Endothelial DLL4 Is an Adipose Depot-Specific Fasting Sensor Regulating Fatty Acid Fluxes.

BACKGROUND: Adaptation of fat depots to change in fuel availability is critical for metabolic flexibility and cardiometabolic health. The mechanisms responsible for fat depot-specific lipid sensing and shuttling remain elusive. Adipose tissue microvascular endothelial cells (AT-EC) regulates bidirectional fatty acid fluxes depending on fed or fasted state. How AT-EC sense and adapt to metabolic changes according to AT location remains to be established. METHODS: We combined transcriptional analysis of native human AT-EC together with in vitro approaches in primary human AT-EC and in vivo and ex vivo studies of mice under fed and fasted conditions. RESULTS: Transcriptional large-scale analysis of human AT-EC isolated from gluteofemoral and abdominal subcutaneous AT revealed that the endothelium exhibits a fat depot-specific signature associated with lipid handling and Notch signaling enrichment. We uncovered a functional link between metabolic status and endothelial DLL4 (delta-like canonical notch ligand 4), which decreases with fasting. DLL4 regulates fatty acid uptake through nontranscriptional modulation of macropinocytosis-dependent long chain fatty acid uptake. Importantly, the changes in DLL4 expression, in response to energy transition state, is impaired under obesogenic conditions, an early alteration coinciding with a defect in systemic fatty acid fluxes adaptation and a resistance to weight loss. CONCLUSIONS: DLL4 is a major actor in the adaptive mechanisms of AT-EC to regulate lipid fluxes. It likely contributes to fat depot-dependent metabolism in response to energy transition states. AT-EC alteration with obesity may favor metabolic inflexibility and the development of cardiometabolic disorders.

A Two-Step Approach for Breast Augmentation with Chest Wall Deformity?

Breast augmentation in the case of chest wall deformity can be challenging. It is essential to treat the two problematics separately, and not to attempt compensation for asymmetry with vastly different breast implants. With this work, we wish to highlight the approach based on the use of custom-made 3D implants, enabling optimal correction of thoracic deformity. A first case study illustrates a one-step approach to correcting deformity and augmenting the breast. The importance of separate management of these issues lies in the fact that possible normalization of thoracic dysmorphia alone can sometimes lead to withdrawal of the request for breast augmentation. We illustrate this with a second case report with optimal patient satisfaction after isolated correction of a pectus excavatum.Level of Evidence V 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 .

Characterization and Safety Profile of a New Combined Advanced Therapeutic Medical Product Platelet Lysate-Based Fibrin Hydrogel for Mesenchymal Stromal Cell Local Delivery in Regenerative Medicine.

Adipose-derived mesenchymal stromal cells (ASC) transplant to recover the optimal tissue structure/function relationship is a promising strategy to regenerate tissue lesions. Because filling local tissue defects by injection alone is often challenging, designing adequate cell carriers with suitable characteristics is critical for in situ ASC delivery. The aim of this study was to optimize the generation phase of a platelet-lysate-based fibrin hydrogel (PLFH) as a proper carrier for in situ ASC implantation and (1) to investigate in vitro PLFH biomechanical properties, cell viability, proliferation and migration sustainability, and (2) to comprehensively assess the local in vivo PLFH/ASC safety profile (local tolerance, ASC fate, biodistribution and toxicity). We first defined the experimental conditions to enhance physicochemical properties and microscopic features of PLFH as an adequate ASC vehicle. When ASC were mixed with PLFH, in vitro assays exhibited hydrogel supporting cell migration, viability and proliferation. In vivo local subcutaneous and subgingival PLFH/ASC administration in nude mice allowed us to generate biosafety data, including biodegradability, tolerance, ASC fate and engraftment, and the absence of biodistribution and toxicity to non-target tissues. Our data strongly suggest that this novel combined ATMP for in situ administration is safe with an efficient local ASC engraftment, supporting the further development for human clinical cell therapy.

A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement.

BACKGROUND: Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications. OBJECTIVES: This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution. METHODS: Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis. RESULTS: A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline. CONCLUSIONS: Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

Cell immaturity and white/beige adipocyte potential of primary human adipose-derived stromal cells are restrained by culture-medium TGFß1.

Human adipose-derived stem/stromal cells (hASCs) can differentiate into specialized cell types and thereby contribute to tissue regeneration. As such, hASCs have drawn increasing attention in cell therapy and regenerative medicine, not to mention the ease to isolate them from donors. Culture conditions are critical for expanding hASCs while maintaining optimal therapeutic capabilities. Here, we identified a role for transforming growth factor ß1 (TGFß1) in culture medium in influencing the fate of hASCs during in vitro cell expansion. Human ASCs obtained after expansion in standard culture medium (Standard-hASCs) and in endothelial cell growth medium 2 (EGM2-hASCs) were characterized by high-throughput transcriptional studies, gene set enrichment analysis and functional properties. EGM2-hASCs exhibited enhanced multipotency capabilities and an immature phenotype compared with Standard-hASCs. Moreover, the adipogenic potential of EGM2-hASCs was enhanced, including toward beige adipogenesis, compared with Standard-hASCs. In these conditions, TGFß1 acts as a critical factor affecting the immaturity and multipotency of Standard-hASCs, as suggested by small mother of decapentaplegic homolog 3 (SMAD3) nuclear localization and phosphorylation in Standard-hASCs vs EGM2-hASCs. Finally, the typical priming of Standard-hASCs into osteoblast, chondroblast, and vascular smooth muscle cell (VSMC) lineages was counteracted by pharmacological inhibition of the TGFß1 receptor, which allowed retention of SMAD3 into the cytoplasm and a decrease in expression of osteoblast and VSMC lineage markers. Overall, the TGFß1 pathway appears critical in influencing the commitment of hASCs toward osteoblast, chondroblast, and VSMC lineages, thus reducing their adipogenic potential. These effects can be counteracted by using EGM2 culture medium or chemical inhibition of the TGFß1 pathway.

Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb?

PURPOSE: Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS: We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS: Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION: The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

Correcting of Calf Atrophy With a Custom-Made Silicone Implant: Contribution of Three-Dimensional Computer-Aided Design Reconstruction: A Pilot Study.

BACKGROUND: Calf shape is an essential aesthetic parameter of the leg, and calf atrophy can lead to complex problems. The functional consequences of calf atrophy are generally moderate. Prefilled silicone gel implants represent the vast majority of currently placed prostheses, but this technique does not ensure optimal adaptation of the implant shape due to loss of volume. OBJECTIVES: The aim of this study was to describe an innovative procedure for correcting acquired calf atrophy based on 3-dimensional (3D) modeling. METHODS: The study involved 22 patients treated for calf atrophy caused by illness. Implants were made with solid rubber silicone, and 3D reconstructions were created by computer-aided design based on computed tomography scans. The implants were introduced through a horizontal popliteal incision. RESULTS: Forty-one implants were placed. No cases of infection, hematoma, or compartment syndrome were encountered. We experienced 1 case of skin necrosis and 1 case of periprosthetic seroma. In addition, lipofilling was performed in 5 cases. Two patients sought to benefit from a surgical reduction in implant size. CONCLUSIONS: Our innovative procedure to correct calf atrophy with custom solid rubber silicone implants produces a calf shape that better adapts to volume loss than prefilled silicone gel implants. The material maintains its shape and facilitates retrofitting of the prosthesis. There is no risk of hull formation or breakage, and the life span of the implants is limitless. This 3D computer-aided design approach has optimized our reconstructions.

Circumferential pharyngectomy in laryngectomised patient and pharyngeal reconstruction by tubed free flap.

BACKGROUND: Metachronous tumour in head and neck cancer patients is a frequent situation with a generally poor prognosis, often improving in case of surgical treatment. METHOD: This article presents the surgical technique for early stage hypopharyngeal metachronous tumour resection and pharyngeal reconstruction by tubed free flap in laryngectomised patient. CONCLUSION: Selected laryngectomised patients presenting with early stage hypopharyngeal metachronous tumours can benefit from a safe carcinologic resection and reconstruction.

Medial Sural Artery Perforator Flap for Leg and Knee Coverage: Extended Skin Paddle With 2 Perforators.

BACKGROUND: For soft-tissue defect coverage in the lower leg and around the knee joint, the gastrocnemius muscle flap is the most commonly used. Having constant anatomy, a long pedicle, and decreased donor site morbidity, the medial sural artery perforator (MSAP) flap may represent a good reconstructive alternative. The aim of this report was to present the experience of using a dual perforator MSAP pedicled flap. METHODS: Nineteen patients underwent soft-tissue reconstruction by MSAP flap in the one third of the lower leg and around the knee joint. Eleven patients were injured in traffic accidents. Exposure of a knee prosthesis required flap coverage in 4 cases. The other defect etiologies were a gunshot wound, bone abscess due to a sickle cell anemia, bone exposure due to a full thickness burn, and sarcoma resection. Defect dimensions ranged from 7 × 5 cm to 15 × 8 cm. Seventeen flaps were harvested with 2 perforators. Donor sites were closed primary in 16 of the 19 cases. RESULTS: The sizes of the MSAP flaps ranged from 7 to 22 cm × 5 to 8 cm. The procedure was uneventful in 17 cases. The 2 unsuccessful flaps developed a distal necrosis, for which an excision with direct suture was made secondary. Complete healing was achieved in all cases. CONCLUSIONS: The pedicled MSAP flap represents a versatile option in soft-tissue defect coverage of the lower leg and around the knee joint. Inclusion of 2 perforators could render the flap safer and increase its skin paddle, making it suitable for larger defects.

Impact of Lipo-Body Lift Compared to Classical Lower Body Lift on Postoperative Outcome and Patient's Satisfaction: A Retrospective Study.

INTRODUCTION: Lately, the growing number of bariatric procedures performed each year led to an increasing demand for lower trunk reconstruction. Our team previously described the lipo-body lift (LBL) technique into lower duration of drainage and therefore seromas and other complications. In this study, we compared the classical body lift (CBL) technique to the LBL procedure. MATERIALS AND METHODS: All patients who underwent a LBL or CBL after massive weight loss between November 2012 and October 2017 were included. Surgery outcome parameters were collected as well as patient satisfaction through a satisfaction score realized at least after 1 year postoperative. Comparisons between CBL and LBL were conducted to assess the surgery's safety and the patient's satisfaction. RESULTS: A total of 130 patients were included, 61 patients who had a LBL were compared to 69 patients who had a CBL. The mean patient age was 39.64 ± 9.97 (21-66) years old, the mean body mass index before plastic surgery was 26.83 ± 3.08 kg/m2 (19.83-32.69), and the average weight loss was 53.40 ± 17.37 kg. The two groups had comparable preoperative data. Duration of drainage and hospital stay was significantly lower in the LBL group than in the CBL (p < 0.0001 and p < 0.0001, respectively). Surgical outcomes were comparable between groups as well as patient satisfaction scores. CONCLUSION: Lipo-body lift allows early discharge of the patient by reducing the duration of drainage without increasing the risk for complications. In our opinion, this technique should be used for type 1 and 2 patients with no contraindication for abdominal liposuction. LEVEL OF EVIDENCE III: 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.

Breast desmoid tumor management in France: toward a new strategy.

PURPOSE: Desmoid tumors (DTs) are rare tumors that originate from myofibroblastic tissue. Recently, initial wait and see was recommended (ESMO guidelines Ann Oncol 2017) in the most frequent locations. This study investigates the outcome of breast desmoid tumor (BDT) according to the initial strategy. METHOD: Data from all consecutive patients treated from a BDT in four referral centers were collected. Only intra-mammary desmoid tumors were included. A pathological review and a molecular analysis (CTNNB1 gene mutation) were performed (National re-reading network of sarcomas-RRePS). Patients were grouped according to initial strategy: surgery group (SG) and active surveillance group (ASG). RESULTS: A total of 63 patients (61 women, 2 men) met the inclusion criteria. Median age was 50 years (16-86). CTNNB1 mutation was found in 61% (n = 36). SG included 46 patients (73%) (41 partial mastectomies, 2 mastectomies, and 3 mastectomies associated to parietectomies). Surgical margins were positive in 15 patients (33.3%). Median follow-up of SG was 24.9 (0.5-209) months; and 4 patients (8.7%) developed recurrence. ASG included 17 patients (27%). Their median follow-up was 42.2 (0-214) months, and 15 patients (88.2%) did not require any additional treatment. Six patients (35%) had a spontaneous regression, 9 patients (52%) were stable, and 2 patients presented a significant progression that was treated by partial mastectomy. CONCLUSION: This study supports an initial nonsurgical approach to BDTs followed by surgery based on tumor growth in select cases, which is consistent with current ESMO recommendations.

Lymphatic Vasculature Requires Estrogen Receptor-α Signaling to Protect From Lymphedema.

OBJECTIVE: Estrogens exert beneficial effect on the blood vascular system. However, their role on the lymphatic system has been poorly investigated. We studied the protective effect of the 17ß estradiol-the most potent endogenous estrogen-in lymphedema-a lymphatic dysfunction, which results in a massive fluid and fat accumulation in the limb. APPROACH AND RESULTS: Screening of DNA motifs able to mobilize ERs (estrogen receptors) and quantitative real-time polymerase chain reaction analysis revealed that estradiol promotes transcriptional activation of lymphangiogenesis-related gene expression including VEGF (vascular endothelial growth factor)-D, VEGFR (VEGF receptor)-3, lyve-1, and HASs (hyaluronan synthases). Using an original model of secondary lymphedema, we observed a protective effect of estradiol on lymphedema by reducing dermal backflow-a representative feature of the pathology. Blocking ERα by tamoxifen-the selective estrogen modulator-led to a remodeling of the lymphatic network associated with a strong lymphatic leakage. Moreover, the protection of lymphedema by estradiol treatment was abrogated by the endothelial deletion of the receptor ERα in Tie2-Cre; ERαlox/lox mice, which exhibit dilated lymphatic vessels. This remodeling correlated with a decrease in lymphangiogenic gene expression. In vitro, blocking ERα by tamoxifen in lymphatic endothelial cells decreased cell-cell junctions, inhibited migration and sprouting, and resulted in an inhibition of Erk but not of Akt phosphorylation. CONCLUSIONS: Estradiol protection from developing lymphedema is mediated by an activation of its receptor ERα and is antagonized by tamoxifen. These findings reveal a new facet of the estrogen influence in the management of the lymphatic system and provide more evidence that secondary lymphedema is worsened by hormone therapy.

Rapidly growing breast desmoid tumor with intra-thoracic involvement after reconstructive surgery for breast cancer.

Desmoid tumors are very rare soft tissue neoplasia that are slow growing and locally aggressive. They grow anywhere in the body and are rarely develop in the breast . Histopathologic examination confirms diagnosis. Recurrence rate is very high even after complete resection. We report the management of a rare case of rapidly growing breast desmoid with intra-thoracic involvement causing cardiac compression.

A comparison of flap reconstruction vs the laying open technique or excision and direct suture for pilonidal sinus disease: A meta-analysis of randomised studies.

Many treatments have been described for pilonidal disease, but recurrence cannot be completely eliminated. The aim of this study was to perform a meta-analysis of randomised, controlled trials comparing flap repair vs the laying open technique and/or excision and direct closure techniques in the treatment of chronic pilonidal sinus disease. The primary outcome measure was the recurrence rate. Secondary outcomes were complete wound-healing time, duration of the incapacity to work, quality of life and patient satisfaction, postoperative pain, wound infection, bleeding or haematoma, skin wound complications, and duration of hospital stay. Seventeen studies were included. The meta-analysis demonstrated a lower risk of recurrence, a shorter duration of incapacity to work, a lower risk of wound infections, a lower risk of skin wound complications, and a shorter duration of hospitalisation in favour of flap vs direct closure. A shorter time to complete wound healing and a shorter duration of incapacity to work for flap vs the laying open technique were observed. Superiority of flap repair vs direct closure in pilonidal sinus treatment was demonstrated in this meta-analysis. These results suggest avoiding primary direct closure in clinical practice. Compared with the laying open technique, flaps result in faster healing and a shorter time to return to activities.

The Use of Pedicled Perforator Flaps in Chest Reconstruction: A Systematic Review of Outcomes and Reliability.

BACKGROUND: In recent years, pedicled perforator flaps have revolutionized plastic surgery by reducing donor site morbidity and ensuring larger and deeper reconstructions with local pedicled cutaneous flaps. The aim of the study was to make a systematic review of perforator pedicled propeller flaps (PPPFs) in chest reconstruction. METHODS: Pubmed and Cochrane databases were searched from 1989 to October 2016 for articles describing the use of PPPFs in chest reconstruction. The preferred reporting items for systematic reviews and meta analyses statement was used in the selection process. The review was registered on international prospective register of systematic reviews. Furthermore, operative technique, indications and complications were searched. RESULTS: Twenty-four articles were selected (174 patients and 182 flaps). Oncological surgery was the first etiology (34.5%), followed by infections (11.5%), chest keloid scars (6.23%), malformations (4.6%), burns (3.4%), chronic ulcers (2.3%), Verneuil disease (1.8%), and acute wounds (1.8%). The arc of rotation was between 90° and 120° in 24.2%. The mean surface of flaps was 127.45 ± 123.11 cm. Dissection was subfascial in 78.5% of the cases. Complications were found in 9.9% of patients and included mainly wound dehiscence (4.4%) and hematoma/seroma (2.2%). One case of total necrosis (0.5%) and 2 cases of partial necrosis (1.1%) were found. CONCLUSIONS: The possibility of numerous pedicles makes it possible for PPPFs to offset most areas of wall chest defects. Furthermore, this surgical technique is reliable and reproducible, with lower donor site morbidity than that in the case of muscular flaps, which are classically used in this location.

Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis.

INTRODUCTION: Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?" METHODS: This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I2 index were computed. RESULTS: We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016). CONCLUSION: In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.

Comparison of propeller perforator flap and venous supercharged propeller perforator flap in reconstruction of lower limb soft tissue defect: A prospective study.

INTRODUCTION: In lower limbs, reliability of propeller perforator flaps (PPF) remains uncertain. The main complication is venous congestion, which can lead to distal necrosis. We aim to highlight if venous supercharging of PPF could substantially limit complications in lower limb coverage. METHODS: Between 2011 and 2016, we developed a standardized procedure of venous supercharging in the lower limb reconstruction with PPF using saphenous veins anastomosis. Then, we prospectively compared a consecutive series of 30 PPF to cover lower limbs defect, with a consecutive series of 30 venous-supercharged PPF (vsPPF). Etiologies of trauma, flap harvesting, complications, and outcomes were compared. RESULTS: The etiologies of the defect were acute trauma in 67.6% of reconstruction with PPFs and 60% of reconstruction with vsPPFs (P = 0.826). The average size of the skin paddle was 48.1 ±18.2 cm2 for PPF and 58.9 ±19.5 cm2 for vsPPF, and the average arc of rotation was 126.7° ±33.1 for PPF and 121.3° ±31.9 for vsPPF. The average sizes and rotation arcs between the two flaps were not significantly different (P = 0.031, P = 0.527). The operative time was significantly increased for vsPPF when compared to PPF procedure (128.8 ±8.5 minutes vs. 81.3 ±10.1 minutes, P < 0.001). Venous congestion was significantly higher in PPF with 11 cases than in vsPPF with two cases (36.7% versus 6.7%, P = 0.010). Distal necrosis were significantly higher in PPF with nine cases than in vsPPF with 1 cases (30% versus 3.3%, P = 0.012). Following poor flap evolution, stitches removal was significantly more frequent in PPF with 11 cases than in vsPPF with one case (36.7% vs 3.3%, P = 0.002). Leeches application was significantly more frequent for PPF procedures with nine cases, than for vsPPF with one case (30% vs 3.3%, P = 0.012). The average length of hospital stay for PPF was significantly longer than for vsPPF (8.78 versus 7.11 days, P = 0.026). CONCLUSION: The vsPPF is a reliable alternative to PPF to cover small- and medium-size defect in lower limbs, reducing venous congestion and overall complications.

Morphometric Analysis of the Umbilicus According to Age.

BACKGROUND: Morphometric and anatomical analyses of the shape and position of the umbilicus have been conducted in adults, but umbilicoplasty in children remains challenging because growth is still occurring. OBJECTIVES: The main objective of this study was to evaluate the difference in the position and shape of the umbilicus between childhood and adulthood. The secondary objective was to improve the surgical management of umbilicoplasty in children. METHODS: This prospective single-center study focused on the morphometric analysis of the umbilicus in 200 adults and children. All data, including standardized measures and pictures, were determined by one single operator. RESULTS: Despite a variation of approximately 2% in the xiphoid-pubis distance, the location of the umbilicus remains stable during the entire growth period. In a supine individual, the location is at one half to two thirds of the xiphoid-pubis distance (slightly lower in children), with a mean ratio of 0.57 for the xiphoid-umbilicus distance to the xiphoid-pubis distance. In the general population, the most common shapes are round and vertical oval. T-shaped umbilici were only observed in adults. Round and protruding shapes were twice as frequent in children under 18 as in adults. The horizontal oval shape was twice as frequent in adults. CONCLUSIONS: Abdominal growth and changes in the repartition of subcutaneous adipose tissues with age are responsible for the vertical orientation and deepening of the umbilicus as well as its horizontal orientation. To promote final cosmetic outcomes, secondary umbilicoplasty must place the umbilicus between one half and two thirds of the xiphoid-pubis distance.

Distally Based Medial Plantar Flap: A Classification of the Surgical Techniques.

The proximally based medial plantar flap is considered to be the reference standard for heel reconstruction. Although less well-studied, a distally based medial plantar flap is a suitable alternative when used to cover a distal foot defect, especially of the hallux, first metatarsal, or metatarsophalangeal joint. Our objective was to provide a complete description and propose a classification of the different surgical procedures used to harvest this flap. A review of the data reported in the MEDLINE database until May 2017 concerning the distally based medial plantar flap was performed. We have illustrated the different surgical procedures through a case series. Three approaches or "types" of flap have been described, and we have proposed a classification for reconstructive surgeons. In type 1, the plantar pedicle is ligatured before division into the medial and lateral plantar artery. In type 2, the medial plantar pedicle is cut proximally just after division. In type 3, the flap is harvested to include the fasciocutaneous perforator vessels, as an advancement flap or a propeller perforator flap. A distally based medial plantar flap affords adequate and reliable coverage of the weightbearing zone. Because the donor site drawbacks are minimal, this flap is a useful option for distal foot reconstruction, and reconstructive surgeons should remember this flap. The type 1 flap appears to be associated with a minimal risk of flap necrosis, even in those with diabetes or arteriopathy, and can cover even the most distal defect.