Umbilical Stalk Research Articles

A Three-Step Approach (MUC) for Umbilicoplasty: Creating a Deep Umbilical Depression in Lipoabdominoplasty.

Various methods of umbilicoplasty have been proposed to create an aesthetically pleasing umbilicus. However, following conventional lipoabdominoplasty, some patients, particularly those with a thin layer of abdominal fat, may exhibit a shallow navel. A modified umbilicoplasty with a three-step approach was performed between Jan 2019 and Mar 2023. The three-step procedure included multiple plications, umbilical stalk fixation, umbilical insertion and central gathering (MUC). Patients were followed up for at least 6months. Umbilical depth and complications were recorded. A total of 36patients were performed with MUC umbilicoplasty, with a mean age of 36.1years. Patients were satisfied with umbilical appearance. The average depth of the navel after MUC procedure was 1.8±0.3cm. A patient developed a hypertrophic scar in the umbilicus, which was treated with an intralesional injection of triamcinolone acetonide. No other complications were observed. The MUC approach to umbilicoplasty provides a deep umbilical depression with minimal scars. This three-step procedure is particularly beneficial for patients with a thin layer of abdominal fat. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does Concomitant Umbilical Hernia Repair Increase the Risk of Complications in Abdominoplasty? A Propensity Score Matched Analysis.

Patients seeking cosmetic abdominoplasty often have umbilical hernias. Optimal management and safety of concomitant umbilical hernia repair with abdominoplasty is not well described. The goal of this study was to compare complication rates following abdominoplasty with or without umbilical hernia repair. A retrospective propensity score matched cohort study of patients who underwent an abdominoplasty at Massachusetts General Hospital was performed. Direct umbilical hernia repair was performed by making a fascial slit inferior or superior to the umbilical stalk. The fascial edges were approximated with up to three 0-Ethibond sutures (Ethicon, Raritan, NJ) from the preperitoneal or peritoneal space. Propensity score matching was used to adjust for confounding variables. The authors identified 231 patients with a mean [standard deviation] age of 46.7 [9.7] years and a mean BMI of 25.9 [4.4] kg/m2. Nine (3.9%) had diabetes, 8 (3.5%) were active smokers, and the median number of previous pregnancies was 2. In total, 223 (96%) had a traditional abdominoplasty, whereas 8 (3.5%) underwent a fleur-de-lys approach. Liposuction was performed on 90%, and 45.4% underwent simultaneous breast or body contouring surgery. The overall complication rate was 6.9%. Propensity scores matched 61 pairs in each group (n = 122) with closely aligned covariates. There was no significant difference in total complication rates between abdominoplasty alone vs abdominoplasty with hernia repair. There were no cases of skin necrosis or umbilical necrosis in either group. Performing umbilical hernia repair with abdominoplasty is safe when utilizing the technique reported in this series.

Rectus Muscle Plication in Mini-abdominoplasty with Umbilicus Preservation.

Diastasis recti is a frequent problem that women, particularly, experience after pregnancy. It is an abdominal wall defect in which there is more than 2 cm separation between the abdominal rectus muscles. Aside from being repaired most commonly with a full abdominoplasty, in some cases, diastasis might present with minimal excessive adipocutaneous tissue, thus requiring a mini-abdominoplasty. Because umbilical transposition is not needed in that latter scenario, diastasis repair is only possible by ligating and cutting the existing umbilical stalk to be able to have a direct clear access to the supraumbilical linea alba. However, detaching the umbilical stalk will most certainly lead to the displacement of the umbilicus inferiorly. To overcome this problem, we performed a modified mini-abdominoplasty technique, which repairs the recti diastasis, keeps the umbilical stalk in place, and leaves behind a mini-abdominoplasty scar, thus providing a more cosmetically appealing result in addition to a radical solution to the defect. Moreover, this technique can be performed by any qualified plastic surgeon under basic operating settings.

Influence of birth weight, sex and disinfection on the involution of umbilical structures in calves.

Umbilical disinfection for calves is often recommended, but scientific studies do not always show a positive effect on disease prevention. In addition, there is little to no metric data on umbilical involution or on factors influencing the size of umbilical structures. Therefore, the aim of this study was to investigate the physiological involution of umbilical structures and the effect of two different umbilical treatment methods. After birth, calves' umbilical cord stumps were treated witheither an iodine tincture (n = 43) or an antibiotic spray (n = 41) or were left untreated (n = 42). On days 0, 1, 3, 7 and 14 after birth, calves were examined and external umbilical structures were measured. In addition, on day 14 (±2 days), a sonographic examination of umbilical structures was conducted. The treatment applied had no significant effect on the size of umbilical structures during the first 14 days of life. However, the diameter of the umbilical stalk was larger in male calves and calves with a higher birth weight than in female calves and calves with a lower birth weight. The study was carried out on only one farm, so the generalisability of the findings may be limited. Umbilical structures showed significant involution over time and were influenced by birth weight and sex.

Natural Umbilicoplasty Without Visible Scarring: An Easily Taught and Reproducible Technique

Abstract Goals/Purpose The umbilicus is a focal point in an abdominoplasty, but the variety of published techniques can create confusion when deciding which incision is optimal for inset. Recently, an excellent technique was described that results in a scarless caudal umbilicus with superior hooding (2022 Samargandi). A similar technique has been used by this abstract’s senior author (J.G.) for over 20 years and has subsequently been implemented in our residency training. The inset is accomplished through an inverted-V incision in the abdominoplasty flap. The technique avoids excessive vertical tension on the abdominoplasty closure, a complicating factor of aggressive abdominoplasty advancement that can lead to vascular compromise in the inferomedial aspect of the flap. Insetting the umbilicus prior to resection of this inferior excess can allow for greater advancement of the abdominoplasty and decreased risk of flap over-resection. Methods/Technique The umbilical inset through an inverted-V incision in the abdominoplasty flap has been performed in all the senior author’s (J.G.) patients over the past 20 years. Following inferior wedge resection of the native umbilical stalk, the apex of the inferiorly based (inverted-V) flap is sutured to the dermis of the umbilical stalk and to the rectus fascia. The superolateral margins of the native umbilicus are approximated to the abdominoplasty skin. The sole deep suture inferomedially tethers the most visible aspect of the umbilicoplasty to the abdominal wall. The inverted-V incision in the abdominoplasty flap prior to low transverse closure increases the vertical tension on the flap and enables a safe resection of the inferior excess tissue. This technique has been taught to all residents in our training program and quickly incorporated in our abdominoplasty closures. Results/Complications Incising the inverted-V in the abdominoplasty flap eases tension on the low transverse wound closure. All residents have been able to independently perform this technique. Among the patients who have undergone this technique, none have experienced necrosis of the inferior aspect of the abdominoplasty flap or of the umbilical stalk base. As gravity encourages relaxation of the abdominoplasty skin, the superior aspects of the umbilicoplasty are overshadowed by the resulting superior hooding. This technique yields a natural-appearing umbilicus with adequate depth and a camouflaged inferior inset. Our patients frequently comment on the “untouched” appearance of their umbilici. No patients have required revisions of the umbilical inset, and none have experienced necrosis of the inferomedial aspect of the abdominoplasty flap. Residents have reported quick integration and predictable umbilical positioning with this technique. Conclusion The technique is easy to teach and can be rapidly incorporated by surgeons in practice, as well as in training. We are excited to see this technique having recently been described and feel strongly that its widespread adoption should be entertained. The inset during abdominoplasty flap advancement, prior to final resection of the inferior excess skin, can simplify decision-making for where to position the umbilicus and how much inferior excess tissue to resect. In addition to realizing the aesthetic superiority of this umbilicoplasty technique, it is important to proclaim the benefit of insetting prior to final abdominoplasty closure and the intuitive sense with which the new position of the umbilicus can be determined.

Umbilical Complications following DIEP Flap Breast Reconstruction: Demonstrating the Added Benefit of Preoperative Imaging.

Despite the umbilicus being an essential aesthetic unit, current literature on umbilical outcomes following abdominally based breast reconstruction is limited. In this study, the authors aim to elucidate the incidence and predictors of umbilical complications following deep inferior epigastric perforator (DIEP) flaps, with a particular emphasis on past abdominal surgery by type and measures that can be obtained easily from preoperative imaging. An institutional review board-approved retrospective review of 258 patients who underwent DIEP flap reconstruction from 2011 through 2020 was performed. Patient demographics, preoperative laboratory studies, and intraoperative factors were appraised. Preoperative computed tomographic angiography or magnetic resonance angiography was used to measure umbilical stalk height (SH), abdominal wall thickness (AWT), and total fascial diastasis. Patients with and without perfusion-related umbilical complications were compared. Forty patients (15.5%) developed umbilical complications, including 20 patients with epidermolysis or scab, 12 with dehiscence, and 14 with partial necrosis. Patients with complications had a significantly higher rate of hypertension, previous abdominal midline incision, more lateral perforators per flap, longer umbilical stalk, and larger SH/AWT ratio ( P < 0.05). Logistic regression revealed that SH ( P = 0.006) and SH/AWT ratio ( P < 0.001) were the only significant predictors, with the latter having a greater area under the receiver operating characteristic curve (area under the curve, 0.79; P < 0.001). Radiographic measurements of umbilical SH and SH/AWT ratio reliably predict the occurrence of umbilical complications, with the ratio having a more robust predictive ability. The authors propose the use of routine preoperative imaging to identify high-risk patients who may benefit from prophylactic measures. Risk, III.

A Three-Dimensional Printed Tool for Precise and Easy Umbilical Identification during Abdominoplasty.

The umbilicus, albeit small, holds significant aesthetic value as the focus of the abdomen.1 The attention paid to this structure during abdominoplasty is of high importance and it can be challenging or time-consuming to relocate the umbilical stalk without efficient tools or techniques. The authors propose a simple technique that uses an inexpensive, three-dimensional printed tool to permit quick and accurate location of the umbilical stalk before creation of the opening for the new umbilicus. The tool resembles a hollow, bottomless pyramid with a 3.5 cm base length. A pyramidal design offers an apex that can be palpated without collapsing under pressure. Its hollow quality allows lateral collapsibility for easy removal. The tool has suture tabs and slots to pass a suture through and allow for securing to the fascia. The tools were printed on an Original Prusa SL1 3D printer using 85A TPU Flexible Filament 1.75 mm with 0.3 mm layer at 465ºF. The tools were steam-sterilized with appropriate controls in autoclave. Versions of the tool with adjusted dimensions were used in heavier patients whose skin thickness necessitated a more prominent marker of the enclosed umbilical stalk. After muscle plication, the tool was placed on top of the umbilical stalk, enclosing it. A single 3-0 polydioxanone suture stitch was secured through the pyramid’s slots and suture tabs. [See Video 1 (online), which demonstrates the pyramid enclosing the umbilical stalk.] The superior abdominal skin flap was then lowered into position, trimmed, and secured inferiorly at the suprapubic incision site with sutures. The location for the opening of the new umbilicus was then attempted through palpation along the abdominal skin flap’s midline. [See Video 2 (online), which demonstrates palpation and detection of the tool.] The concealed apex was definitively located where the opening for the new umbilicus was created. The tool’s securing suture was removed and the collapsible sides were pinched in order to remove the tool easily from the body. [See Video 3 (online), which demonstrates the tool’s flexibility during extraction from the opening.] The umbilical stalk was in the exact spot of the new umbilicus, which was inset in the usual fashion. The tool was discarded after a single use. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"The tool is sutured and secured to fascia around the umbilical stalk. In this video, the surgeon demonstrates the first step in using the three-dimensional printed tool during an abdominoplasty. He has sutured the tool to the fascia around the exposed umbilical stalk.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_e5cicw3s"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"Vertical stability aids in palpation and detection. In this video, the surgeon demonstrates how the tool is resistant to a reasonable amount of vertical pressure. This vertical stability is advantageous when detecting the concealed apex of the tool during palpation of its overlying abdominal skin, which has since been lowered back into its natural position.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_l7b4dzpe"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3.","caption":"Horizontal flexibility allows for easy extraction from the abdomen. In this video, the surgeon demonstrates the tool’s horizontal (or lateral) flexibility. It collapses easily and deforms laterally when pressure is applied only to its sides. Once the new umbilical opening is created, the tool has served its purpose and can now be pinched laterally in order to extract it easily from the created hole.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_fhdte4p6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Other tools with a similar purpose are not as easily produced or effective in diverse patient populations, unlike our tool’s thoughtful design and open source that readily allows customization.2,3 This tool was used successfully in 12 abdominoplasties using progressive tension sutures.4 There were no complications or infections from the use of the tool. A spool of filament, which can print 200 to 250 pyramids, each taking 1 to 2 minutes to print, costs less than $30. The ability to create this tool using only a computer and three-dimensional printer represents an affordable and efficient way to locate the new umbilical opening, saving the surgeon time while achieving a more desirable aesthetic outcome. PATIENT CONSENT The patient provided written informed consent for use of the patient’s images. ACKNOWLEDGMENTS The authors would like to acknowledge the craftsmanship of Brian Mirth and Austin Mirth and thank them for assistance in designing and printing this surgical tool. DISCLOSURE The authors have no conflict of interest or financial interest to declare in relation to the content of this article.

Safety of Concomitant Umbilical Hernia Repair during Abdominoplasty: A Propensity Score Matched Analysis

PURPOSE: Over 97,000 abdominoplasties were performed in 2020 in the United States alone. Patients seeking a cosmetic abdominoplasty often have concurrent umbilical hernias stemming from shared risk factors for fascial and skin laxity. Optimum management and the safety of performing umbilical hernia repair during the same operation as an abdominoplasty is not well described. In this context, we compared the complication rates of performing an abdominoplasty with an umbilical hernia with abdominoplasty alone. Further we share our technique for umbilical hernia repair. METHOD: We performed a retrospective propensity score-matched cohort study of patients (n=271) who underwent an abdominoplasty at Massachusetts General Hospital between January 2014 and December 2020 by the senior author. Patients with panniculectomy were excluded to give a more homogenous population. Patients who underwent repair of an umbilical hernia at the time of the abdominoplasty were identified. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in patient baseline covariates. The primary outcome was any post-operative complication. Secondary outcomes included umbilical necrosis, skin flap necrosis, hematoma, venous thromboembolism, seroma, infection, and hernia recurrence. RESULTS: One-to-one propensity-score matching yielded 63 patients in each exposure group (126 patients total) with the distribution of observed baseline covariates closely aligned. If an umbilical hernia was present, a fascial slit was made inferior or superior to the umbilicus, the hernia contents were reduced if needed, and the fascial edges were approximated with one to three 0-Ethibond sutures from underneath. Within the matched cohort, there was no significant difference in total complication rates (abdominoplasty alone 8% (n=5) vs. abdominoplasty with hernia repair 6% (n=4) p=1.00). Similarly, there were no significant differences in any of the secondary outcomes (p>0.05). Specifically, there were no cases of abdominal skin necrosis or umbilical necrosis in either group. CONCLUSION: Performing umbilical hernia repair during the same operation as an abdominoplasty is safe without significantly increasing risk to the patient. Avoiding the dissection of or through the umbilical stalk may help provide adequate blood supply for survival. Future prospective studies are needed to evaluate patient-reported and long-term outcomes. REFERENCES: 1. ASPS Plastic Surgery Statistics Report 2020. Accessed 3/1/2022. 2. Person H, Mojallal A, Braye F, Shipkov H. Techniques of Concomitant Abdominoplasty and Umbilical Hernia Repair: A Review. Aesthet Surg J. Jun 14 2021;41(7):NP831-NP839. doi:10.1093/asj/sjab094 3. van Schalkwyk CP, Dusseldorp JR, Liang DG, Keshava A, Gilmore AJ, Merten S. Concomitant Abdominoplasty and Laparoscopic Umbilical Hernia Repair. Aesthet Surg J. Nov 12 2018;38(12):NP196-NP204. doi:10.1093/asj/sjy100

An Algorithmic Approach to Umbilical Inset during DIEP Flap Reconstruction.

An aesthetically pleasing umbilicus is a critical component to the overall cosmesis and resultant patient satisfaction after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Because of variables in body habitus, comorbidities, and technical aspects of the procedure, patients undergoing DIEP flap breast reconstruction are at a higher risk of umbilical complications and poor aesthetic appearance of the neoumbilicus compared with those undergoing cosmetic abdominoplasty. To minimize these potential problems and maximize the overall aesthetic appearance of the abdomen, the authors propose an algorithmic approach to umbilical inset after DIEP flap harvest that takes into account several critical factors: the thickness of the subcutaneous tissue of the abdominal flap, the length of the umbilical stalk, and the depth of the umbilical bowl. This simple algorithmic approach is a useful tool that will assist surgeons in minimizing umbilical complications and delivering a superior cosmetic appearance to the abdominal donor site in DIEP flap reconstruction.

The Outcome of the Combined Procedure of Abdominoplasty and Repair of Umbilical Hernia

Abstract Background Umbilical hernias (UH) are common in patients seeking abdominal contouring surgery and the question of simultaneous abdominoplasty and UH repair is raised. This presents, however, a risk to the umbilicus vascularization with possible umbilical necrosis. As a result, the umbilicus maintains its only blood supply from the underlying fascial attachments via the umbilical stalk. Abdominoplasty in the setting of a hernia repair can improve patients satisfaction, particularly appearance, hygiene, self-confidence and decrease the incidence of recurrence. Objective To assess the outcome of the combined procedure of abdominoplasty and repair of umbilical hernia. Patients and Methods This study Included 26 patients (18 females and 8 males) who were selected from those who presented to the department of general surgery at EL Demerdash University Hospital and Nasr city insurance hospital during the period between april2019 and october 2019. All patients had a physical examination of the UH and diastasis. Divided into two groups, each group formed of 13 patients. First group (group A) with patients underwent herniorrphy alone and the other group (group B) with patients underwent hernioplasty with combined abdominoplasty. Results It may be concluded that (1) during an abdominoplasty, midline fascial plication and ventral hernia repair can be performed in defects &amp;lt;3 cm without mesh reinforcement with no increase in hernia recurrence rates, (2) in patients with defects &amp;gt; 3 cm, mesh reinforcement is indicated after suture hernia repair and midline plication,, yields lower recurrence of abdominal deformity and less refashioning procedures with minimal complications. Conclusion Finally, it may help to reduce the incidence of recurrence by enabling removal of a large pannus and the resultant weight on the anterior abdominal wall, though this has not been proven. Also it improves the quality of life and obtains patients satisfaction with this approach.

SubCutaneous OnLay endoscopic Approach (SCOLA) for midline ventral hernias associated with diastasis recti.

Minimally invasive surgery for diastasis recti has gained attention in the recent past, with several reports with different names and particularities being suggested by the authors. SCOLA (Subcutaneous OnLay endoscopic Approach) is an example of this technique, described here in standardized technique. Basic steps to perform the procedure are detailed, beginning with patient and surgical team positioning, including trocar placement and tips and tricks of the subcutaneous dissection, steps needed to achieve full dissection of the preaponeurotic space, diastasis recti plication, mesh positioning and fixation and drain positioning with fixation of the umbilical stalk. Regardless of different names and small technical variations, endoscopic pre-aponeurotic mesh positioning can be performed with well-established steps on a reproducible fashion, aiming to achieve better results. Careful attention should be paid to appropriate patient selection and drain placement to reduce seroma rate, the most common complication.

637 Free Abdominal Tissue Transfer and Utilization of the Umbilical Stalk for “Tubular” Reconstruction in Ear, Nose and Throat Defects: A Case Series

Abstract Introduction Head and neck defects, whether from burns or cancer resections, are complex and often require free flap reconstruction. Radial forearm and anterolateral thigh (ALT) flaps are commonly used due to their thin and versatile nature. However, abdominal based free tissue transfer is one valuable alternative that can cover large defects and may become a more appropriate option on the reconstructive ladder when the defect includes reconstruction of a tubular structure, such as the external auditory canal, a neck tracheostomy/stoma site or an external nasal opening. We present a novel utilization of abdominal free tissue transfer for coverage of large ear and scalp burn defects as well as neck and midface defects with usage of the umbilical stalk for tubed reconstruction. Methods Four patients presented for reconstruction: two patients had sustained large ear and scalp burns resulting in complete ear loss; one had a large neck defect resulting from recurrent cancer resection which necessitated a laryngectomy and stoma creation; and one patient had a large central face defect post-cancer resection. All four patients underwent an abdominal based free tissue transfer with reconstruction of the external auditory canal in the ear and scalp burns, stoma creation in the neck defect, and the external nasal opening in the central face defect, all utilizing the vascularized umbilical stalk for the tubed reconstruction. Results All patients recovered post-operatively without any reported complications such as tubular stenosis or contracture while maintaining umbilical stalk tubular patency. Conclusions Reconstruction of a tubed structure in head and neck defects, whether the external auditory meatus, an external nasal opening or a neck stoma post burn or cancer resection, can be a difficult and challenging operation fraught with potential complications. We present a novel method of reconstruction of large defects employing the use of the uniquely thin and vascularized umbilical stalk for tubular reconstruction.

Invasive basal cell carcinoma of the umbilical stalk.

Invasive basal cell carcinoma of the umbilical stalk.

Techniques of Concomitant Abdominoplasty and Umbilical Hernia Repair: A Review

Different methods of simultaneous full abdominoplasty and umbilical hernia repair were proposed. To review We reviewed them and compared the results concerning the umbilical hernia repair outcomes and umbilical stalk survival. A literature research was performed until 28 December 2019. Other hernia repair and mini-abdominoplasty (without umbilical transposition) were excluded. The primary outcomes analysed were umbilical hernia recurrence, mesh infection, and umbilical necrosis rates. Six studies were included (5 retrospectives series, 1 case report). Hernia was repaired by an open approach (3 studies, 28 patients) or a laparoscopic approach (3 studies, 67 patients). Umbilical hernia repair consisted in mesh placement in intraperitoneal or retromuscular/preperitoneal plane, or suture technique in intraperitoneal plane. None hernia recurrence, mesh infection, or umbilical necrosis were described. Both open and laparoscopic approaches of simultaneous abdominoplasty and umbilical hernia repair seem to be safe regarding the umbilical stalk vascularisation, hernia recurrence and mesh infection rates. However, more well-designed studies are needed to prove this hypothesis.

The fibers of the circular junction of the linea alba in normal adult anatomy.

The linea alba (LA) is known to be useful to surgeons for making surgical incisions. Laparoscopic entry into the peritoneal cavity using the open technique may involve identification of a point just above or below the umbilicus where the peritoneum is fused to the LA. This anatomical site is found through superficial dissection to expose the junction between the umbilical stalk (US) and the LA, where distinct fibers seem to form a unique ligament-like structure in normal adult anatomy. This point, in fact, is part of a circular fibrous structure that exists almost like a ring around the remnant US. It is formed by the fusion of oblique and transverse fibers of the LA with circular fibers from proliferation of an encircling band of compact mesoderm to close a patent umbilical ring. We describe and name this anatomical landmark as junctio circularis alba or the "circular junction of the LA" as encountered in normal adult human anatomy. We believe this is crucial for describing key surgical procedures at this site to aid effective surgical training and reduce iatrogenic complications from laparoscopic port site entries.

The periumbilical incision for anterior lumbar interbody fusions.

The traditional retroperitoneal approach for the anterior lumbar interbody fusion (ALIF) uses a longitudinal paramedian incision. In this study, we use a discrete periumbilical incision. A 270-degree semicircular incision is made around the umbilicus and the subcutaneous tissue is dissected radially at a 45-degree angle, creating a mound around the umbilical stalk. Once the anterior sheath is encountered, the steps of the operation converge with those of the traditional approach. In this study, 30 patients underwent a periumbilical ALIF with an average of 2.1 levels fused. Perioperative outcomes were comparable to those described in the ALIF literature. No patients experienced complications attributable to the periumbilical incision.

Efficacy and cardiorespiratory effects of lumbosacral intrathecal 2% procaine and 2% xylazine with or without sedation in calves undergoing umbilical surgery

ABSTRACT Aims: To compare the effects of intrathecal anaesthesia using procaine and xylazine, with and without sedation with I/V xylazine and butorphanol, on sedation and cardiorespiratory measures in calves undergoing umbilical surgery. Methods: Male dairy calves, aged <3 months, were recruited that had enlargement of the umbilical stalk which was abnormal when palpated. They were assigned to receive either intrathecal injection between the sixth lumbar and first sacral vertebrae of 4 mg/kg of 2% procaine and 0.2 mg/kg 2% xylazine, with I/V injection of 0.02 mg/kg xylazine and 0.1 mg/kg of butorphanol (IT + SED group; n = 6), or the same intrathecal injection and I/V injection of 0.9% saline (IT group; n = 7). Surgery to correct abnormalities was carried out with calves positioned in dorsal recumbency. Rescue analgesia with injections of 2% procaine around the surgical wound was administered when movements triggered by surgery were observed. Post-operative analgesia was provided using I/V 0.5 mg/kg meloxicam. Duration of surgery was recorded, as well as degree of sedation, heart rate, systolic (SAP), diastolic (DAP) and mean (MAP) arterial blood pressure during surgery. Results: All anaesthetic and surgical procedures were successfully performed. Mean total duration of surgery was similar for the IT + SED and the IT groups (30.33 (SD 10.09) and 31.00 (SD 10.21) minutes, respectively) (p = 0.92). All calves were at least mildly sedated from 5 minutes after injections to the end of the surgery. One calf in the IT + SED group and three calves in the IT group required rescue analgesia when the umbilicus was manipulated. Between 0 and 10–15 minutes after injection, decreases in mean heart rate, SAP, MAP and DAP were observed in both groups. Mean SAP was lower in the IT + SED than the IT group. Hypotension (MAP<60 mm Hg) was present in four calves from the IT + SED group and in one from the IT group. Conclusions and clinical relevance: Intrathecal administration of 2% procaine and 2% xylazine allowed the successful completion of umbilical surgery, but 30% of calves needed rescue analgesia during surgery. Clinically, the addition of I/V sedation seemed to provide better analgesia than intrathecal block alone but resulted in greater hypotension.

Prevention of Umbilical Sagging After Medium Definition Liposuction

BackgroundThe loss of the umbilical vertical axis, causing a horizontal shape deformity after liposuction, is a current aesthetic issue. The use of energy devices, such as LASER and VASER, has been advocated as an option for improving skin retraction, but no data are available on the prevention of umbilical sagging.ObjectivesThe authors sought to describe a technique for preventing umbilical deformities after medium definition liposuction employing suction-assisted liposuction.MethodsOver a period of 31 months, 62 patients underwent medium definition liposuction with direct needle fixation of the umbilical stalk to prevent horizontal umbilical deformities. All patients underwent surgery performed by a single surgeon (G.B.). All patients underwent objective measurements of the umbilical shape before and after the procedure utilizing digital image measurements by Mirror Image software, version 6.0 (Fairfield, NJ). Statistical analysis was performed with IBM SPSS Statistics V26. The mean age of the patients was 28.8 years. The follow-up evaluation was performed 2 weeks and 9 months postoperatively.ResultsOver a period of 31 months, 60 patients (96.7%) who underwent abdominal etching liposuction showed maintenance of (n = 9, 14.5%) or improvements in the umbilical shape 9 months postoperatively (n = 51, 82.2%, P < 0.05). Two patients (3.2%) experienced worsening of the umbilical shape after surgery despite suture fixation.ConclusionsHorizontal shape deformities of the umbilicus after liposuction can be improved by utilizing direct needle fixation of the umbilical stalk. The approach has been shown to be effective, safe, and reproducible for the prevention of umbilical sagging in selected patients.Level of Evidence: 4

Ventral Abdominal Wall Defects.

1. Sara A. Mansfield, MD, MS* 2. Tim Jancelewicz, MD, MA, MS* 1. *Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN Clinicians should be aware of the strategies for prenatal and postnatal management of infants with omphalocele and gastroschisis. After completing this article, readers should be able to: 1. Recognize the implications and differences in management between gastroschisis and omphalocele. 2. Review the initial stabilization and management of infants with omphalocele and gastroschisis. 3. Review the surgical management options and rationale for infants with ventral abdominal wall defects. Abdominal wall defects represent a wide spectrum of congenital anomalies. These can range from lethal limb-body wall syndrome to benign umbilical cord hernias. Gastroschisis and omphalocele are the 2 most common defects and are the focus of this review. Although both of these diseases affect the umbilical area, they differ widely in their underlying pathogenesis, genetics, and associated disorders. Consequently, their management techniques and outcomes are quite different. This article reviews the pathogenesis, genetics, diagnostics, and outcomes for each disease, followed by an in-depth review of recent management updates. ### Pathogenesis Omphalocele (or exomphalos) is a herniation of the abdominal viscera through a midline abdominal wall defect (Fig 1). This defect is located at the base of the umbilical stalk, and herniated viscera are covered by a 3-layer membrane of peritoneum, Wharton jelly, and amnion. This contrasts with umbilical cord hernias, which are covered by intact skin and contain only a small protrusion of abdominal contents, and gastroschisis, which has no covering at all and occurs to the right of midline (Table). Omphaloceles are present in approximately 1 per 1,100 pregnancies. However, there is a high rate of spontaneous abortion, making the incidence of omphalocele per live birth approximately 1 per 4,000 to 1 per 6,000. (1) …

Secondary Abdominoplasty: Management of the Umbilicus after Prior Stalk Transection.

Patients with prior umbilical stalk detachment, secondary to limited abdominoplasty or prior umbilical hernia repair, may in the future be candidates for full abdominoplasty. In these patients, a circumferential incision around the umbilicus detaches the remaining cutaneous blood supply, prompting concern for umbilical viability. Minimal literature exists to guide clinical decision-making for these patients. Inquiries were made to Louisiana Society of Plastic Surgery members and the Plastic Surgery Education Network online forum of the American Society of Plastic Surgeons. Metrics obtained included patient age, sex, nature of primary surgery, time between umbilical stalk detachment and secondary full abdominoplasty, complications, and whether rectus plication was performed at the time of secondary surgery. Eleven physicians provided complete documentation for 18 cases. All patients healed without evidence of umbilical ischemia or necrosis. Average patient age was 40.6 years. Average interval between procedures was 3.6 years. Sixty-seven percent of patients had the umbilicus delayed before the secondary procedure, with the median delay time being 18 days. Rectus fascia was plicated during secondary surgery in 72 percent of patients. This is the first reported series of patients undergoing full abdominoplasty after prior umbilical stalk detachment. It is also the first time the Plastic Surgery Education Network online forum has been used to collect research data, highlighting its potential as a valuable research tool. The data set was obtained from a wide range of practices, which allows for consideration of various technical solutions when this or other diverse clinical scenarios are encountered. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.