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

Journal of Gynecology and Obstetrics (2006) 94 , 37 — 40 CLINICAL ARTICLE www.elsevier.com/locate/ijgo Reconstruction

CLINICAL ARTICLE

and Obstetrics (2006) 94 , 37 — 40 CLINICAL ARTICLE www.elsevier.com/locate/ijgo Reconstruction technique for

www.elsevier.com/locate/ijgo

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 Sa˜o Paulo, Sa˜o Paulo, Brazil

b Department of Gynecology and Obstetrics, Escola Paulista de Medicina/Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil

c Department of Radiology, Escola Paulista de Medicina/Federal University of Sa˜o Paulo, Sa˜o 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 undergoing resection of umbilical endometriosis. Methods: Umbilical reconstruction using 2 semicircular defatted skin flaps was performed in 7 patients surgically treated 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.

Endometriosis;

Neo-omphaloplasty;

Neo-umbilicoplasty

1. Introduction

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).

The ideal umbilicus stems from a rounded 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-

0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

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E.M. Kokuba et al.

38 E.M. Kokuba et al. Figure 1 Umbilical endometriosis: painful, purple tumor. gion is performed before

Figure 1 Umbilical endometriosis: painful, purple tumor.

gion is performed before the surgical procedure. 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 measures 1.5 cm and its inner extremity 1.0 cm, but these dimensions can vary according to the subcutaneous fat layer of the patient ( Fig. 2). Skin and tumor are first excised according to preoperative marking ( Fig. 3); then, the skin flaps are defatted ( Fig. 4) and fixed to the aponeurosis of the rectus abdominis muscles with 3 4—0 mono- nylon sutures ( Fig. 5 ). Finally, closure of the remaining soft tissues is carried out following a standard procedure, using 4—0 monocryl sutures for subdermal and intradermal sutures ( Fig. 6 ).

3. Results

The 7 patients treated using this technique since October 2000 received a minimum follow-up of 6 months. Although hypertrophic scars developed in 2 patients, anatomical aspect, depression, and ab- dominal wall scar were considered satisfactory

and ab- dominal wall scar were considered satisfactory Figure 2 Marking: an ellipse with 2 semicircular

Figure 2 Marking: an ellipse with 2 semicircular flaps.

Figure 2 Marking: an ellipse with 2 semicircular flaps. Figure 3 Resected area. ( Figs. 7—9

Figure 3 Resected area.

( Figs. 7—9 ). There were no recurrences of umbilical endometriosis.

4. Discussion

The aim of umbilical reconstruction is to create a natural-looking umbilicus with a permanent de- pression, leaving the smallest scar possible [2,4— 8] . When reconstructing the umbilicus, plastic

surgeons should strive to attain attractive charac- teristics, i.e., a modest size, a T or vertical shape, and a superior shelf or hood [3] . In 1975, Borges [9] described a new technique with local flap that left an extensive transverse scar in the abdominal wall. Kirianoff and Jamra in

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. in 2000 [13] all reported cases of late umbilical reconstruction without tissue loss in the periumbil- ical region. The techniques used by these authors were designed for delayed reconstruction on an intact abdominal surface and cannot be applied to patients with extensive tissue loss in the umbilical

region.

cannot be applied to patients with extensive tissue loss in the umbilical region. Figure 4 Defatted

Figure 4 Defatted semicircular flap.

Reconstruction technique for umbilical endometriosis

39

Reconstruction technique for umbilical endometriosis 39 Figure 5 Flaps fixation to aponeurosis: 3 4—0 mono- nylon

Figure 5 Flaps fixation to aponeurosis: 3 4—0 mono- nylon sutures.

In 1992, Miller and Balch [5] presented an b iris Q technique for tumor resection and immediate umbilical reconstruction. Since scar tension is distributed among 4 flaps, this is a useful tech- nique in patients with great tissue loss in the umbilical region. Immediate reconstruction pre- sents 2 problems slightly different from those encountered in delayed reconstruction. First, more tissue is required, which must be retrieved

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

of a natural umbilicus [13,14] . Besides, part of the Figure 6 Skin margin closure with

Figure 6 Skin margin closure with intradermal sutures.

the Figure 6 Skin margin closure with intradermal sutures. Figure 7 Immediate results. scar is hidden

Figure 7 Immediate results.

scar is hidden within the umbilicus, as described in 1990 by Illouz [14] . Many techniques have been proposed for umbil- ical reconstruction. However, it is difficult to obtain a good result when umbilical tissue loss has occurred and immediate neo-onphaloplasty is re- quired. Considering this hurdle, it is important to know many different ways of reconstructing the umbilicus, including those using local flaps, skin or cartilage grafts, or other materials. The knowledge

skin or cartilage grafts, or other materials. The knowledge Figure 8 Ten months postoperatively, anterior view.

Figure 8 Ten months postoperatively, anterior view.

The knowledge Figure 8 Ten months postoperatively, anterior view. Figure 9 Ten months postoperatively, lateral view.

Figure 9 Ten months postoperatively, lateral view.

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E.M. Kokuba et al.

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 b dog ears Q 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.

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. b Iris Q 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. Sa˜o Paulo, Brazil7 Federal University of Sa˜o Paulo; 1996.