture. In the 13th
century, the Italian mathematician Leonardo Fibonacci
introduced the golden mean number sequence and studied
the golden section. For this reason, concepts and objects
related to the golden ratio are typically named Fibonacci,
such as the golden mean or Fibonacci Caliper. This compass-like instrument is made of three arms. The lateralmost arms identify the extremes of a line, whereas the
central arm divides the given line according to the golden
mean. Being compass like, it is possible to open/close the
instrument to the desired size and the central arm always
identifies the golden ratio of the given line (Fig. 6). Luca

Aesth Plast Surg

Fig. 6 Above, left Stainless steel hand-made Fibonacci caliper

(golden mean caliper) opened and closed. Above, right 46-year-old
breast cancer patient undergoing delayed right autologous breast
reconstruction with DIEP flap after failed implant reconstruction for
nipple-sparing mastectomy and contralateral periareolar mastopexy
for symmetry. The abdomen is temporarily closed and the Fibonacci
caliper is pointed between the xiphoid and the abdominal crease to
find the ideal navel position (point /). Below, left An 18-gage needle
perpendicularly placed through point / to project it on the abdominal
fascia to precisely fix the navel. Below, right Navel position at the
divine proportion is confirmed with the Fibonacci caliper at the end of

Pacioli and Leonardo Da Vinci introduced the concept of

the golden ratio (called divine proportion) in the analysis
of human body proportions in the famous De Divina Proportione book. These findings influenced one of the most
popular paintings of Leonardo Da Vinci, the Mona Lisa.
Besides the observation that vertical body anthropometrics
usually follow the golden ratio, in plastic surgery literature,
this ratio has been usually limited to facial anthropometric
analysis and not for other parts of the body. In dentistry, the
concept of the golden proportion in teeth size and position
analysis has been introduced by Levin [14]. His concepts
and instruments (dental golden mean gage and grids) have
deeply influenced the dentistry practice worldwide. Nowadays, the Fibonacci caliper is frequently used by artists,
designers, and architects to produce works that are aesthetically pleasant to human eyes.
After the results of our observational study, we have
been using the Fibonacci caliper intraoperatively since
August 2013 to precisely locate the navel in abdominoplasty and DIEP flap breast reconstruction (Fig. 6). At the
beginning of the procedure, the navel is isolated and
skeletonized on its pedicle in a triangular shape with the
apex pointing downward. After the superior abdominal flap

is undermined in the suprafascial plane and plication of the

rectus sheath achieved, when needed, the patient is placed
in a semi-Fowler position and the superior abdominal flap
is temporarily advanced to the inferior suprapubic incision.
At this point, the ideal new navel position is marked by
calculating the golden ratio (1.618) of the line connecting
the xiphoid to the abdominal crease (usually the inferior abdominal incision) along the midline. This point
(called /) can be easily marked with the aid of the Fibonacci caliper. Point / identifies the center of the new
umbilicus. An 18G cannula needle is then inserted through
/ perpendicularly to the abdominal flap to exactly project
it on the rectus sheath (point /), where the umbilical stalk
will be centerd with four cardinal 3-0 absorbable stitches.
Omphaloplasty is then performed by an inferior-based triangular incision on the abdominal skin centerd on point /,
defatting around the skin recipient and insetting of the
navel in its new position with two layers of absorbable and
fast absorbable sutures. The operation is then completed as
in standard abdominoplasty. Since the first historical report
by Vernon in 1957 [1], many omphaloplasty techniques
with different incision patterns to relocate the navel have
been described, with no consensus on the optimal one.
However, all these techniques share the same principles:
obtaining a pleasant navel shape (i.e., round or vertical
oval, innie and with superior hooding) with minimization
of scar visibility. Incorporating abdominal skin flaps within
the neo-omphaloplasty incision pattern may be advantageous to interrupt the periumbilical scars to avoid circumferential scar contraction and navel stenosis [15]. We
are currently evaluating in our clinical series the resulting
navel position and the influence on the hooding observed
postoperatively using this new approach.

The observational study of 81 worldwide recognized top
bikini models for 2013 reveals that, besides being midline,
the most attractive navel position is located at the XU:UC
golden ratio. Abdominal aesthetic unit analysis is suggested for proper navel positioning, as pelvic bony landmarks are not reliable references. The use of the Fibonacci
(golden mean) caliper intraoperatively might aid in the
proper positioning of the navel in abdominoplasty.
The vertical oval shape, the presence of superior hooding, and the absence of protrusion are the main features
that make a navel attractive for human eyes, confirming
conclusions from other navel shape studies.
Conflict of interest None of the authors has a financial interest in
any of the products, devices, or drugs mentioned in this manuscript.


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