Elliptical Incision Research Articles

Congenital double upper lip: review of literature and report of a case

Congenital maxillary double lip is a rare anomaly in which a fold of redundant labial tissue becomes apparent at rest or while smiling. This might pose cosmetic or functional problems, as well as serious impact on psychological well-being, especially when it affects young children or adolescents. The treatment of choice is surgical excision. This paper presents a successfully managed case of maxillary double lip using elliptical incision under local anesthesia in a 15-year-old female patient.

The Fixomull skin support method for wound closure in patients with fragile skin

We report the Fixomull (BSN Medical, Hamburg, Germany) skin support technique for wound closure, a novel method for closing elliptical incisions in patients with fragile skin. After the lesion of concern is excised, a strip of Fixomull is applied to the skin adjacent to the wound edge with an approximately 2 mm gap between the Fixomull and the incision edge. The wound is then closed with interrupted sutures through the Fixomull, with care to ensure wound edge eversion. Fixomull provides extra tensile strength. The sutures are removed at approximately 14 days, and the patient given a prophylactic course of oral antibiotics only if at high risk of infection. This is a simple, time efficient, inexpensive and effective measure to avoid skin grafts and reduce skin tears and trauma in patients with thin, fragile skin. In our practice there have been no significant skin infections using this technique.

Posterior sagittal approach for resection of sacrococcygeal teratomas

The aim is to evaluate the ease of access, surgical trauma and cosmetic results of posterior sagittal approach for sacrococygeal teratomas (SCTs). From January 2002 to June 2010, we operated 19 cases of SCT exclusively through posterior sagittal approach. Patients were placed in knee chest position. An elliptical incision was made for the excision of the tumor. Care was taken to preserve all the muscles and other vital tissue in this area. Coccygectomy was performed in all patients. Closure was performed in layers. It was possible to resect all tumors from this approach and none of the patients required revision of the incision. Complete resection was possible in 17 patients while two had residual disease due to local extension. Minimal wound dehiscence was noted in four patients that healed spontaneously. It was possible to perform excision even in very large masses. Wound scar was satisfactory in most patients with preservation of gluteal folds. It is therefore concluded that posterior sagittal approach for SCT is feasible, with good access and cosmetic results.

Simplified Technique for Parastomal Hernia Repair After Radical Cystectomy and Ileal Conduit Creation

To review the results of parastomal hernia repair with a simplified technique of translocation of the stoma with no need for a midline incision. A total of 405 radical cystectomies with creation of an ileal conduit were reviewed at our institution. The primary goal of the review was to determine the incidence of parastomal hernias in a large series of cystectomies and their management at our institution. Surgical correction of parastomal hernia was indicated in case of pain, discomfort, risk of bowel obstruction, and/or distortion of the abdominal wall. The simplified technique includes an elliptical incision around the stoma and dissection of the hernia's sac down to the level of the fascia. The sac is incised and the peritoneum is entered. The ileal conduit is thereafter mobilized to guarantee sufficient length. This is crucial to be able to transpose the conduit 5-10 cm superiorly and to obtain a tension-free ileostomy. Sixty-three patients (16%) presented during the follow-up after ileal conduit a palpable defect or bulge adjacent to the stoma. The review highlighted 19 patients (4.69%) who developed a parastomal hernia and underwent surgical repair. Four cases (21%) recurred at a median follow-up of 55 months. Recurrence was not found to be related to gender, age, body mass index, protein level, radiotherapy, adjuvant chemotherapy, or previous abdominal surgery on univariate analysis. Postoperative complications included one wound infection (5.2%) and one stomal necrosis (5.2%). The technique herein proposed simplifies the management of parastomal hernia repair by avoiding a midline incision, which implies a reduction in surgical trauma with acceptable recurrence and postoperative complication rate.

Retrospective comparison of non-skin-sparing mastectomy and skin-sparing mastectomy with immediate breast reconstruction.

Background. We compared Skin-sparing mastectomy (SSM) with immediate breast reconstruction and Non-skin-sparing mastectomy (NSSM), various types of incision in SSM. Method. Records of 202 consecutive breast cancer patients were reviewed retrospectively. Also in the SSM, three types of skin incision were used. Type A was a periareolar incision with a lateral extension, type B was a periareolar incision and axillary incision, and type C included straight incisions, a small elliptical incision (base line of nipple) within areolar complex and axillary incision. Results. Seventy-three SSMs and 129 NSSMs were performed. The mean follow-up was 30.0 (SSM) and 41.1 (NSSM) months. Respective values for the two groups were: mean age 47.0 and 57; seven-year cumulative local disease-free survival 92.1% and 95.2%; post operative skin necrosis 4.1% and 3.1%. In the SSM, average areolar diameter in type A & B was 35.4 mm, 43.0 mm in type C and postoperative nipple-areolar plasty was performed 61% in type A & B, 17% in type C, respectively. Conclusion. SSM for early breast cancer is associated with low morbidity and oncological safety that are as good as those of NSSM. Also in SSM, Type C is far superior as regards cost and cosmetic outcomes.

Conventional Linear versus Purse-string Skin Closure after Loop Ileostomy Reversal: Comparison of Wound Infection Rates and Operative Outcomes

PurposeWound infection after an ileostomy reversal is a common problem. To reduce wound-related complications, purse-string skin closure was introduced as an alternative to conventional linear skin closure. This study is designed to compare wound infection rates and operative outcomes between linear and purse-string skin closure after a loop ileostomy reversal.MethodsBetween December 2002 and October 2010, a total of 48 consecutive patients undergoing a loop ileostomy reversal were enrolled. Outcomes were compared between linear skin closure (group L, n = 30) and purse string closure (group P, n = 18). The operative technique for linear skin closure consisted of an elliptical incision around the stoma, with mobilization, and anastomosis of the ileum. The rectus fascia was repaired with interrupted sutures. Skin closure was performed with vertical mattress interrupted sutures. Purse-string skin closure consisted of a circumstomal incision around the ileostomy using the same procedures as used for the ileum. Fascial closure was identical to linear closure, but the circumstomal skin incision was approximated using a purse-string subcuticular suture (2-0 Polysorb).ResultsBetween group L and P, there were no differences of age, gender, body mass index, and American Society of Anesthesiologists (ASA) scores. Original indication for ileostomy was 23 cases of malignancy (76.7%) in group L, and 13 cases of malignancy (77.2%) in group P. The median time duration from ileostomy to reversal was 4.0 months (range, 0.6 to 55.7 months) in group L and 4.1 months (range, 2.2 to 43.9 months) in group P. The median operative time was 103 minutes (range, 45 to 260 minutes) in group L and 100 minutes (range, 30 to 185 minutes) in group P. The median hospital stay was 11 days (range, 5 to 4 days) in group L and 7 days (range, 4 to 14 days) in group P (P < 0.001). Wound infection was found in 5 cases (16.7%) in group L and in one case (5.6%) in group L (P = 0.26).ConclusionBased on this study, purse-string skin closure after a loop ileostomy reversal showed comparable outcomes, in terms of wound infection rates, to those of linear skin closure. Thus, purse-string skin closure could be a good alternative to the conventional linear closure.

Long-Term Results of a Versatile Technique for Umbilicoplasty in Abdominoplasty

Umbilical repositioning is a main step in performing abdominoplasty. The surgical aims are minimal visible scars and a natural-appearing result. Reported techniques do not completely satisfy the aesthetic targets for all types of patients. A previous study reported a versatile technique for umbilicoplasty based on an elliptical vertical incision of the umbilical skin and a double opposing "Y" incision on the abdominal flap to create a new umbilicus. This report describes the long-term results with this technique. A total of 111 abdominoplasties were performed. Patient satisfaction and postoperative results were evaluated over a 5-year follow-up period. A modified 5-ml syringe was used to assess the depth and volume of the umbilical stalk. Depth value variations were statistically compared using the Wilcoxon test. For all the patients, a three-dimensional umbilicus with an adequate depression was created. In four cases, deepithelialization of the umbilical skin occurred. After 1 postoperative year, no significant changes in umbilical shape, dimension, depth, or appearance were observed. After 5years, no significant changes in shape or appearance were observed. The cicatricial umbilical stenosis occurrence was 4.5%. A small significant decrease in umbilical depth was noted. Overall, the results remained satisfying at this writing. The reported technique is easy to learn, simple to perform, and stable over time. It gives a natural depth appearance, ensures optimal position, pulls scars deeply, and allows achievement of different shapes according to the patient's habitus.

Surgery of Primary Melanomas

Surgery remains the mainstay of melanoma therapy, regardless of the tumor site. Only the early diagnosis combined with proper surgical therapy currently gives patients affected by this malignancy the chance for a full cure. The main goal of surgical therapy is to provide the local control of the disease and to secure long-term survival of the patient without reasonable functional and esthetic impairment. The recommended method of biopsy—excisional biopsy, as an initial diagnostic and, to some extent, therapeutic procedure—is performed under local anesthesia as an elliptical incision with visual clear margins of 1–3 mm and with some mm of subcutaneous tissue. The extent of radical excision of the primary tumor (or scar after excisional biopsy) is based on the histopathologic characteristics of the primary tumor and usually consists of 1–2 cm margins with primary closure. The philosophy behind conducted randomized clinical trials has been to find the most conservative surgical approach that is able to guarantee the same results as more demolitive treatment. This has been the background of the trials designed to define the correct margins of excision around a primary cutaneous melanoma. Much less definition can be dedicated to the surgical management of patients with non-cutaneous melanomas.

Laparoscopic excision of infected urachal cyst: Illustration of technique

The urachus is a fibrous cord structure connecting the urinary bladder dome and the umbilicus.1 Persistent urachal anomalies are rare conditions which commonly present as infection. Conventional treatment is excision of the umbilicus together with the entire tract with or without a cuff of the urinary bladder.2–3 Complete excision will result in a large laparotomy wound and related short-term disadvantage. With the advance of the laparoscopic technique, more and more patients have undergone laparoscopic excisions.4–6 We herein report a case and illustrate the laparoscopic technique in the accompanying video. A 22-year-old man presented to us with a 3-day history of umbilical pain and fever and was not responding to antibiotic treatment prescribed by a private doctor. On physical examination, his umbilicus was inflamed with some pus-like discharge. Contrast computed tomography (CT) scan was carried out and findings were suggestive of infected urachus. Laparoscopic excision of the infected urachus was suggested to the patient and he agreed to the operation. The operation was carried out under general anaesthesia and the patient was placed in the supine position. A urinary catheter was inserted. One 10–11-mm camera port was inserted in the right side of the patient's abdomen at the level of the umbilicus by an open technique. Two 5-mm working ports were then inserted under laparoscopic guidance. All ports were placed at the right side of the abdomen. Thirty-degree laparoscopy was used so that it gave a clear view of the posterior surface of the anterior abdominal wall. An ultrasonic dissector was used to dissect the peritoneum around the infected urachal cyst. Further dissection was carried out along the preperitoneal plane so that the entire median umbilical ligament was dissected out. We traced down along the tract until the dome of the urinary bladder was reached. The urinary bladder was then distended with 300-mL methylene blue solution. Double clipping of the tract was applied just proximal to the dome of the urinary bladder. The whole tract was fully mobilized up to the umbilical attachment. Trans-umbilical elliptical skin incision was carried out and the tract separated from the umbilicus. The entire tract was then retrieved through the umbilical wound with a specimen bag. The umbilical fascia was closed with interrupted PDS-1 sutures and the umbilicus was reconstructed with interrupted 3-0 nylon. Other port sites and skin wounds were closed with subcuticular sutures. The patient recovered well and was discharged the next day after operation. Additional video images may be found in the online version of this article. Visit http://cshk.org/surgical_practice/multi-media_article/May_2010_issue_MM4_video.htm Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author of the article.

Non-bifid “fish-tail” plasty: a less cumbersome technique, to improve cosmesis at the lateral end of mastectomy scars

Introduction: The closure of transverse elliptical mastectomy incisions has been described with various modifications since 1915. The technical challenge is to avoid a fold of skin persisting laterally (“dog-ear”). This may result in unsatisfactory long term discomfort and poor cosmetic result. We describe a novel technique of non-bifid fish-tail plasty and its aim to avoid revision surgery.

Foreskin trapped by zipper: a case report

Abstract We present an 84 year-old-male patient with foreskin trapped by his zipper. After several failed attempts with scissors, screwdriver and others we practise an elliptic incision to resolve the problem. Foreskin injuries are frequent in children but are rare in adult men. There are some techniques described for solving the problem using scissors, screwdriver, traction and surgery.

Foreskin trapped by zipper: a case report

We present an 84 year-old-male patient with foreskin trapped by his zipper. After several failed attempts with scissors, screwdriver and others we practise an elliptic incision to resolve the problem. Foreskin injuries are frequent in children but are rare in adult men. There are some techniques described for solving the problem using scissors, screwdriver, traction and surgery.

Mucosal reduction for correction of congenital maxillary double lip.

Congenital double lip is rare and usually involves the upper lip. A part from a deformity that interferes with speech and mastication, operation may be indicated for cosmetic reasons. We report a case of 12 years old patient with double lip deformities who was operated in our department for cosmetic reasons. We used an elliptical excision of the mucosal excess. Satisfactory aesthetic results were achieved. INTRODUCTION Congenital double lip is rare and generally involves the upper lip (1). A double vermilion with a transverse furrow between the two borders appears when the orbicularis oris muscle contracts during a smile. The incidence of this anomaly is not known and it may be either isolated or in association with other congenital abnormalities. (2) Treatment is by excision of the excess mucosa and submucosal tissue. We present a case of congenital double lip with literature review. CASE REPORT A 13-year-old boy was evaluated for excess maxillary labial mucosa with the resulting appearance of a maxillary double lip (Fig. 1). The deformities had been present since birth and became more prominent as he grew. No other congenital deformities were noted. The appearance of the lip was due to folding of the mucosa as the lip was retracted when smiling (Fig. 2). The excess labial mucosa was localized to either side of the midline (Fig. 3), forming a sessile, hypertrophied mass that extended mediolaterally the distance between the midpoints of the maxillary lateral incisors. We operated under general anaesthesia. The excess buccal mucosa was excised by two elliptical excisions, one on each half of the lip, and combined with a central Z-plasty to release the constricting band (Fig. 4). Closure was by running 4/0 polyglactin 910 (Vycril) suture (Fig. 5). Postoperative recovery was uneventful apart from swelling that resolved in about 10 days. He was happy with the cosmetic results. After two years there were no signs of relapse or late complications. Figure 1 Fig.1: The upper lip when the mouth is open; note the short central constriction and mucosal bulging on both sides Mucosal reduction for correction of congenital maxillary double lip. 2 of 4 Figure 2 Fig.2: Double lip deformity when the patient smiles Figure 3 Fig.3: The excess labial mucosa was localized to either side of the midline Figure 4 Fig.4: Diagram of the Z-plasty with two elliptical excisions Figure 5 Fig.5: Appearance of the lip at the end of operation DISCUSSION Double lip (DL) may be either a congenital abnormality or an acquired deformity. The congenital form usually involves the upper lip, but it may also affect the lower lip. (3, 4) It usually occurs as a redundant fold of tissue on the mucosal part of the lip. During the development of the mucosa, the upper lip consists of two transverse zones viz, an outer zone, which is smooth and similar to the skin called the pars glabrosa and the inner zone, which is villous and similar to the oral mucosa, termed as the pars villosa (5).The DL develops during the second or third intrauterine month as a result of the persistence of the horizontal sulcus between the pars glabrosa and the pars villosa. (5, 6) Acquired double lip deformity can occur after an injury, in association with Ascher syndrome, or as a result of habitual pulling of the mucosa through a diastema (1). Differential diagnosis of double lip include hemangioma, lymphangioma, angioedema, cheilitis glandularis and cheilitis granulomatosis (6). Various operations to correct a double lip have been described. Guerrero-Santos and Altamirano described the use of a W-plasty (7). Simple excision through an elliptical incision was advocated by Reddy and Kotewara (8). In patients with a short central constriction band as our case, the use of two elliptical incisions combined with a vertical Z-plasty result in a pleasing appearance of the upper lip with a natural-looking tubercle (9). The postoperative swelling can need about 10 days to be Mucosal reduction for correction of congenital maxillary double lip. 3 of 4 resolved (9). The cosmetic results are generally very good and make psychic satisfaction. The relapse and complications such as glandular hypertrophy or mucocele are extremely rare. CONCLUSION Congenital double lip is a rare oral anomaly. Surgical treatment is indicated when the excess tissue interferes with mastication or speech or more often for esthetic reasons. The results are generally very good and complications are extremely rare

Squeeze Eversion Of Small Sebaceous Cyst – Novel Technique To Prevent Rupture During Excision

Sebaceous cysts are common and it may be difficult remove them without rupturing the capsule. The author describes a novel technique of initial gentle dissection after an elliptical or linear incision, followed by everting of the cyst by gentle squeeze which often helps to shell it out without damaging the capsule.

Index of Suspicion

Index of Suspicion

A Novel Approach for the Reconstruction of Medial Canthal and Nasal Dorsal Defects

Medial canthal and dorsal nasal defects after surgery have been a challenging problem for surgeons and patients. The main purpose in reconstruction is not solely covering the defects with similar skin and soft tissue, but also causing minimal donor-area morbidity. The authors described an elliptical fashioned frontal island flap at the level of the frontal hairline, nourished by the vascular network composed of supraorbital and supratrochlear arteries, then carried subcutaneously to the defect area at medial canthus and upper nose. Any extra incisions above the eyebrow to control the pedicles were not necessary. Donor region was closed primarily; thus, scarring was hidden at the hairline. We present our frontal hairline island flap design and results in our series of 10 patients.In our study, we aimed to reduce scarring at donor area by planning a forehead island flap in an elliptical fashion at the frontal hairline. There are no more incisions than the elliptical incision over the hairline. Primary closure of skin flaps at the donor ensures a final scar that is hidden at the frontal hairline border. Forehead hairline island flap is an important flap for small- and medium-size defects as an alternative to conventional paramedian forehead flap.

Clinical study of treatment for recalcitrant ingrown toenail by partial distal phalanx removal

The aim of this study was to identify putative aetiological factors of recalcitrant ingrown toenail and then to introduce a new surgical technique for its treatment on the basis of this identification. We found that many of our patients had an upturned morphology on the distal phalanx beneath the recalcitrant ingrown toenail. We thereby designed a new operative technique to treat this problem. From October 1997 to May 2006, 31 patients (38 toes), who were operated on using the new technique, were assigned to the experimental group. Another 38 patients, who were randomly selected from the population without an ingrown toenail, were assigned to the control group. Briefly, the operation is performed as follows: make an elliptical skin incision distal to the hyponychium. Remove the wedge of tissue through incision, together with the periosteum on the lateral side of the distal phalanx. Expose and then transect the distal part of the distal phalanx. Twenty-nine patients (36 toes) were included in the follow up which varied in length from 8 to 29 months. None of them had recurrent symptoms. In conclusion, an upturned abnormality of the distal phalanx may contribute, at least partly, to the formation of recalcitrant ingrown toenail. The partial distal phalanx removal could be considered as an effective technique in recalcitrant ingrown toenail therapy.

A New Approach to Nipple Reconstruction: The Modified S-Flap

Sir: Many different techniques have been described by plastic surgeons to achieve nipple reconstruction. The most important aspect of nipple reconstruction is persistence in nipple projection and its comparison to the contralateral nipple.1,2 In an attempt to maintain nipple projection and aesthetics, we have devised a new approach to nipple construction using what we call a modified S-flap. The S-flap nipple reconstruction technique was designed to address certain characteristics of other nipple reconstruction techniques that may lead to unwanted contraction of nipple or loss of projection, shape, and size. The S-flap nipple reconstruction was performed on all patients requesting nipple reconstruction following breast reconstruction over a 5-year period (July of 1999 through July of 2004). The technique was described to our patients as a modified S-flap reconstruction. An elliptical incision was performed down to the subcutaneous fat layer with modified S-flap extensions to prevent constriction of the randomized bare skin flaps. The faces of the randomized skin flaps were opposed to each other. These flaps are then assimilated to the contralateral nonoperative nipple during suturing. Figures 1 and 2 illustrate the design of our proposed reconstruction. Areola tattooing was performed approximately 8 to 10 weeks after surgery if satisfactory wound healing was achieved. The base of the nipple was also tattooed, but the S-flap walls and tip of the nipple were left untattooed to decrease injury and contraction. This would preserve the nipple projection.Fig. 1.: The modified S-flap design. A 4 × 2-cm elliptical incision was performed down to the subcutaneous fat layer with modified S-flap extensions to prevent constriction of the randomized bare skin flaps. Each letter corresponds to the specific points of angulations of the S incision. (Reprinted with permission from Frank Papay, M.D.)Fig. 2.: The modified S-flap design. The faces of the randomized skin flaps were opposed by matching A to A′ and B to B′ as described in Figure 1. These flaps are then assimilated to the contralateral nonoperative nipple during suturing. (Reprinted with permission from Frank Papay, M.D.)As the final stage of breast reconstruction, nipple reconstruction changes the breast mound into a complete anatomical breast by achieving the aesthetics of the contralateral breast. Nipple reconstruction also increases self-esteem in the patient.1,3 Nipple projection, areola color, and symmetry are extremely vital for complete nipple reconstruction.4 A number of flap designs for nipple reconstruction have been well described in the literature. The techniques that have withstood the test of time are those that are surgically reliable and maintain nipple projection. The main obstacle in achieving acceptable nipple shape and size is contraction.4 The current standard of nipple-areola reconstruction is a technique that includes pulled-out flaps or star flaps to increase nipple projection and intradermal tattooing for areola pigmentation.1,2,4,5 Some authors believe that there should be stratification of nipple reconstruction depending on the type of breast reconstruction used. 5 Moreover, some authors believe that nipple projection is determined by the quality of the reconstructed skin dermis, namely, its thickness and vascularity. Our proposed method of the modified S-flap nipple reconstruction has not only preserved size and shape of the nipple-areola complex but also proved to be aesthetically acceptable to our patients. Kiran Narra, M.D. Department of General Surgery L. Michael Diaz, M.D. Department of Plastic Surgery Louisiana State University Baton Rouge, La. Frank A. Papay, M.D. Department of Plastic Surgery The Cleveland Clinic Foundation Cleveland, Ohio

선천성 전이개 누공에서 임상양상과 치료결과

Background and Objectives: The preauricular fistula is the most common congenital anomaly of the ear. Usually it is in an asymptomatic state, but in case of recurrent infection, it must be treated with surgery. The aim of this study was to assess clinical characteristics and treatment outcomes of fistulectomy in the congenital preauricular fistula. Materials and Methods: This study was a retrospective analysis 110 patients (133 ears) of the congenital preauricular fistula who underwent a fistulectomy from January 1995 to July 2004. All the fistulectomy was performed with the same technique which involved an elliptical skin incision around the fistula opening and dissection of the fistula tract using a probe with methylene blue staining after identification of the temporalis fascia. Results: The fistulas were mainly located on the unilateral side of the ear (79 patients, 71.8%). Mostly the opening of the fistula was located on anterior portion at the crus of the helix (120 ears, 90.2%). In bacterial culture and antibiotics sensitivity test of the 23 ears, the most common colonizing species was Staphylococcus epidermidis (9 ears, 39.1%) and methicillin resistant bacteria were 9 ears (39.1%). The majority of length of fistula tract of the 123 ears was 16—20 mm (41 ears, 33.3%). The postoperative recurrence rate was 4.5% (6 ears). Conclusion: The current study indicates that an adequate use of preoperative antibiotics according the result of bacterial culture and antibiotic sensitivity test, and a thorough identification of the fistula tract may be an effective method in the fistulectomy for lowering of the recurrence rate. (J Clinical Otolaryngol 2008;19:46–50)

A Versatile Technique for Repositioning of the Umbilicus in Abdominoplasty

Sir: Umbilical repositioning is a main step during abdominoplasty. The surgeon aims for minimal visible scars and a natural-looking result.1 Several techniques have been described, but none of them completely satisfy the aesthetic targets in all patients. Evidence of scar or retraction with umbilical stenosis may occur.2 The use of Y or double-Y cutaneous incisions has improved aesthetic results.3,4 We introduce a versatile technique for umbilicoplasty: an elliptical vertical incision of the umbilical skin and a double-opposing Y incision on the abdominal flap, to create a stable, natural-looking umbilicus. A prospective, open-label study was performed. Forty patients underwent abdominoplasty using the present technique for umbilicus repositioning. Patient age ranged between 24 and 63 years (36 women and four men). Body mass index ranged from 26 to 47 kg/m2 (mean, 33 kg/m2). Patient satisfaction and postoperative results were evaluated over a 12-month follow-up period. A modified 5-ml syringe was used to assess the depth and volume of the umbilical stalk. Variations in depth between 1 and 12 months were statistically compared using the Wilcoxon test. The umbilical skin is sharply incised vertically. The umbilical pedicle blood supply is preserved. The umbilical dermis is attached to the abdominal rectus fascia in four cardinal points with polyglecaprone 25 4–0 suture. In patients with a thin habitus, it is important to plicate the periumbilical fascia sufficiently to create an inverted umbilicus. The elliptical umbilical island is tightened against the tensed abdominal fascia without distortion. The site of umbilicus repositioning is determined by its projection on the abdominal flap. A small, double-opposing Y cutaneous incision is made in this point. The vertical size must be approximately the same as that of the original umbilicus. The angle and size of the four lateral incisions can be modified according to the width we want to obtain. Defatting is performed through the double-opposing Y incision. The umbilical skin is sutured to the surrounding abdominal skin with 4–0 nylon sutures. Four of these sutures are left longer and tied over a paraffin gauze patch to ensure deep umbilicus positioning. In all patients, an umbilicus with adequate depression was created. In one case, de-epithelization of the umbilical skin occurred and healed spontaneously in 2 weeks. After 12 months, no significant changes in shape, dimension, and appearance were observed. All patients were pleased with the final result. No cicatricial umbilical stenosis occurred, and no statistical significance was found comparing mean depth variations between 1 and 12 months (10.67 ± 1.34 ml and 10.4 ± 1.19, respectively; p = 0.0543). This technique gives a natural depth appearance, ensures optimal position, pulls scars deeply, avoids visible scarring, and allows achievement of different shapes according to the patient’s habitus (Figs. 1 and 2). Any umbilical size, in either obese or thin patients, can be created with this method. The double-opposing Y incision reinforces the vertical shape, creates natural umbilical dimpling, and prevents stenosis with stable results. This technique is easy to learn and simple to perform, effectively hides scars, and gives a youthful appearance to the umbilicus.Fig. 1.: Preoperative view of the umbilicus.Fig. 2.: Twelve-month postoperative view.Marco Mazzocchi, M.D., Ph.D. Luca A. Dessy, M.D. Andrea Figus, M.D. Department of Plastic Surgery University “La Sapienza” Rome, Italy DISCLOSURE The authors did not receive any financial support for this study, nor were they in any way commercially involved with any company.