ABSTRACT
Background
Delayed abdominal wound healing remains a common complication following abdominally based autologous breast reconstruction. We hypothesized that the type of umbilical inset incision impacts the incidence of delayed wound healing due to differential disruption of abdominal wall vascularity, particularly in the infraumbilical region.
Methods
A retrospective review was conducted of all patients undergoing abdominally based autologous breast reconstruction at a single center between 2014 and 2021. The primary outcome was delayed abdominal wound healing, classified as major (requiring readmission or reoperation), minor (managed with outpatient care, antibiotics, or debridement), or both. Umbilical inset incision type was evaluated as a predictor using univariate and multivariate analysis.
Results
Four hundred and eighty‐eight patients and 791 flaps were included. Patients were on average 51 ± 9 years old and had a median body mass index of 28 (IQR 7) kg/m2. The most used umbilical incision was an elliptical incision (193, 40%) followed by vertical (141, 29%), inverted‐U (30, 6%), other (39, 8%), and unknown (81, 17%). Abdominal wound healing complications occurred in 63 (13%) patients. The incidence of abdominal wound healing complications was lowest with elliptical incisions (p < 0.001). In a multivariate regression model controlling for age, BMI, diabetes, smoking history, and flap weight, umbilical incision predicted abdominal wound healing complications, with inverted‐U and vertical incisions conferring higher odds of abdominal wound healing complications (OR 5.9, 95% CI [1.6, 20.8] and OR 4.6, 95% CI [2.0, 11.4], p < 0.05) as compared to elliptical incisions.
Conclusion
Abdominal wall vascularity likely plays a critical role in donor site healing following autologous reconstruction. In this large cohort, inverted‐U and vertical umbilical inset incisions were associated with the highest rates of wound healing complications.
Keywords: breast, DIEP, free flap, microsurgery, umbilicus, wound healing
1. Introduction
Abdominally based autologous breast reconstruction (ABR), particularly using perforator flaps such as the deep inferior epigastric perforator (DIEP) flap, has become a mainstay in postmastectomy reconstruction due to its durability, natural aesthetic outcome, and preservation of muscle function (Bennett et al. 2018). Reconstruction with these flaps is preferred by some women compared to implant‐based breast reconstruction (IBBR) (Liu et al. 2014). However, donor site morbidity, including abdominal wall hernia/bulge and delayed abdominal wound healing, remains a relatively common and significant complication that can adversely affect patient satisfaction and recovery time (Mortada et al. 2022; Tomouk et al. 2017).
Delayed abdominal wound healing is a challenging problem that is frustrating for patients. Dressing changes and draining wounds can be bothersome and disruptive to patient lives for a long period of time depending on the size of the wound. These wounds frequently occur in the midline of the abdomen, which is the portion of the abdominal skin flap that is under the most tension after closure and furthest from the remaining abdominal wall blood supply. This area is also directly inferior to the inset of the neo‐umbilicus (Fisher et al. 2020). During the procedure, the process of umbilical transposition requires surgical manipulation that may compromise the vascularity of the surrounding abdominal wall, decreasing its ability to heal and leading to dehiscence and wound formation. Various umbilical inset incision types, such as diamond, elliptical, vertical, and inverted‐U, are used based on surgeon preference and patient anatomy, but limited data exist comparing their impact on donor site wound healing (Hespe et al. 2021; Lesavoy et al. 2012; Kurt Yazar et al. 2019; Ahmed et al. 2024).
Previous studies have identified factors such as BMI, smoking status, diabetes, and flap type as predictors of delayed wound healing (Huang et al. 2024). However, the contribution of the type of umbilical inset incision to this outcome has not been well characterized. While defatting of the periumbilical region may be performed regardless of incision design to improve aesthetic contour, the incision type represents a reproducible technical variable that may correlate with the degree of local tissue manipulation and potential disruption of periumbilical perforators. This study aims to evaluate the relationship between umbilical inset incision type and abdominal wound healing complications in a large cohort of patients undergoing abdominally based ABR at a single high‐volume academic center.
2. Methods
2.1. Study Design and Patient Selection
A retrospective cohort study was conducted of all consecutive patients who underwent abdominally based ABR at NYU‐Langone Health between January 2014 and December 2021. Eligible patients were identified through a review of institutional medical records. Inclusion criteria included patients undergoing free abdominally based ABR by one of the senior authors of this study (JPL, VT, MC, NK, OC). Exclusion criteria included all patients not undergoing free abdominally based ABR, including IBBR or ABR with an alternative flap.
2.2. Data Collection and Outcomes Measures
Demographic and clinical data were extracted from electronic medical records, including age, body mass index (BMI), smoking history, diabetes status, neoadjuvant or adjuvant chemotherapy, radiation therapy, and flap type. Surgical variables included type of mastectomy (nipple sparing vs. skin sparing), laterality of reconstruction (unilateral vs. bilateral), timing (immediate vs. delayed), and umbilical inset incision type. Umbilical inset incisions were categorized into four groups based on operative reports: elliptical, inverted‐U, vertical, and other. The degree of periumbilical defatting or subcutaneous undermining was not consistently documented in operative reports and therefore could not be quantified; consequently, incision design was used as the primary technical variable for analysis.
The primary outcome was delayed abdominal wound healing, defined as any disruption of the abdominal donor site incision requiring additional intervention after postoperative Day 14. Wound complications were further classified as major—defined as any complication requiring readmission or reoperation—and minor—defined as any complication requiring outpatient antibiotics, procedures, or wound care. The incidence of full‐thickness umbilical necrosis was also recorded as a secondary outcome.
2.3. Statistical Analysis
Descriptive statistics were reported as mean ± standard deviation for normally distributed continuous variables and median with interquartile range (IQR) for non‐normally distributed continuous variables, and as frequency and percentage for categorical variables. The association between umbilical inset incision type and delayed wound healing was first evaluated in univariate analyses using Pearson's chi‐square and Fisher's exact tests for categorical variables and analysis of variance and Mann–Whitney tests for continuous variables. Factors found significant on univariate analysis and other clinically relevant variables were then analyzed in a multivariate logistic regression model. All statistical analyses were performed using R Statistical Software (version 1.1.447; R Foundation for Statistical Computing, Vienna, Austria) and p < 0.05 was considered statistically significant.
3. Results
3.1. Patient Demographics
Four hundred and eighty‐eight patients and 791 flaps were included. Patients were on average 51 ± 9 years old and had a median BMI of 28 (IQR 7) kg/m2. Most reconstructions were immediate (557 breasts, 71%) and utilized a DIEP flap (704, 90%), followed by msTRAM (69, 9%), SIEA (6, 0.8%), and TRAM (6, 0.8%). Four patients had their umbilicus excised due to concerns about viability, and were excluded from the subsequent analyses. Among the remaining 484 patients, 193 (40%) had their umbilicus brought through an elliptical incision, followed by vertical (141, 29%), other (39, 8%), and inverted‐U (30, 6%). The other category consisted of a variety of miscellaneous techniques including cruciate, cross, x‐pattern, transverse, and modified‐x (Table 1). In the remaining 81 (17%) patients, the umbilical incision type was unknown. There were no patient demographics or comorbidities that were associated with choice of umbilical incision type.
TABLE 1.
Incision types and details.
| Incision type | Details |
|---|---|
| Elliptical incision | Midline vertical incision with removal of skin in an elliptical fashion |
| Inverted‐U incision | Semicircular incision with inferior skin flap |
| Vertical incision | Midline vertical incision without removing skin |
| Other | Includes cruciate, cross, x‐pattern, transverse, and modified‐x |
3.2. Outcomes
Abdominal wound healing complications occurred in 63 (13%) patients. In nine (2%) of patients, abdominal wound healing complications were considered “major,” and in 58 (12%) patients, they were considered “minor.” The incidence of abdominal wound healing complications was highest with vertical incisions (21%), followed by inverted‐U (20%), other (13%), and elliptical (8%, Figure 1, p < 0.01). When considering other patient factors related to delayed abdominal wound healing, only age and smoking history were significant: patients who had abdominal wound healing complications were 2.9 years older (53.2 vs. 50.3 years, p = 0.01) compared to those who did not have complications and patients who were ever smokers had higher complications than those who never smoked (18% vs. 11%, p = 0.026) (Table 2). When considering flap‐level characteristics related to delayed abdominal wound healing, only flap weight was significant, with higher flap weight in those who had complications (650 vs. 576 g, p = 0.002) compared to those who did not (Table 2).
FIGURE 1.
Abdominal wound healing by umbilical incision type.
TABLE 2.
Abdominal wound healing by patient demographics and operative characteristics.
| Patient‐level characteristics | Abdominal wound healing complication? | p | ||
|---|---|---|---|---|
| No (N = 421) | Yes (N = 63) | Total (N = 484) | ||
| Age (years), mean (SD) | 50.35 (8.60) | 53.24 (8.06) | 50.73 (8.58) | 0.010 |
| BMI (kg/m 2 ), median (Q1, Q3) | 27.51 (24.29, 30.87) | 28.53 (25.55, 31.86) | 27.83 (24.35, 31.24) | 0.072 |
| BMI | 0.095 | |||
| Underweight (< 18.5) | 1 (0.2%) | 0 (0.0%) | 1 (0.2%) | |
| Normal (18.5–24.9) | 123 (29.3%) | 13 (20.6%) | 136 (28.2%) | |
| Obese I (30–34.9) | 95 (22.6%) | 14 (22.2%) | 109 (22.6%) | |
| Obese II (35–39.9) | 31 (7.4%) | 11 (17.5%) | 42 (8.7%) | |
| Obese III (≥ 40) | 9 (2.1%) | 0 (0.0%) | 9 (1.9%) | |
| Overweight (25–29.9) | 161 (38.3%) | 25 (39.7%) | 186 (38.5%) | |
| Smoking history | 0.026 | |||
| Ever smoker | 138 (33.3%) | 30 (47.6%) | 168 (35.1%) | |
| Never smoker | 277 (66.7%) | 33 (52.4%) | 310 (64.9%) | |
| Race | 0.836 | |||
| Nonwhite | 124 (45.6%) | 22 (44.0%) | 146 (45.3%) | |
| White | 148 (54.4%) | 28 (56.0%) | 176 (54.7%) | |
| Diabetes | 0.343 | |||
| No | 388 (92.4%) | 56 (88.9%) | 444 (91.9%) | |
| Yes | 32 (7.6%) | 7 (11.1%) | 39 (8.1%) | |
| Hypertension | 0.204 | |||
| No | 324 (77.1%) | 44 (69.8%) | 368 (76.2%) | |
| Yes | 96 (22.9%) | 19 (30.2%) | 115 (23.8%) | |
| Flap‐level characteristics | Abdominal wound healing complication? | p | ||
|---|---|---|---|---|
| No (N = 679) | Yes (N = 109) | Total (N = 788) | ||
| Flap weight, median (Q1, Q3) | 576.00 (409.00, 745.00) | 650.00 (513.00, 876.50) | 592.00 (425.00, 768.00) | 0.002 |
| Flap type | 0.090 | |||
| DIEP | 610 (90.1%) | 94 (87.0%) | 704 (89.7%) | |
| msTRAM | 59 (8.7%) | 10 (9.3%) | 69 (8.8%) | |
| SIEA | 3 (0.4%) | 3 (2.8%) | 6 (0.8%) | |
| TRAM | 5 (0.7%) | 1 (0.9%) | 6 (0.8%) | |
| Mesh used? | 0.805 | |||
| Yes | 70 (10.5%) | 12 (11.3%) | 82 (10.6%) | |
| No | 595 (89.5%) | 94 (88.7%) | 689 (89.4%) | |
Umbilical incision was not significantly associated with the incidence of major or minor abdominal wound healing complications. Five patients had documented umbilical necrosis; 3 (60%) had elliptical umbilical incisions and 2 (40%) vertical (p = ns). Only BMI was a predictor, with a higher BMI observed among those who had umbilical necrosis compared to those who did not (34 vs. 28, p = 0.028).
In a multivariate regression model predicting abdominal wound healing complications using covariates pertinent to wound healing such as age, BMI, diabetes, smoking history, and flap weight, umbilical incision was again found to be a significant predictor of wound healing complications. Compared to elliptical incisions, inverted‐U incisions conferred a higher odds of abdominal wound healing complications (OR 5.9, 95% CI [1.6, 20.8], p = 0.01) as did vertical incisions (OR 4.6, 95% CI [2.0, 11.4], p < 0.01, Figure 2). No other demographic or operative variables were significant.
FIGURE 2.
Predictors of abdominal wound healing including umbilical incision.
4. Discussion
Delayed abdominal wound healing remains a notable source of morbidity following abdominally based ABR. In this large single‐institution series of patients undergoing abdominally based ABR, we found that umbilical inset incision type significantly impacts the risk of delayed abdominal wound healing. The inverted‐U and vertical incisions for umbilical inset were associated with the highest complication rates. Our findings suggest that the geometry of the umbilical inset incision plays an important role in abdominal wall vascularity and postoperative healing.
These results add nuance to the existing literature on abdominal donor site outcomes, which has primarily focused on flap type, BMI, smoking, comorbidities, and dressing type as predictors of wound complications (Huang et al. 2024; Timmermans et al. 2018; Haas et al. 2025). Our study highlights the importance of technical decision making during the operation as a modifiable risk factor, and few studies to date have examined this variable in isolation. Notably, elliptical incisions demonstrated lowest rates of delayed healing. This may reflect a larger area of skin excised, less need for subcutaneous tissue dissection and undermining, and preservation of periumbilical abdominal blood vessels supplying the incision, or simply reduced tension during closure. We acknowledge that many surgeons perform some degree of periumbilical defatting regardless of incision design to improve the aesthetic contour of the umbilicus. However, incision geometry may still influence the extent of tissue manipulation required to deliver and inset the umbilicus, which could secondarily affect local perfusion. Although full‐thickness umbilical necrosis was rare (< 1%), it underscores the vascular sensitivity of this central zone and the need for careful planning when selecting incision design. Other studies have also introduced the neo‐umbilicus as standard technique for DIEP closure without any wound healing issues (Linder and Fansa 2023).
The vertical and inverted‐U incisions, while providing improved visualization during umbilical inset and a favorable aesthetic outcome, involve incisions with a smaller working space and greater need for tissue dissection and undermining in order to facilitate inset, as compared to the elliptical incisions. This may involve additional subcutaneous “defatting” or undermining to facilitate inset, which has the potential to compromise small periumbilical perforators and increase the relative “watershed” zone caudal to the umbilical inset (Figure 3). Because the degree of defatting was not quantified in this retrospective analysis, this mechanism should be interpreted as a proposed explanation rather than a directly measured variable (Joseph et al. 2016). This “watershed” zone corresponds to the abdominal zone I, which is potentially also at increased risk of wound formation due to tension from closure (Nergård et al. 2021). Supporting our theory, Fisher et al. found that selective umbilical ablation in high‐risk patients at the time of abdominal flap harvest resulted in significantly fewer donor site wound complications (Fisher et al. 2020). Haddock et al. have also written about the reduction in abdominal wounds with selective umbilical excision and delayed umbilicoplasty in DIEP patients (Haddock et al. 2020). While aesthetic outcomes were not the focus of this study, preoperative and postoperative photographs of patients demonstrate that all umbilical incision types can yield a natural‐appearing result (Figure 4). Surgeons have evolved in their choice of umbilical incision type over time, and no single design has consistently been demonstrated to be superior with respect to aesthetic outcomes.
FIGURE 3.
Conceptual illustration demonstrating the proposed caudal “watershed” zone associated with umbilical inset incision design, comparing (A) elliptical incisions and (B) vertical and inverted‐U incisions. This figure represents a hypothesized mechanism of altered perfusion and is not based on direct perfusion measurements.
FIGURE 4.
Representative photographs of umbilical inset types.
In patients at elevated risk for wound healing complications, such as those with elevated BMI or concerning comorbidities, delayed umbilicoplasty may offer a strategic alternative to immediate umbilical inset during DIEP flap reconstruction. Importantly, this is not an inferior long‐term aesthetic choice. Haddock et al. have reported good aesthetic outcomes from delaying umbilicoplasty and report that individuals with delayed umbilicus reconstruction were rated to be significantly more attractive than individuals with preservation of the native umbilicus and no umbilicus across similar BREAST‐Q patient satisfaction scores (Haddock et al. 2024). By deferring the umbilical reconstruction to a secondary stage, perfusion to the central abdominal wall can be maximized during the critical healing window, potentially reducing the risk of delayed wound healing and umbilical necrosis. Although this approach necessitates a minor secondary procedure, many of these patients are already receiving minor secondary breast revisions, and the umbilicoplasty could easily be performed at this time (Smith et al. 2023; Nelson et al. 2019). It is important to note that umbilectomy is not without complication, as these patients have been found to be at a higher risk of seroma for which progressive tension sutures are recommended during abdominal closure to reduce dead space (Lakatta et al. 2024).
Limitations of this study include its retrospective design and the possibility of surgeon bias in incision selection. Additionally, we did not standardize postoperative care protocols or wound care interventions across the study period, which could influence minor complication rates. Aesthetic appraisal of the umbilicus once healed was also not included in this study. Finally, although the cohort size is large, the relatively low event rate of a complication limited the statistical power of subgroup comparisons. Despite these limitations, this is one of the largest studies to date evaluating the impact of umbilical inset incision type on abdominal donor site healing. Our findings support a more critical approach to umbilical inset incision planning, particularly in high‐risk patients or those with comorbidities that predispose to poor healing.
5. Conclusions
In this large retrospective cohort, umbilical inset incision type emerged as a significant predictor of delayed abdominal wound healing following abdominally based ABR. Inverted‐U and vertical incisions were associated with the highest rates of abdominal wound complications, although the precise mechanism may relate to incision geometry, associated tissue manipulation, or both. Surgeons should consider the vascular implications of umbilical inset incision design when planning flap harvest and closure, particularly in patients at elevated risk for wound healing complications. Preference for an elliptical incision may reduce morbidity and optimize donor site outcomes.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors have nothing to report.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and institutional restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy and institutional restrictions.