The belly button, also known as the umbilicus, is a funnel-shaped scar located in the midline of the abdomen usually about 2/3s the distance between the chest and the pubic region. It is, of course, the remnant of where the umbilical cord was attached to the newborn. It is the only topographic aesthetic feature on an otherwise flat or round abdominal wall. While it has great variability in size and shape amongst humans, an inverted appearance that is not too large is desired.

In a tummy tuck, making a ‘new’ belly button is the last portion of the operation. It is new only from the perspective that it requires a skin incision through the abdominal skin flap which has been stretched down. The original stalk of the belly button is the same, its exit out through the skin is new. While a relatively small procedure in comparison to the scope of the overall tummy tuck, it is an important aesthetic feature that many patients may use to pass judgement on the results of their surgery.

When I am making a new belly button during a tummy tuck, the objectives are three-fold. First and most importantly, place the belly button in the midline directing on a vertical line between the xiphoid process and the pubis. Secondly, make the shape of the belly button vertical in orientation and not round or horizontal. This is accomplished by how the belly button is cut out from the original abdominal skin segment that was removed and the skin pattern made in the abdominal skin through which it reappears. (make it a vertical dome-shape) Lastly, keep the scar surrounding the belly button as hidden as possible by having it pulled inward.

One of the keys to accomplishing some of these tummy tuck belly button goals is fascial suture fixation. Permanent sutures are placed at various locations around the belly button from the underside of its skin to the underside of the abdominal skin and then down to the abdominal fascia. By tying these sutures down, the entire belly button area (and central abdominal region) is pulled inward creating a funnel or ‘drain in the center of the floor’ effect.

These fascial sutures also distribute the pressure on all sides of the belly button and give it a more pleasing shape. The location of these sutures also creates a vertical shape by being placed at the 12, 4 and 8 o’clock positions. This creates a favorable contour feature of the abdomen and pulls the circular belly button scars inward to a more hidden location.

While the re-creation of a belly button is the smallest portion of performing a tummy tuck, it requires finesse and attention to some details to get more than just a round ‘mushroom’ of an umbilical result. These same belly button surgery principles can be applied to revisions of a prior unsatisfactory tummy tuck result as well.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The belly button goes by a variety of names including the navel and umbilicus. Whatever it is called, it is a very recognizeable anatomic structure and is the one scar that all humans share. But that centrally located scar can have a variety of shapes which fall into two main categories, an innie and an outie. Why one develops versus the other is purely coincidental and has nothing to do with how the umbilical cord is clamped at birth. Cord clamping is done several inches away from the navel and does not affect its eventual shape.

The outer belly button can be socially bothersome for some. Because the vast majority of the population has an inne, those that have an outie can feel it is unusual and abnormal. I have had more than one patient tell me that they felt stares and ridicule as a child or teenager. Some go to great lengths to keep covered. This may bring them to seek surgical change of this abdominal ‘malformation’. The number of women (and some men) seeking an umbilicoplasty procedure has been magnified by this era of navel beautification where piercings and tattooing have become popular. Humorously, on a website dedicated to the Top 25 Celebrity Bellybuttons, not a single outie appears amongst them.

When converting an outie bellybutton to an innie requires understanding of why it appears as such. An inverted bellybutton is a tethered scar band that attachs to the fascia in the midline between the two vertically-oriented rectus abdominus muscles. These muscles are not truly united but connected by their enveloping fascia. The inne scar attaches to this fascia between the muscles. Commonly during a mini-tummy tuck using the umbilical float technique, cutting the base of the inverted belly button from the fascia will reveal a small opening and fat protrusion from the intra-abdominal cavity, demonstrating from whence it originally came.

The outie bellybutton in most cases is the result of this small hole persisting as the cut umbilical stump heals during birth. This allows a small stalk of peritoneal fat to protrude through resulting in an umbilical scar that heals with a dome due to the presence of this fat rather than an inversion. This is why you can push on an outie and make it go in, and then have it pop right back out. You are pushing this fat back inward and, sometimes if you push deep enough, you can even feel the fascial defect. Thus, every outie is in reality a ‘mini’ umbilical hernia. This also explains why a woman can have an inne which converts to an outie after pregnancy, the pressure of the intra-abdominal fetus unmasks the inherent fascial weakness at the base of the belly button.

In an outie umbilioplasty, the goal is an improved navel shape. The aesthetically attractive navel is one that is described as vertical, narrow, symmetric and with an upper hood in women. For men it is acceptable to just have a rounder inversion without a hood. The realistic goal in an umbilicoplasty is to make the inversion vertical and narrow.

The procedure can be done under either local or IV sedation anesthesia. The incision can be made either vertical through the skin dome or in a half-moon shape at its base. As soon as one goes through the skin, the protruding stalk of fat will be seen. Dissection is done around the stalk of fat to the surrounding rectus fascia. The fascial defect is isolated and the fat either amputated or pushed back inward. Several large sutures are placed across the fascial defect to approximate the fascial edges. Excess skin is then trimmed from the edges of umbilical skin and sutured down to the fascia with dermal sutures in a vertical fashion. This creates the innie shape. The skin edges now deep inside the new inne are then closed with running small dissolveable sutures. The new inner is then packed with Vaseline gauze and covered with a clear water-proof dressing. The entire umbiliplasty operation takes less than one hour.

Afterwards the only physical restriction is no working out that would stress the abdominal or stomach muscles for one month after surgery. The gauze dressing ore removed one week later. Patients report only mild discomfort in the first few days after surgery.

Converting an outie to an inne bellybutton employs the principle of a mini-umbilical hernia repair and inward skin plication as part of the umbilicoplasty. It is a very successful procedure that can help those patients feel more comfortable with the shape of this central abdominal region.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The belly button, navel, or medically known as the umbilicus, is the scar from the umbilical cord which was divided at birth. This results in a depression in the skin which is attached to the underlying muscle fascia or covering sheath of the muscles. The divided cord scar typically forms a cavity or an “innie”. In some cases, an “outie” develops due to extra skin left behind from the umbilical cord. Many people feel that an “innie” is more appealing in appearance than an “outie.”

The shape of the belly button comes from the how the scar attaches to the underlying fascia, the looseness of surrounding abdominal skin, the fat under the skin, and how flat or protuberant one’s abdomen is. As a result, belly buttons vary greatly in their size and shape. While hidden for decades, the bellybutton has more recently become an attractive and sexy physical feature with the current fashion trends which flaunt an open midriff and an exposed belly button. Its recent fashion importance is illustrated by estimates that about one-third of college women now have pierced belly buttons. I see many middle-aged women in my practice who also have such piercings, trying to appear youthful and sexy.

Attractive belly buttons have been judged to be small and vertical in orientation, or have a T shape with a thin vertical hollow capped by an upper hood of skin. Belly buttons that are horizontal or irregular, often from the effects of pregnancy, weight gain or age, or if one has an outie are considered unattractive.

Most people are not aware that there are plastic surgical techniques to sculpt the belly button, known as an umbilicoplasty. Umbilicoplasty surgery can be done alone or as a necessary part of most tummy tuck surgeries. When done alone, it can be done under local anesthesia as an outpatient procedure. All incisions are placed inside the belly button. The skin inside the belly button is reshaped, and often small amounts are removed to help the reshaping. The skin is then sculpted by sutures into a newly shaped belly button. This result will be permanent once healed. One can return to work the same day and begin exercises in just a few days. All sutures inside the reshaped belly button are dissolveable. In some cases, usually where a protrusion exists, a small hernia is present which can be fixed at the same time. In these cases, I prefer to go to the operating room and perform the procedure under general anesthesia. Umbilical hernias are often covered by one’s medical insurance.

As part of a full tummy tuck where the skin and fat cutout goes above the exiting belly button, a new belly button must be formed after the tummy tuck is closed. A new outer hole is made (I prefer an inverted heart-shape pattern) and the stalk of the belly button is brought up and sewn to it. I like to keep the belly button stalk short so that when it is sewn to the outer skin it pulls down, creating a ‘drain in the center of the floor’ effect which helps in making a more youthful appearance.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

As plastic surgery has worked its way into the mainstream of American society, it is no surprise that procedures are being done today that were not imaginable a mere ten years ago. And I am not referring here to surgery wonders of technology and scientific advancement (although that exists also), I am talking about what patients desire to have done. This is a reflection and commentary on contemporary American culture, not necessarily how far the science of plastic surgery has come.

 
As I talk with friends and colleagues about some of the plastic surgery procedures that I do today, I have come to realize that some of them may be considered ‘unusual’ . Certainly, some of them are different than traditional perceptions of plastic surgery. Many are relatively minor procedures that can be performed in the office and probably reflect the trend toward treating smaller concerns. They are the opposite of bariatric plastic surgery, for example, where a new subspecialty of plastic surgery has developed to treat the sequelae of gastric bypass and massive weight loss patients. The emergence of larger plastic surgeries and big procedures doesn’t occur very often but every few decades. But the emergence of more minor plastic surgery procedures occurs much more frequently. Here is a list of my unusual plastic surgery procedures that have emerged and become popular in the past decade.

 
Buttock Implants/Fat Injections - The appeal of a larger, more rounded buttocks is certainly a body image of recent note. Whether done by transferring fat from one body part to another or by an implant placed through an incision near the tailbone, the desire for buttock enhancement could not have been envisioned ten or twenty years ago. There is actually a great number of patients who would like buttock reduction but no single good procedure exists for that problem.

 
Labial Reduction - Whether due to discomfort from rubbing on clothes or during inetrcourse or simply to ‘look better’, reducing the size of a woman’s labia is now a common procedure. One would never have thought that such a concealed part of the anatomy would create a demand for treatment. A very simple and effective procedure, labial reduction restores the outer appearance of the vagina to a more youthful appearance.

 
Earlobe Reduction/Enhancement - As woman age and with the lifelong use of ear rings, the ear lobes will frequently get longer. The size of the ar lobe can easily8 be reduced in the office and it is a procedure that I often do at the same time of a facelift. Aging may also make one’s earlobes get quite thin and almost shriveled in appearance in very thin females. Injectable fillers, such as Juvaderm or Radiesse, can give an immediate rejuvenation effect to the earlobes that may last as long as a year.

 
Eyebrow/Eyelash Transplants - The science of hair transplantation has evolved to the point that single hair (follicle) transplants are now routinuely done in scalp hair restoration. It is quite logical that single follicular transplantation be applied to very small areas such as the eyebrow and even the eye lashes. The alternatives of permanent makeup, colored pencils, and false eyelashes made opting for actual hair tranplants a difficult decision. But some few patients do.

 
Umbilioplasty - While every full tummy tuck patient gets a new bellybutton (umbilicus), some non-tummy tuck patients want one also. Most commonly, it is to change an outie to an inne belly button.

 
Nipple Reduction/Nipple Enlargement - I have seen it both ways. The concern of large nipples is that they can be very visible through clothes…and at all times. Reducing the size of the nipple is a simple procedure and some women may lose a little sensation. Most recently, I have started to some men that want their nipples reduced also! Conversely, nipple enlargement or enhancement is about changing an inverted nippled (which is turned inward) to one that has some outward projection. While not quite as predictable (long-term result) as nipple reduction, the nipple can be released and brought more outward.

 
Corner of Mouth Lift - The downturning of the corners of one’s mouth with age gives a sad or angry appearance. A simple procedure in which a small amount of skin is removed and the corners lifted up and the mouth line leveled gives a nice and subtle improvement. Such a procedure is a simple office operation or is often done as part of a facelift. This is actually an old procedure that has now been ‘reinvented’ or rediscovered.

One wonders what this list will be in another ten years!

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis