The previous transverse incision had a widened unstable scar which was marked. An elliptical incision 8 x 5 cm, was made with # 10 blade and then carried down to the fascia with electrocautery. Single skin hooks are placed in the neo-umbilicus and an 11 blade is used to incise circumferentially around the umbilicus using the old scar. Sharp dissection is used to bevel away from the umbilical stalk to preserve an adequate vascular pedicle. Umbilicus is then freed down to the level of the fascia and marked with a stitch for easy retrieval
Fasciocutaneous flap is raised superiorly with careful attention to the preservation of the umbilicus. Flap is raised to the level of the subxiphoid process and costal margins. Laterally, intercostal perforators are preserved. Once the flap has been raised, the sinus tract skin was excised with blade and cavity was excited completely with bovie, this was found to go down through the anterior rectus sheath into the rectus muscle. At the end of the excision a defect in the anterior rectus sheath measuring 7x5 cm was then repaired with #1 Stratafix suture, the patient is placed in beach chair position (with the bed flexed gently). Hemostasis is obtained and the abdomen is irrigated with warm normal saline.
Two #15 French Blake drains was placed in the subcutaneous plane and brought out through the Mons and secured with 3-0 nylon. New location of umbilicus was marked through the sinus excision site and umbilicoplasty was inset with 4-0 PDS deep dermal and horizontal mattress 5-0 nylon, ensuring that there is no twisting of the stalk.
The fasciocutaneous flap was advanced for a distance of 35 x 25 cm and the incision was closed in three layers with 2-0 PDS approximating the scarpa's fascia and in a tri-stitch centrally anchoring to the abdominal wall fascia. Then,Dermis approximated with 3-0 PDS in a deep dermal fashion and a running subcuticular 3-0 Stratafix Spiral double armed