Morphometric Analysis of the Umbilicus According to Age

Morphometric Analysis of the Umbilicus According to Age Abstract Background Morphometric and anatomical analyses of the shape and position of the umbilicus have been conducted in adults, but umbilicoplasty in children remains challenging because growth is still occurring. Objectives The main objective of this study was to evaluate the difference in the position and shape of the umbilicus between childhood and adulthood. The secondary objective was to improve the surgical management of umbilicoplasty in children. Methods This prospective single-center study focused on the morphometric analysis of the umbilicus in 200 adults and children. All data, including standardized measures and pictures, were determined by one single operator. Results Despite a variation of approximately 2% in the xiphoid-pubis distance, the location of the umbilicus remains stable during the entire growth period. In a supine individual, the location is at one half to two thirds of the xiphoid-pubis distance (slightly lower in children), with a mean ratio of 0.57 for the xiphoid-umbilicus distance to the xiphoid-pubis distance. In the general population, the most common shapes are round and vertical oval. T-shaped umbilici were only observed in adults. Round and protruding shapes were twice as frequent in children under 18 as in adults. The horizontal oval shape was twice as frequent in adults. Conclusions Abdominal growth and changes in the repartition of subcutaneous adipose tissues with age are responsible for the vertical orientation and deepening of the umbilicus as well as its horizontal orientation. To promote final cosmetic outcomes, secondary umbilicoplasty must place the umbilicus between one half and two thirds of the xiphoid-pubis distance. Level of Evidence: 4 The umbilicus is our first scar, a visible trace of our intrauterine life. After birth, the remnant stump of the umbilical cord falls off and the site heals during the first 10 days of life. Throughout the world, the umbilicus has cultural and religious meanings as well as cosmetic and even sexual attributes. This first scar is common to all human beings and a symbol of filiation. Once hidden as an intimate and personal feature, it is now in the open and even decorated with jewelry in some societies. Anatomically, the umbilicus, is located at the intersection of a horizontal line extending through the iliac crests (when the patient is standing) and a vertical midline.1 The umbilicus can present with different shapes: vertical oval (the most common and most sought after), horizontal oval, T-shaped, round, deformed, or protruding.2 The absence of the umbilicus, due to treatment of congenital or acquired pathologies of the anterior abdominal wall, is often a source of psychological distress for the patient.3 The surgical solution to this problem is umbilicoplasty. Various techniques can be used to create a new umbilicus.3-5 Currently, morphometric and anatomical analyses to optimize abdominoplasty techniques have only been conducted in adults.6,7 Umbilicoplasty in children remains a challenging procedure with regard to shaping a new umbilicus and managing scarring on a growing abdomen. The main objective of this study was to evaluate the different positions and shapes of the umbilicus between childhood and adulthood via morphometric analysis. The secondary objective was to improve umbilicoplasty surgical management in children. METHODS Patients This prospective single-center study focused on the morphometric analysis of the position and shape of the umbilicus in 200 adult and pediatric patients. Patients were enrolled in the study after receiving clear information on its objectives and signing an informed consent form (adult patients or pediatric patients’ parents). Exclusion criteria were a history of congenital malformation of the umbilicus, abdominal surgery, and pregnancy. Data Collection The following data were collected from participants via a questionnaire (Appendix A, available online as Supplementary Material at www.aestheticsurgeryjournal.com) between November 2015 and April 2016: age, weight, height, body mass index (BMI), medical, surgical, and obstetrics history. Morphometric measures were standardized to allow comparison of all patients from nonwalking infants to walking patients. For each patient, both the position of the umbilicus and its dimensions were recorded (Figure 1). Position of the umbilicus included: (A) the distance between the inferior part of the xiphoid process and the center of the umbilicus; (B) the distance between the center of the umbilicus and the upper part of the pubis; (C) the distance between the umbilicus and the right anterior superior iliac spine (ASIS), (cʹ) distance between the umbilicus and the left anterior superior iliac spine; (D) the distance between the center of the umbilicus and the straight line going through the top of the iliac crests; and (E) the distance between the anterior superior iliac spines. The dimensions of the umbilicus included the depth of the umbilicus, the width of the umbilical ring (in the horizontal plane), and the height of the umbilicus (in the vertical plane). Figure 1. View largeDownload slide Diagram showing the standardized measures of the umbilicus morphometric study (abdomen in the frontal plane). Figure 1. View largeDownload slide Diagram showing the standardized measures of the umbilicus morphometric study (abdomen in the frontal plane). Measurements were collected with participants in the supine position. A second series of measures in the upright position were collected from persons who could walk. All inclusions and measures were performed by one investigator (N.C.) to avoid inter-rater measurement biases. Shape The shape of the umbilicus was described based upon the 6 shapes reported by Delpierre et al2: T-shaped, vertical oval, horizontal oval, round, deformed, or protruded. Only one shape was possible per participant. A clinical examination was performed for each participant to screen for umbilical hernia or diastasis of the rectus abdominal muscles. To avoid the constraints of age-related differences in size, we calculated the length, width, and depth ratio of the umbilicus for each patient in the supine position in relation to the xiphoid-pubis distance. The shape was also described in the upright position when possible because it can be altered by gravity.8 Ethics The CNIL (Commission nationale de l’informatique et des libertés), a French institutional review board, granted approval for the study, and written informed consent was collected from all participants or their parents. Statistical Analysis Data are described as means and standard deviations for quantitative variables and as samples and percentages for qualitative variables. Correlations between age, BMI, and position and morphology of the umbilicus were evaluated using a t test, Wilcoxon signed-rank test simple linear regression, Pearson’s correlation test, chi-square test, or Fisher’s exact test, according to the conditions of application. The threshold for significance was set at 0.05. Analyses were performed using SAS software version 9.3. RESULTS Population The study included 200 participants, 92 males (46%) and 108 females (54%), whose ages ranged from 2 months to 84 years. The mean age of study patients was 29.68 years for the total sample, 6.02 years for the 61 patients <18 years, and 40.06 years for the 139 patients ≥18 years. Population characteristics (sex ratio, age, BMI) are listed in Table 1. Results are presented for the total study population and by subgroups based on age: <5 years, <10 years, <15 years, <18 years, and ≥18 years. Two representative patients are shown in Figures 2 and 3. Table 1. Synthesis of the Results of the Umbilicus Morphometric Study (Position, Measures, Shapes) in 200 Cases According to Age <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) ASIS, anterior superior iliac spine; XP, xiphoid-pubis distance; XPL, xiphoid-pubis line; XU, xiphoid-umbilicus distance. *Significant difference between the subgroup “≥18-years-old” and the other subgroups. **Non-significant difference. ***Not available. View Large Table 1. Synthesis of the Results of the Umbilicus Morphometric Study (Position, Measures, Shapes) in 200 Cases According to Age <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) ASIS, anterior superior iliac spine; XP, xiphoid-pubis distance; XPL, xiphoid-pubis line; XU, xiphoid-umbilicus distance. *Significant difference between the subgroup “≥18-years-old” and the other subgroups. **Non-significant difference. ***Not available. View Large Figure 2. View largeDownload slide A 28-year-old representative female patient with a round umbilicus. Figure 2. View largeDownload slide A 28-year-old representative female patient with a round umbilicus. Figure 3. View largeDownload slide A 29-year-old representative male patient with a protruded umbilicus. Figure 3. View largeDownload slide A 29-year-old representative male patient with a protruded umbilicus. Umbilicus Position With regard to the ASIS, between 84.8% and 87.1% of patients across subgroups had their umbilicus located on the midline (Table 1). The position of the umbilicus on the xiphoid-pubis line did not vary much with age (Figure 4). Figure 4. View largeDownload slide Position of the umbilicus (XU/XP) according to age and linear correlation. Figure 4. View largeDownload slide Position of the umbilicus (XU/XP) according to age and linear correlation. The ratio of the xiphoid-umbilicus distance to the xiphoid-pubis distance was 0.58 ± 0.05 in the supine position (0.60 ± 0.05 in the upright position) for patients in the <5-year, <10-year, <15-year, and <18-year subgroups vs 0.56 ± 0.05 in the supine position (0.58 ± 0.05 in the upright position) in patients in the ≥18-year subgroup. However, the umbilicus was significantly lower (P <0.05) in patients younger than 18 years vs patients who were 18 years or older, with a 2% difference in the xiphoid-pubis distance. Among patients who were <18 years old of age, 58 (95.1%) had their umbilicus located between one half and two thirds of the xiphoid-pubis line and 3 of them (4.9%) had their umbilicus above that line. Among patients who were ≥18 years old of age, 128 (92.1%) had their umbilicus positioned between one half and two thirds of the xiphoid-pubis line, 10 (7.2%) had their umbilicus located above that line, and 1 individual (0.7%) had his umbilicus below that line. Most patients, children and adults alike, had their umbilicus located between one half and two thirds of the xiphoid-pubis line (Figure 5). Figure 5. View largeDownload slide Repartition of the different positions of the umbilicus on the xiphoid-pubis line according to age. Figure 5. View largeDownload slide Repartition of the different positions of the umbilicus on the xiphoid-pubis line according to age. Umbilicus Dimensions The dimensions of the umbilicus in the general population and the various subgroups are listed in centimeters, with ratios reported with regard to the xiphoid-pubis distance (Table 1). We noted significant widening and deepening of the umbilicus with increasing age (P <0.05). The average difference was 0.31 cm for the width, 0.21 cm for the height, and 0.55 cm for the depth between patients who were <18 years old vs those ≥18 years old. The widening and deepening of the umbilicus occurred mainly after the age of 18, and dimensions did not vary much prior to that age. Figure 6 shows a representative oval umbilicus and the variation in its height, width, and depth. Proportions were consistent within subgroups. Figure 6. View largeDownload slide Representation of the three dimensions (height, width, and depth) of the umbilicus according to age and the different subgroups, respecting the proportions (regardless of the shape of the umbilicus). Figure 6. View largeDownload slide Representation of the three dimensions (height, width, and depth) of the umbilicus according to age and the different subgroups, respecting the proportions (regardless of the shape of the umbilicus). Umbilicus Shape Round and vertical oval shapes were the most common in the general population and in the subgroups, but the frequency of the different umbilicus shapes varied with age (Table 1). In patients who were <18 years old, round and protruded shapes were 1.5 to 2 times more common compared with older patients: 47.5% vs 26.6% (P <0.05) and 4.9% vs 2.9% (sample too small for statistical analysis), respectively. Conversely, the horizontal oval shape was twice as common in patients who were ≥18 years old compared with younger patients, 27.3% vs 14.8% (P <0.05). The horizontal oval shape was the second most common shape after the age of 18. The round shape, which was the most common in patients who were <18 years, was only the third most common among adults. The T-shaped umbilicus was only observed in individuals ≥18 years old (13.7%). The frequency of the round shape decreased by about 10 percentage points between the following subgroups <5 years old and <18 years old (58.8% vs 47.5%, respectively), whereas the frequency of the vertical oval shape increased by about 10 percentage points between these subgroups (23.5% vs 32.8%). DISCUSSION Morphometric analyses of the umbilicus have rarely focused on pediatric cases. However, congenital abdominal wall defects can lead to an absent umbilicus9 or surgery requiring umbilicus repositioning.10 The presence of an umbilicus is a sign of normalcy in our society, and it promotes social adaptation. Umbilicoplasty is the only method for restoring a more anatomical appearance for a scarred abdomen, and several umbilicoplasty techniques exist.4,5 The multitude of procedures described in the literature underscores the challenges in obtaining satisfactory long-term cosmetic results. The objective of the current work was not to describe a new umbilicoplasty technique, but rather to propose surgical management guidelines for positioning and shaping the umbilicus during umbilicoplasty in children, guided by age-based morphometric observations. In our study, BMI increased with age, but the variations observed in dimensions and shape of the umbilicus could be caused by several factors. Our morphometric study showed that the umbilicus’ position is stable during abdominal growth, from birth to adulthood,1,11-14 and it remains in the anatomical region between midpoint and the two thirds of the xiphoid-pubis line. This finding demonstrates that abdominal growth is harmonious above and below the umbilicus during normal growth. However, the umbilicus was significantly lower (P <0.05) in patients who were <18 years old vs those ≥18 years old, but the difference was slight (2% of the xiphoid-pubis distance). In our study the umbilicus was commonly found on the midline. This finding contradicts the results reported by Rohrich et al15 who found the umbilicus on the midline in only 0% to 1.7% of the population studied. The difference in results is probably due to the methodology used in the respective studies. Our measurements were based on palpable bone prominences, whereas Rohrich et al15 used the lateral borders of the waist identified in pictures of patients. We also observed that the dimensions of the umbilicus changed with growth.11,12,14-16 Depth increased significantly with age, especially after 18 years of age, and the ratio of the xiphoid-umbilicus distance to the xiphoid-pubis distance was 2.2 times higher in adults compared with children. However, umbilicus height and width ratios decreased with age due to growth of the abdomen. Regarding the “ideal” shape of the umbilicus, several studies have reported that the vertical oval shape is preferred.13,14,16-19 This shape is the most common, along with the round shape, as reported in most studies in the literature.2,11,12,16,20 However, we found that the vertical oval and round shapes were not the most frequent in patients under 18 years old, and in patients who were ≥18 years old, the round shape was the third most common after the vertical oval and horizontal oval shapes. The shape of the umbilicus is typically round before the age of 5, and it changes with age through 2 distinct phenomena that tend to deform the umbilicus in orthogonal directions: abdominal growth and accumulation of subcutaneous periumbilical adipose tissue.21 Abdominal growth starts before the age of 18 and is responsible for the vertical orientation of the umbilicus, causing an initially round-shaped umbilicus to become a vertical oval. The increase in subcutaneous periumbilical adipose tissue mostly occurs during adulthood, as demonstrated by the significant increase of mean BMI after 18 years vs before 18 years. In addition, the anchoring of the umbilicus in the deep muscle fascia planes contributes to increased umbilicus depth and the creation of a horizontal fold after age 18 years. Similarly, one can observe natural horizontal folds at the abdominal level that are responsible for the horizontal deformation of the umbilicus.22 This horizontal deformation may also be involved in transforming a round-shaped umbilicus into a horizontal oval and a vertical oval umbilicus into one that is T-shaped. Impact on Surgery The secondary objective of this work was to propose adapting surgical management according to the patient’s age to optimize the cosmetic outcomes in adulthood. Although the basics of umbilicoplasty remain simple, surgical outcomes are often disappointing because they are not stable over time. Abdominal growth in children adds an additional challenge to achieving a successful surgical repair. Umbilicoplasty creates a new umbilical scar that will either not grow or grow only slightly. In addition, contractile wound healing might also occur, further reducing the degree of success. The invagination of the new umbilicus is difficult to obtain, and it tends to fade over time.4 Faced with these observations, we propose re-creation of an umbilicus that is similar in dimensions to an adult umbilicus (a little wider and with increased invagination if possible), even in young children. A nonresorbable thread is essential to suture the cutaneous flaps and anchor the umbilicus into the muscle plane. This deep anchoring is essential to sustain invagination alongside the growth of subcutaneous adipose tissue. Secondary umbilicoplasty can be proposed at any age, as soon as the child expresses the need for surgical management, but it is best to avoid the surgery during puberty because of potential wound healing issues.4 Positioning the umbilicus between one half and two thirds of the xiphoid-pubis distance is essential because this ratio hardly changes over time. Further studies evaluating the impact of growth on the position and shape of the neoumbilicus surgically created in childhood should be considered. For example, in anticipation of the initial growth-related vertical deformation followed by horizontal deformation due to the accumulation of adipose tissue around the umbilicus, one might adapt the procedure to base the shape of the neoumbilicus on the patient’s age. A horizontal oval umbilicus could be appropriate before the age of 5, a round one between the age of 5 and puberty, and a vertical oval shape in adults to corresponds to the “ideal” shape reported in the literature. (Figure 7). Figure 7. View largeDownload slide Umbilicoplasty surgical management guidelines regarding the position and shape of the umbilicus according to age. Figure 7. View largeDownload slide Umbilicoplasty surgical management guidelines regarding the position and shape of the umbilicus according to age. Study Limitations This study had several limitations. First, the comparison of nonwalking vs walking participants required collected measurements of patients lying in the supine position. Previous morphometric studies on the umbilicus have typically collected measurements with patients in a standing position, which also enabled studying how gravity affected the shape of the umbilicus. A second limitation of our study was the low enrollment of pediatric patients. More than two thirds of the patients were over 18 years of age, and if we had increased the number of pediatric participants we might have detected greater morphometric differences between these subgroups and more precisely identified the effects of abdominal growth on the umbilicus. This study begins to address the lack of descriptive morphometric studies in pediatric umbilici in the scientific literature, but additional studies are needed to provide surgical management guidelines for umbilicoplasty in congenital or acquired anomalies. CONCLUSIONS The umbilicus retains a stable position over time according to age. Despite a 2% variation in the xiphoid-pubis distance, the umbilicus is essentially in its “adult” position right from birth. The shape of the umbilicus becomes vertical due to abdominal growth before the age of 18. After the age of 18, it becomes horizontal due to the accumulation of subcutaneous periumbilical adipose tissue. Our morphometric study on the position and shape of the umbilicus does not permit proposing definitive guidelines on secondary umbilicoplasty in children. Further studies are needed to evaluate the impact of growth on the position and shape of the neoumbilicus created during umbilicoplasty in childhood. However, we can recommend the following reconstructions: a horizontal oval shape before the age of 5, a round shape between the age of 5 and puberty, and a vertical oval shape in adults. We additionally recommend that positioning be close to two thirds of the xiphoid-pubis distance before the age of 5 years and equidistant between one half and two thirds of the xiphoid-pubis distance at later ages. In addition, the invagination of the new umbilicus must be performed with caution to ensure that it will remain deep despite the accumulation of subcutaneous periumbilical adipose tissue with age. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgment The authors would like to thank the American Memorial Hospital Foundation, Inc (Boston, MA, USA) for its continuing advice and support. REFERENCES 1. Dubou R , Ousterhout DK . Placement of the umbilicus in an abdominoplasty . Plast Reconstr Surg . 1978 ; 61 ( 2 ): 291 - 293 . Google Scholar CrossRef Search ADS PubMed 2. Delpierre V , Coquerel-Beghin D , Aktouf A , Auquit-Auckbur I , Milliez PY . Biometric and morphometric analyse of the umbilicus: about 70 cases . Ann Chir Plast Esthet . 2012 ; 57 ( 6 ): 575 - 579 . Google Scholar CrossRef Search ADS PubMed 3. Bongini M , Tanini S , Messineo A , Facchini F , Ghionzoli M . Umbilical reconstruction in children: a simplified operative technique . Aesthetic Plast Surg . 2015 ; 39 ( 3 ): 414 - 417 . Google Scholar CrossRef Search ADS PubMed 4. Jayyosi L , Boudaoud N , Okiemy O et al. Umbilicus in children . Ann Chir Plast Esthet . 2016 ; 61 ( 5 ): 713 - 721 . Google Scholar CrossRef Search ADS PubMed 5. Tenorio X , Chaouat M , Mimoun M . Reconstruction de l’ombilic . In: EMC , ed. Techniques chirurgicales. Chirurgie plastique reconstructrice et esthétique . Paris : Elsevier Masson SAS ; 2008 : 645 - 677 . 6. Joseph WJ , Sinno S , Brownstone ND , Cleveland EC , Thanik VD . Creating the perfect umbilicus: a systematic review of recent literature . Aesthetic Plast Surg . 2016 ; 40 ( 3 ): 372 - 379 . Google Scholar CrossRef Search ADS PubMed 7. Visconti G , Visconti E , Bonomo L , Salgarello M . Concepts in Navel Aesthetic: A Comprehensive Surface Anatomy Analysis . Aesthetic Plast Surg . 2015 ; 39 ( 1 ): 43 - 50 . Google Scholar CrossRef Search ADS PubMed 8. Choudhary S , Taams KO . Umbilicosculpture: a concept revisited . Br J Plast Surg . 1998 ; 51 ( 7 ): 538 - 541 . Google Scholar CrossRef Search ADS PubMed 9. Binet A , Gelas T , Jochault-Ritz S et al. VAC® therapy a therapeutic alternative in giant omphalocele treatment: a multicenter study . J Plast Reconstr Aesthet Surg . 2013 ; 66 ( 12 ): e373 - e375 . Google Scholar CrossRef Search ADS PubMed 10. Rem K , François Fiquet C , Kadlub N et al. Prune belly syndrome: modified Monfort abdominoplasty with a horizontal scar and a dermal layer . Eur J Plast Surg . 2015 ; 38 ( 3 ): 225 - 228 . Google Scholar CrossRef Search ADS 11. Abhyankar SV , Rajguru AG , Patil PA . Anatomical localization of the umbilicus: an Indian study . Plast Reconstr Surg . 2006 ; 117 ( 4 ): 1153 - 1157 . Google Scholar CrossRef Search ADS PubMed 12. Parnia R , Ghorbani L , Sepehrvand N , Hatami S , Bazargan-Hejazi S . Determining anatomical position of the umbilicus in Iranian girls, and providing quantitative indices and formula to determine neo-umbilicus during abdominoplasty . Indian J Plast Surg . 2012 ; 45 ( 1 ): 94 - 96 . Google Scholar CrossRef Search ADS PubMed 13. Yu D , Novicoff WM , Gampper TJ . The average size and position of the umbilicus in young men and women . Ann Plast Surg . 2016 ; 76 ( 3 ): 346 - 348 . Google Scholar CrossRef Search ADS PubMed 14. El-Sharkawy A , Said T , Shafik I , Khalifa H . A study of the aesthetic patterns of the umbilicus among Egyptians with a new technique for umbilical reconstruction de novo . Kasr El-Aini J Surg . 2004 ; 5 ( 3 ): 87 - 99 . 15. Rohrich RJ , Sorokin ES , Brown SA , Gibby DL . Is the umbilicus truly midline? Clinical and medicolegal implications . Plast Reconstr Surg . 2003 ; 112 ( 1 ): 259 - 263 ; discussion 264. Google Scholar CrossRef Search ADS PubMed 16. Pallua N , Markowicz MP , Grosse F , Walter S . Aesthetically pleasant umbilicoplasty . Ann Plast Surg . 2010 ; 64 ( 6 ): 722 - 725 . Google Scholar CrossRef Search ADS PubMed 17. Lee SJ , Garg S , Lee HP . Computer-Aided Analysis of the “Beautiful” Umbilicus . Aesthet Surg J . 2014 ; 34 ( 5 ): 748 - 756 . Google Scholar CrossRef Search ADS PubMed 18. Craig SB , Faller MS , Puckett CL . In search of the ideal female umbilicus . Plast Reconstr Surg . 2000 ; 105 ( 1 ): 389 - 392 . Google Scholar CrossRef Search ADS PubMed 19. Cavale N , Butler PE . The ideal female umbilicus ? Plast Reconstr Surg . 2008 ; 121 ( 5 ): 356e - 357e . Google Scholar CrossRef Search ADS PubMed 20. Baroudi R . Umbilicaplasty . Clin Plast Surg . 1975 ; 2 ( 3 ): 431 - 448 . Google Scholar PubMed 21. Sakamoto Y , Kamagata S , Hirobe S , Hayashi A . Umbilical shape by age and growth: a Japanese study . Plast Reconstr Surg . 2010 ; 126 ( 2 ): 97e - 98e . Google Scholar CrossRef Search ADS PubMed 22. Psillakis JM , Appiani E , De La Plaza R. Color Atlas of Aesthetic Surgery of the Abdomen . New York, NY : Thieme Medical Publishers ; 1991 : 6 - 7 . © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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Abstract

Abstract Background Morphometric and anatomical analyses of the shape and position of the umbilicus have been conducted in adults, but umbilicoplasty in children remains challenging because growth is still occurring. Objectives The main objective of this study was to evaluate the difference in the position and shape of the umbilicus between childhood and adulthood. The secondary objective was to improve the surgical management of umbilicoplasty in children. Methods This prospective single-center study focused on the morphometric analysis of the umbilicus in 200 adults and children. All data, including standardized measures and pictures, were determined by one single operator. Results Despite a variation of approximately 2% in the xiphoid-pubis distance, the location of the umbilicus remains stable during the entire growth period. In a supine individual, the location is at one half to two thirds of the xiphoid-pubis distance (slightly lower in children), with a mean ratio of 0.57 for the xiphoid-umbilicus distance to the xiphoid-pubis distance. In the general population, the most common shapes are round and vertical oval. T-shaped umbilici were only observed in adults. Round and protruding shapes were twice as frequent in children under 18 as in adults. The horizontal oval shape was twice as frequent in adults. Conclusions Abdominal growth and changes in the repartition of subcutaneous adipose tissues with age are responsible for the vertical orientation and deepening of the umbilicus as well as its horizontal orientation. To promote final cosmetic outcomes, secondary umbilicoplasty must place the umbilicus between one half and two thirds of the xiphoid-pubis distance. Level of Evidence: 4 The umbilicus is our first scar, a visible trace of our intrauterine life. After birth, the remnant stump of the umbilical cord falls off and the site heals during the first 10 days of life. Throughout the world, the umbilicus has cultural and religious meanings as well as cosmetic and even sexual attributes. This first scar is common to all human beings and a symbol of filiation. Once hidden as an intimate and personal feature, it is now in the open and even decorated with jewelry in some societies. Anatomically, the umbilicus, is located at the intersection of a horizontal line extending through the iliac crests (when the patient is standing) and a vertical midline.1 The umbilicus can present with different shapes: vertical oval (the most common and most sought after), horizontal oval, T-shaped, round, deformed, or protruding.2 The absence of the umbilicus, due to treatment of congenital or acquired pathologies of the anterior abdominal wall, is often a source of psychological distress for the patient.3 The surgical solution to this problem is umbilicoplasty. Various techniques can be used to create a new umbilicus.3-5 Currently, morphometric and anatomical analyses to optimize abdominoplasty techniques have only been conducted in adults.6,7 Umbilicoplasty in children remains a challenging procedure with regard to shaping a new umbilicus and managing scarring on a growing abdomen. The main objective of this study was to evaluate the different positions and shapes of the umbilicus between childhood and adulthood via morphometric analysis. The secondary objective was to improve umbilicoplasty surgical management in children. METHODS Patients This prospective single-center study focused on the morphometric analysis of the position and shape of the umbilicus in 200 adult and pediatric patients. Patients were enrolled in the study after receiving clear information on its objectives and signing an informed consent form (adult patients or pediatric patients’ parents). Exclusion criteria were a history of congenital malformation of the umbilicus, abdominal surgery, and pregnancy. Data Collection The following data were collected from participants via a questionnaire (Appendix A, available online as Supplementary Material at www.aestheticsurgeryjournal.com) between November 2015 and April 2016: age, weight, height, body mass index (BMI), medical, surgical, and obstetrics history. Morphometric measures were standardized to allow comparison of all patients from nonwalking infants to walking patients. For each patient, both the position of the umbilicus and its dimensions were recorded (Figure 1). Position of the umbilicus included: (A) the distance between the inferior part of the xiphoid process and the center of the umbilicus; (B) the distance between the center of the umbilicus and the upper part of the pubis; (C) the distance between the umbilicus and the right anterior superior iliac spine (ASIS), (cʹ) distance between the umbilicus and the left anterior superior iliac spine; (D) the distance between the center of the umbilicus and the straight line going through the top of the iliac crests; and (E) the distance between the anterior superior iliac spines. The dimensions of the umbilicus included the depth of the umbilicus, the width of the umbilical ring (in the horizontal plane), and the height of the umbilicus (in the vertical plane). Figure 1. View largeDownload slide Diagram showing the standardized measures of the umbilicus morphometric study (abdomen in the frontal plane). Figure 1. View largeDownload slide Diagram showing the standardized measures of the umbilicus morphometric study (abdomen in the frontal plane). Measurements were collected with participants in the supine position. A second series of measures in the upright position were collected from persons who could walk. All inclusions and measures were performed by one investigator (N.C.) to avoid inter-rater measurement biases. Shape The shape of the umbilicus was described based upon the 6 shapes reported by Delpierre et al2: T-shaped, vertical oval, horizontal oval, round, deformed, or protruded. Only one shape was possible per participant. A clinical examination was performed for each participant to screen for umbilical hernia or diastasis of the rectus abdominal muscles. To avoid the constraints of age-related differences in size, we calculated the length, width, and depth ratio of the umbilicus for each patient in the supine position in relation to the xiphoid-pubis distance. The shape was also described in the upright position when possible because it can be altered by gravity.8 Ethics The CNIL (Commission nationale de l’informatique et des libertés), a French institutional review board, granted approval for the study, and written informed consent was collected from all participants or their parents. Statistical Analysis Data are described as means and standard deviations for quantitative variables and as samples and percentages for qualitative variables. Correlations between age, BMI, and position and morphology of the umbilicus were evaluated using a t test, Wilcoxon signed-rank test simple linear regression, Pearson’s correlation test, chi-square test, or Fisher’s exact test, according to the conditions of application. The threshold for significance was set at 0.05. Analyses were performed using SAS software version 9.3. RESULTS Population The study included 200 participants, 92 males (46%) and 108 females (54%), whose ages ranged from 2 months to 84 years. The mean age of study patients was 29.68 years for the total sample, 6.02 years for the 61 patients <18 years, and 40.06 years for the 139 patients ≥18 years. Population characteristics (sex ratio, age, BMI) are listed in Table 1. Results are presented for the total study population and by subgroups based on age: <5 years, <10 years, <15 years, <18 years, and ≥18 years. Two representative patients are shown in Figures 2 and 3. Table 1. Synthesis of the Results of the Umbilicus Morphometric Study (Position, Measures, Shapes) in 200 Cases According to Age <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) ASIS, anterior superior iliac spine; XP, xiphoid-pubis distance; XPL, xiphoid-pubis line; XU, xiphoid-umbilicus distance. *Significant difference between the subgroup “≥18-years-old” and the other subgroups. **Non-significant difference. ***Not available. View Large Table 1. Synthesis of the Results of the Umbilicus Morphometric Study (Position, Measures, Shapes) in 200 Cases According to Age <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) <5 years old <10 years old <15 years old <18 years old ≥18 years old Global population No. of patients 34 46 51 61 139 200 Age* (years)  Range 0.16-4.5 0.16-9 0.16-14 0.16-17 18-84 0.16-84  Mean* 1.75 ± 1.29 3.74 ± 2.63 4.03 ± 3.87 6.02 ± 5.77 40.06 ± 15.44 29.68 ± 20.54 Sex  Male 18 25 28 32 60 92  Female 16 21 23 29 79 108 Mean BMI* (kg/m2) 16.85 ± 2.77 17.11 ± 2.55 17.44 ± 2.93 18.16 ± 3.35 24.62 ± 4.68 22.65 ± 5.24 Walking  No 17 17 17 17 0 17  Yes 17 29 34 44 139 183 XP / ASIS (mean) 1.13 ± 0.22 1.13 ± 0.19 1.13 ± 0.20 1.13 ± 0.18 1.11 ± 0.83 1.11 ± 0.70 Location to ASIS  Median 29 (85.3%) 39 (84.8%) 44 (86.3%) 53 (87%) 121 (87.1%) 174 (87%)  Closer to the left 3 (8.8%) 3 (6.5 %) 3 (5.9 %) 4 (6.5%) 12 (8.6%) 16 (8%)  Closer to the right 2 (5.9%) 4 (8.7%) 4 (7.8%) 4 (6.5%) 6 (4.3%) 10 (5%) Location in XPL  <1/2 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 10 (7.2%) 13 (6.5%)  1/2 to 2/3 32 (94.1%) 43 (93.4%) 48 (94.1%) 58 (95.1%) 128 (92.1%) 186 (93%)  >2/3 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (0.7%) 1 (0.5%) XU/XP* lying 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.58 ± 0.05 0.56 ± 0.05 0.57 ± 0.05 XU/XP* standing 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.60 ± 0.04 0.58 ± 0.05 0.58 ± 0.05 Measurement* (cm)  Height 1.06 ± 0.31 1.13 ± 0.34 1.16 ± 0.35 1.24 ± 0.39 1.45 ± 0.51 1.39 ± 0.49  Width 1.03 ± 0.34 1.01 ± 0.32 1.02 ± 0.35 1.06 ± 0.40 1.37 ± 0.59 1.28 ± 0.56  Depth 0.28 ± 0.39 0.33 ± 0.41 0.39 ± 0.46 0.47 ± 0.48 1.02 ± 0.54 0.85 ± 0.58 Measurement/XP (%) Shape  Round* 20 (58.8%) 26 (56.5%) 26 (51%) 29 (47.5%) 37 (26.6%) 66 (33%)  Vertical oval* 8 (23.5%) 12 (26.1%) 15 (29.4%) 20 (32.8%) 41 (29.5%) 61 (30.5%)  Horizontal oval* 4 (11.8%) 5 (10.9%) 7 (13.7%) 9 (14.8%) 38 (27.3%) 47 (23.5%)  T-shaped* 0 (0%) 0 (0%) 0 (0%) 0 (0%) 19 (13.7%) 19 (9.5%)  Protrude*** 2 (5.9%) 3 (6.5%) 3 (5.9%) 3 (4.9%) 4 (2.9%) 7 (3.5%)  Height* 6.18 ± 2.20 6.03 ± 2.01 5.96 ± 2.00 5.87 ± 1.89 4.72 ± 1.58 5.07 ± 1.76  Width** 6.12 ± 2.57 5.59 ± 2.45 5.44 ± 2.46 5.21 ± 2.40 4.49 ± 1.94 4.71 ± 2.10  Depth* 1.28 ± 2.36 1.63 ± 2.19 1.84 ± 2.23 2.00 ± 2.12 3.33 ± 1.71 2.92 ± 1.94  Deformed 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) ASIS, anterior superior iliac spine; XP, xiphoid-pubis distance; XPL, xiphoid-pubis line; XU, xiphoid-umbilicus distance. *Significant difference between the subgroup “≥18-years-old” and the other subgroups. **Non-significant difference. ***Not available. View Large Figure 2. View largeDownload slide A 28-year-old representative female patient with a round umbilicus. Figure 2. View largeDownload slide A 28-year-old representative female patient with a round umbilicus. Figure 3. View largeDownload slide A 29-year-old representative male patient with a protruded umbilicus. Figure 3. View largeDownload slide A 29-year-old representative male patient with a protruded umbilicus. Umbilicus Position With regard to the ASIS, between 84.8% and 87.1% of patients across subgroups had their umbilicus located on the midline (Table 1). The position of the umbilicus on the xiphoid-pubis line did not vary much with age (Figure 4). Figure 4. View largeDownload slide Position of the umbilicus (XU/XP) according to age and linear correlation. Figure 4. View largeDownload slide Position of the umbilicus (XU/XP) according to age and linear correlation. The ratio of the xiphoid-umbilicus distance to the xiphoid-pubis distance was 0.58 ± 0.05 in the supine position (0.60 ± 0.05 in the upright position) for patients in the <5-year, <10-year, <15-year, and <18-year subgroups vs 0.56 ± 0.05 in the supine position (0.58 ± 0.05 in the upright position) in patients in the ≥18-year subgroup. However, the umbilicus was significantly lower (P <0.05) in patients younger than 18 years vs patients who were 18 years or older, with a 2% difference in the xiphoid-pubis distance. Among patients who were <18 years old of age, 58 (95.1%) had their umbilicus located between one half and two thirds of the xiphoid-pubis line and 3 of them (4.9%) had their umbilicus above that line. Among patients who were ≥18 years old of age, 128 (92.1%) had their umbilicus positioned between one half and two thirds of the xiphoid-pubis line, 10 (7.2%) had their umbilicus located above that line, and 1 individual (0.7%) had his umbilicus below that line. Most patients, children and adults alike, had their umbilicus located between one half and two thirds of the xiphoid-pubis line (Figure 5). Figure 5. View largeDownload slide Repartition of the different positions of the umbilicus on the xiphoid-pubis line according to age. Figure 5. View largeDownload slide Repartition of the different positions of the umbilicus on the xiphoid-pubis line according to age. Umbilicus Dimensions The dimensions of the umbilicus in the general population and the various subgroups are listed in centimeters, with ratios reported with regard to the xiphoid-pubis distance (Table 1). We noted significant widening and deepening of the umbilicus with increasing age (P <0.05). The average difference was 0.31 cm for the width, 0.21 cm for the height, and 0.55 cm for the depth between patients who were <18 years old vs those ≥18 years old. The widening and deepening of the umbilicus occurred mainly after the age of 18, and dimensions did not vary much prior to that age. Figure 6 shows a representative oval umbilicus and the variation in its height, width, and depth. Proportions were consistent within subgroups. Figure 6. View largeDownload slide Representation of the three dimensions (height, width, and depth) of the umbilicus according to age and the different subgroups, respecting the proportions (regardless of the shape of the umbilicus). Figure 6. View largeDownload slide Representation of the three dimensions (height, width, and depth) of the umbilicus according to age and the different subgroups, respecting the proportions (regardless of the shape of the umbilicus). Umbilicus Shape Round and vertical oval shapes were the most common in the general population and in the subgroups, but the frequency of the different umbilicus shapes varied with age (Table 1). In patients who were <18 years old, round and protruded shapes were 1.5 to 2 times more common compared with older patients: 47.5% vs 26.6% (P <0.05) and 4.9% vs 2.9% (sample too small for statistical analysis), respectively. Conversely, the horizontal oval shape was twice as common in patients who were ≥18 years old compared with younger patients, 27.3% vs 14.8% (P <0.05). The horizontal oval shape was the second most common shape after the age of 18. The round shape, which was the most common in patients who were <18 years, was only the third most common among adults. The T-shaped umbilicus was only observed in individuals ≥18 years old (13.7%). The frequency of the round shape decreased by about 10 percentage points between the following subgroups <5 years old and <18 years old (58.8% vs 47.5%, respectively), whereas the frequency of the vertical oval shape increased by about 10 percentage points between these subgroups (23.5% vs 32.8%). DISCUSSION Morphometric analyses of the umbilicus have rarely focused on pediatric cases. However, congenital abdominal wall defects can lead to an absent umbilicus9 or surgery requiring umbilicus repositioning.10 The presence of an umbilicus is a sign of normalcy in our society, and it promotes social adaptation. Umbilicoplasty is the only method for restoring a more anatomical appearance for a scarred abdomen, and several umbilicoplasty techniques exist.4,5 The multitude of procedures described in the literature underscores the challenges in obtaining satisfactory long-term cosmetic results. The objective of the current work was not to describe a new umbilicoplasty technique, but rather to propose surgical management guidelines for positioning and shaping the umbilicus during umbilicoplasty in children, guided by age-based morphometric observations. In our study, BMI increased with age, but the variations observed in dimensions and shape of the umbilicus could be caused by several factors. Our morphometric study showed that the umbilicus’ position is stable during abdominal growth, from birth to adulthood,1,11-14 and it remains in the anatomical region between midpoint and the two thirds of the xiphoid-pubis line. This finding demonstrates that abdominal growth is harmonious above and below the umbilicus during normal growth. However, the umbilicus was significantly lower (P <0.05) in patients who were <18 years old vs those ≥18 years old, but the difference was slight (2% of the xiphoid-pubis distance). In our study the umbilicus was commonly found on the midline. This finding contradicts the results reported by Rohrich et al15 who found the umbilicus on the midline in only 0% to 1.7% of the population studied. The difference in results is probably due to the methodology used in the respective studies. Our measurements were based on palpable bone prominences, whereas Rohrich et al15 used the lateral borders of the waist identified in pictures of patients. We also observed that the dimensions of the umbilicus changed with growth.11,12,14-16 Depth increased significantly with age, especially after 18 years of age, and the ratio of the xiphoid-umbilicus distance to the xiphoid-pubis distance was 2.2 times higher in adults compared with children. However, umbilicus height and width ratios decreased with age due to growth of the abdomen. Regarding the “ideal” shape of the umbilicus, several studies have reported that the vertical oval shape is preferred.13,14,16-19 This shape is the most common, along with the round shape, as reported in most studies in the literature.2,11,12,16,20 However, we found that the vertical oval and round shapes were not the most frequent in patients under 18 years old, and in patients who were ≥18 years old, the round shape was the third most common after the vertical oval and horizontal oval shapes. The shape of the umbilicus is typically round before the age of 5, and it changes with age through 2 distinct phenomena that tend to deform the umbilicus in orthogonal directions: abdominal growth and accumulation of subcutaneous periumbilical adipose tissue.21 Abdominal growth starts before the age of 18 and is responsible for the vertical orientation of the umbilicus, causing an initially round-shaped umbilicus to become a vertical oval. The increase in subcutaneous periumbilical adipose tissue mostly occurs during adulthood, as demonstrated by the significant increase of mean BMI after 18 years vs before 18 years. In addition, the anchoring of the umbilicus in the deep muscle fascia planes contributes to increased umbilicus depth and the creation of a horizontal fold after age 18 years. Similarly, one can observe natural horizontal folds at the abdominal level that are responsible for the horizontal deformation of the umbilicus.22 This horizontal deformation may also be involved in transforming a round-shaped umbilicus into a horizontal oval and a vertical oval umbilicus into one that is T-shaped. Impact on Surgery The secondary objective of this work was to propose adapting surgical management according to the patient’s age to optimize the cosmetic outcomes in adulthood. Although the basics of umbilicoplasty remain simple, surgical outcomes are often disappointing because they are not stable over time. Abdominal growth in children adds an additional challenge to achieving a successful surgical repair. Umbilicoplasty creates a new umbilical scar that will either not grow or grow only slightly. In addition, contractile wound healing might also occur, further reducing the degree of success. The invagination of the new umbilicus is difficult to obtain, and it tends to fade over time.4 Faced with these observations, we propose re-creation of an umbilicus that is similar in dimensions to an adult umbilicus (a little wider and with increased invagination if possible), even in young children. A nonresorbable thread is essential to suture the cutaneous flaps and anchor the umbilicus into the muscle plane. This deep anchoring is essential to sustain invagination alongside the growth of subcutaneous adipose tissue. Secondary umbilicoplasty can be proposed at any age, as soon as the child expresses the need for surgical management, but it is best to avoid the surgery during puberty because of potential wound healing issues.4 Positioning the umbilicus between one half and two thirds of the xiphoid-pubis distance is essential because this ratio hardly changes over time. Further studies evaluating the impact of growth on the position and shape of the neoumbilicus surgically created in childhood should be considered. For example, in anticipation of the initial growth-related vertical deformation followed by horizontal deformation due to the accumulation of adipose tissue around the umbilicus, one might adapt the procedure to base the shape of the neoumbilicus on the patient’s age. A horizontal oval umbilicus could be appropriate before the age of 5, a round one between the age of 5 and puberty, and a vertical oval shape in adults to corresponds to the “ideal” shape reported in the literature. (Figure 7). Figure 7. View largeDownload slide Umbilicoplasty surgical management guidelines regarding the position and shape of the umbilicus according to age. Figure 7. View largeDownload slide Umbilicoplasty surgical management guidelines regarding the position and shape of the umbilicus according to age. Study Limitations This study had several limitations. First, the comparison of nonwalking vs walking participants required collected measurements of patients lying in the supine position. Previous morphometric studies on the umbilicus have typically collected measurements with patients in a standing position, which also enabled studying how gravity affected the shape of the umbilicus. A second limitation of our study was the low enrollment of pediatric patients. More than two thirds of the patients were over 18 years of age, and if we had increased the number of pediatric participants we might have detected greater morphometric differences between these subgroups and more precisely identified the effects of abdominal growth on the umbilicus. This study begins to address the lack of descriptive morphometric studies in pediatric umbilici in the scientific literature, but additional studies are needed to provide surgical management guidelines for umbilicoplasty in congenital or acquired anomalies. CONCLUSIONS The umbilicus retains a stable position over time according to age. Despite a 2% variation in the xiphoid-pubis distance, the umbilicus is essentially in its “adult” position right from birth. The shape of the umbilicus becomes vertical due to abdominal growth before the age of 18. After the age of 18, it becomes horizontal due to the accumulation of subcutaneous periumbilical adipose tissue. Our morphometric study on the position and shape of the umbilicus does not permit proposing definitive guidelines on secondary umbilicoplasty in children. Further studies are needed to evaluate the impact of growth on the position and shape of the neoumbilicus created during umbilicoplasty in childhood. However, we can recommend the following reconstructions: a horizontal oval shape before the age of 5, a round shape between the age of 5 and puberty, and a vertical oval shape in adults. We additionally recommend that positioning be close to two thirds of the xiphoid-pubis distance before the age of 5 years and equidistant between one half and two thirds of the xiphoid-pubis distance at later ages. In addition, the invagination of the new umbilicus must be performed with caution to ensure that it will remain deep despite the accumulation of subcutaneous periumbilical adipose tissue with age. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgment The authors would like to thank the American Memorial Hospital Foundation, Inc (Boston, MA, USA) for its continuing advice and support. REFERENCES 1. Dubou R , Ousterhout DK . Placement of the umbilicus in an abdominoplasty . Plast Reconstr Surg . 1978 ; 61 ( 2 ): 291 - 293 . Google Scholar CrossRef Search ADS PubMed 2. Delpierre V , Coquerel-Beghin D , Aktouf A , Auquit-Auckbur I , Milliez PY . Biometric and morphometric analyse of the umbilicus: about 70 cases . Ann Chir Plast Esthet . 2012 ; 57 ( 6 ): 575 - 579 . Google Scholar CrossRef Search ADS PubMed 3. 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Aesthetic Surgery JournalOxford University Press

Published: Nov 8, 2017

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