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1Division of Plastic and Reconstructive Surgery, 2The Hernia Center, 3Department of Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina, USA Correspondence: Dr James L Fowler, Division of Plastic and Reconstructive Surgery, Department of Surgery, 701 Grove Road, Greenville, South Carolina 29605, USA. Telephone 864-455-7886, fax 864-455-1320, e-mail [email protected] Umbilical hernias are occasionally present in patients desiring abdominoplasty. Current data strongly support the use of synthetic mesh when repairing ventral hernias >3 cm in diameter. Longterm data demonstrate improved recurrence rates with mesh, even for smaller umbilical defects (1,2). With simultaneous abdominoplasty, an open approach to umbilical herniorrhaphy is preferred due to the improved exposure; however, dissection of an umbilical hernia at the fascial level can damage the umbilical perforating vessels, resulting in necrosis and loss. During abdominoplasty, circumferential skin incision around the umbilicus divides the subdermal vessels, making it dependent on the deep inferior epigastric supply. This blood supply originates from the deep inferior epigastric artery, traverses the rectus abdominus muscle and continues through the anterior rectus fascia. Traditional hernia repair, as an onlay or subfascial mesh placement, risks deep umbilical blood flow. Unilateral approach with dissection in the preperitoneal plane enables preservation of unilateral and, potentially, bilateral deep perfusion because the dissection plane is deep to the posterior rectus sheath. We present a patient with a defect 3 cm in size at the umbilicus hernia and diastasis presenting for simultaneous open mesh umbilical hernia repair and abdominoplasty (Figure 1). Umbilical perfusion was maintained during open repair with preservation of unilateral deep perforating vessels and placement of mesh in a plane consisting of both the preperitoneal and retrorectus space.