Aesth Plast Surg (2009) 33:471472

DOI 10.1007/s00266-009-9314-3

LETTER TO THE EDITOR

Sad Umbilicus: Prevention and Treatment

Katia Perim Santana Luiz Haroldo Pereira
Aris Sterodimas

Published online: 26 February 2009

Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009

Although the navel is a functionless depressed scar, it

represents an important and pleasing landmark. Any degree
of umbilical protrusion and horizontal orientation or distorted shape signifies deviation from the ideal female
umbilicus [1].
One of the most common and difficult problems with the
abdomen is treatment of the supraumbilical wrinkling that
may develop in the linea alba after pregnancies or due to
aging, flaccid skin, or excessive fat aspiration, provoking a
defect called sad umbilicus. (Fig. 1).
Various techniques have been used to resolve this
deformity. Toledo [2] tried resecting the wrinkled skin
above the umbilicus through a circular periumbilical incision and with a horseshoe-shaped incision, leaving the
lower pedicle of the umbilicus untouched. The results of
this technique have not been gratifying. In the past, liposuction has been used because the wrinkling skin over the
umbilicus can sometimes be misinterpreted as excess fat,
resulting in an iatrogenic deformity [3]. Fat grafting of this
area also has been done, but the results are not consistent
[3].
Although the ideal shape of the umbilicus has been
debated, recent studies have shown that the young thin
K. P. Santana
Department of Plastic Surgery, Perim Plastic Surgery Clinic,
Av Ataulfo de Paiva 135/803, 22449-900 Rio de Janeiro, Brazil
L. H. Pereira (&)
Department of Plastic Surgery, Luiz Haroldo Clinic, Rua Xavier
da Silveira 45/206, 22061-010 Rio de Janeiro, Brazil
e-mail: haroldo@unisys.com.br
A. Sterodimas
Department of Plastic Surgery, Pontifical Catholic University of
Rio de Janeiro and the Carlos Chagas Post-Graduate Medical
Institute, Av. Beira Mar 406, 20021-020 Rio de Janeiro, Brazil

Fig. 1 Preoperative view of a 34-year-old patient with sad umbilicus deformity

female with an attractive abdomen tends to have a small,

vertically oriented umbilicus [4].
We are proposing a new technique for prevention and
correction of the sad umbilicus. Minimum undermining
through a small incision in the superior part of the umbilicus using a 4-mm liposuction cannula in the midline of
the upper abdomen creates a minimal superior sulcus. Interaponeurotic sutures are performed using 4-0 nylon.
These sutures pull superiorly and tighten the supraumbilical skin by fixing the level of the superficial fascia to the
musculoaponeurotic fascia (Fig. 2). The fixation point on
the musculoaponeurotic fascia is 2 to 3 cm superiorly
compared with the suture point of the superficial fascia.
Two to three sutures, depending on the severity of the case,
are needed.
For prevention of sad umbilicus after performance of
liposuction via an umbilical incision, one to two

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Aesth Plast Surg (2009) 33:471472

interaponeurotic points are performed according to the

same aforementioned technique. The postoperative result
after 24 months is shown in Fig. 3. According to our
experience, this technique creates a vertically oriented
youthful-appearing umbilicus instead of a horizontal sad
umbilicus.
The aesthetic and natural appearance of the umbilicus
after liposuction and abdominoplasty is a key factor in the
overall result and satisfaction of the patient and surgeon
alike [5]. The proposed technique is simple, safe, and
easily reproducible, resulting in a very satisfying aesthetic
and natural-appearing umbilicus in patients.
Fig. 2 Schematic representation of the interaponeurotic suture points

References
1. Craig SB, Faller MS, Puckett CL (2000) In search of the ideal
female umbilicus. Plast Reconstr Surg 105:389392
2. Toledo LS (2004) The overlap of lipoplasty and abdominoplasty:
indication, classification, and treatment (review). Clin Plast Surg
31:353539
3. Pereira LH, Sterodimas A (2008) Treatment of iatrogenic abdominal contour irregularities. Aesth Plast Surg August 28, 2008 [Epub
ahead of print]
4. Lee MJ, Mustoe TA (2002) Simplified technique for creating a
youthful umbilicus in abdominoplasty. Plast Reconstr Surg
109:21362140
5. Rozen SM, Redett R (2007) The two-dermal-flap umbilical
transposition: a natural and aesthetic umbilicus after abdominoplasty. Plast Reconstr Surg 119:22552262

Fig. 3 Postoperative view of the corrected sad umbilicus

deformity

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