Hug Flap and Hamdi Hammock: Two Innovative Techniques for Enhancing Aesthetic Outcomes in Deep Inferior Epigastric Artery Perforator Breast Reconstruction.

Background: Achieving optimal aesthetic outcomes in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction remains a challenge, often necessitating additional procedures for refinement. This study presents two innovative techniques (the hug flap and Hamdi hammock) aimed at enhancing breast projection and inframammary fold (IMF) definition in DIEP flap reconstruction. Methods: The hug flap technique uses de-epithelialized caudal mastectomy skin to augment breast projection, whereas the Hamdi hammock uses a percutaneous purse-string suture to define the IMF. A retrospective review of 782 patients who underwent DIEP flap breast reconstruction between 2007 and 2023 was conducted. Results: The hug flap group required significantly less additional fat grafting compared to other techniques (11% versus 27% and 22%). No total flap losses occurred in the hug flap group, and fat necrosis rates were low. The Hamdi hammock was used in 405 patients with a mean of two lipofilling sessions. Complications were minor and no stitches required removal. Conclusions: The hug flap and Hamdi hammock techniques offer effective and safe methods for enhancing breast projection and IMF definition in DIEP flap reconstruction. These techniques may reduce the need for additional procedures and improve aesthetic outcomes.

The Brussels Breast Surgery Fellowship | A Three-Month Experience in Advancing Skills in Breast Surgery.

ABSTRACT: The Brussels Breast Surgery Fellowship at Brussels University Hospital offers a unique 3-month clinical immersion in reconstructive and aesthetic breast surgery. Under the guidance of fellowship director Prof. Moustapha Hamdi and his esteemed colleagues, the fellow is exposed to a high volume and wide breadth of cases spanning autologous and implant-based breast reconstruction, oncoplastic surgery, breast reduction and mastopexy, implant augmentation, revision breast surgery, and fat grafting. The multidisciplinary team approach, involving close collaboration with breast surgeons, provides valuable experience in oncoplastic planning and execution. In addition to time in the operating theater, the fellow gains knowledge through outpatient clinics, didactic teaching sessions, and clinical research opportunities leveraging the department's extensive prospective database. As the 2023 fellowship awardee, I had the privilege of learning directly from Prof. Dr. Moustapha Hamdi and participating in over 130 cases across the reconstructive and aesthetic spectrum. Unique features of the fellowship included exposure to lymphedema surgery utilizing the Symani robotic system, advanced techniques like the internal bra, volume distribution mastopexies, observation of private aesthetic clinic cases, and optional participation in academic workshops. This fellowship represents an outstanding opportunity to refine one's skills in breast surgery and microsurgery while experiencing the rich culture of Belgium.

Familial Spontaneous Keloids: Examining Thoracic Manifestations in Two Brothers.

Keloids are complex fibroproliferative disorders with diverse clinical presentations. Spontaneous keloids (SKs) represent a rare subtype that emerges without any known preceding traumatic event. This report presents a case of familial spontaneous keloids appearing on the thoracic region in two brothers with no prior history of trauma or keloid occurrence in other family members. The lesions exhibited progressive growth over several years but responded to cycles of triamcinolone treatment. This case underscores an unusual spontaneous occurrence of keloids in the thoracic region of two siblings, highlighting the potential genetic predisposition in the aetiology of these lesions. Additionally, this instance reinforces the concept that keloids can develop spontaneously without any apparent trauma in the affected area.

When the Usual Becomes Unusual: A Closer Look at Mycobacterium marinum Infections.

Mycobacterium marinum (M. marinum) is a slow-growing bacterium predominantly found in aquatic environments. While not highly virulent, it can cause skin and soft tissue infections, often misdiagnosed due to their indolent progression. This paper presents the case of a 42-year-old male data analyst with a chronic, ulcerated lesion on his right middle finger resulting from a minor fish tank injury. Despite multiple interventions, the lesion resisted healing for 10 months. A detailed history raised the suspicion of atypical mycobacterial infection. Despite non-diagnostic initial evaluations, combined antimicrobial therapy with minocycline and rifampicin led to complete lesion healing. Diagnosing M. marinum infection remains a challenge due to its nonspecific presentation. Key diagnostic criteria include resistance to standard antibiotics, history of exposure to aquatic environments, and potential contamination. While cultures are positive in 70-80% of cases, false negatives can occur, necessitating reliance on patient history and histology. Treatment involves combination antibiotics, with the prognosis generally favorable when treated early. This case underscores the importance of considering M. marinum in the differential diagnoses of chronic skin lesions and the significance of targeted therapy.

When Nerves Tell a Different Story: Functional Neurological Disorder (FND) After a Minor Hand Injury.

Hand injuries typically present with localized symptoms. However, we report an unusual case of a 32-year-old female who experienced a transient complete loss of sensation and motor function in her entire left nondominant hand after sustaining a minor 1 cm stab wound between the third and fourth metacarpals. Wound exploration under local anesthesia revealed no tendon, vascular, neural, or bony injury. Remarkably, she spontaneously regained full hand sensation and function within 120 minutes of the injury. Extensive neurological evaluation, including magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction studies (NCS), and somatosensory evoked potentials (SSEPs), ruled out organic pathology and supported a diagnosis of functional neurological disorder (FND), specifically functional movement disorder (FMD). Close collaboration between hand surgeons, neurologists, and occupational therapists is essential for accurate diagnosis and appropriate multidisciplinary management. Further research is needed to elucidate the mechanisms underlying FND and optimize evidence-based treatment for FND in the context of hand trauma. The increased awareness of this condition across specialties involved in hand injury management is crucial to facilitate timely diagnosis and avoid unnecessary interventions.

Comparing the Impact of Diluents and Injection Techniques on Patient Comfort During Indocyanine Green Lymphangiography: A Prospective Study.

Background: Indocyanine green (ICG) lymphography, a key diagnostic tool for lymphedema, is influenced by the dilution process of ICG dye, impacting patient experience. Methods and Results: In our study, we assessed three different ICG diluents-water for injection (WFI), normal saline (NS), and Dextrose® plus human albumin-in five healthy volunteer individuals undergoing superficial lymphography of the upper limb over 3 weeks. Results indicated that NS, as a diluent for ICG, caused the least discomfort during injection, in contrast to WFI, which led to the highest levels of discomfort. Transport time of ICG from the injection site to the axillary lymph nodes was notably shorter in intradermal injections than in subdermal injections. Conclusion: Our findings advocate for using NS as the optimal and cost-effective diluent for ICG, enhancing patient experience.

Bilateral Hematoma Following Air Travel after Breast Augmentation: A Cautionary Tale and Literature Review.

In this study, we report a rare incidence of bilateral hematoma following air travel in a patient who had recently undergone breast augmentation surgery. The case underscores the potential risks associated with flying shortly after such procedures. Through a literature review, we aimed to explore the incidence rates and highlight the need for further research in this area. This case report aims to raise awareness among healthcare professionals and patients about the need for cautious post-surgical travel planning to mitigate the risk of similar complications.

Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach.

The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.

Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies.

BACKGROUND: Hyaluronic acid (HA) dermal fillers are widely used in aesthetic medicine. While generally safe, potential complications can arise. OBJECTIVE: This systematic review aims to identify and classify potential complications linked to the use of HA dermal fillers, as informed by high-quality, low-risk-of-bias studies. METHODS: This review follows the Cochrane review standards for clinical systematic reviews. This systematic review analyzed 48 high level of evidence studies on the use of hyaluronic acid (HA) dermal fillers in non-surgical facial aesthetics and the adverse events that occurred.The inclusion criteria were randomized control studies on HA dermal fillers and their complications. Excluded were case reports, case series, observational studies, and other non-randomized research due to their inability to provide generalized conclusions and their inherent publication bias. RESULTS: Adverse events were classified into three categories: expected reactions, product or technique-related adverse events, and severe adverse events. Most adverse events were short-lived injection site reactions, which resolved spontaneously. Specific HA fillers and injection techniques influenced the occurrence of adverse events, which generally resolved within weeks without treatment. Severe adverse events were rare, persisting for months and requiring active medical intervention. DISCUSSION: This classification system can enhance understanding, prevention, and treatment of HA filler complications, and support patient education. The common complications were injection site reactions, with persistent symptoms treated with topical steroids, NSAIDs, or hyaluronidase. Severe complications included severe edema, angioedema and others, often necessitating specific treatments. CONCLUSION: HA dermal fillers are generally safe and effective, with most adverse events being transient and mild to moderate in severity. Severe adverse events, although rare, do occur and are generally non-treatment related. Informed consent, patient education, and professional training are crucial for safe and successful outcomes. Level of Evidence II 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 .

Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies.

In response to the letter from Drs. Mataro and La Padula addressing our systematic review entitled "Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies", we emphasize the deliberate scope of our research. Our review, grounded in rigorous Cochrane standards, specifically aimed to elucidate the adverse events reported in high-quality randomized control studies. While we recognize the importance of understanding HA's rheological properties for non-surgical facial aesthetics, our primary focus was on clinical outcomes and adverse events. Concerns insinuated about our methodologies based on the exclusion of rheological parameters are addressed, clarifying that such a decision was a deliberate scope limitation and not an oversight. We reaffirm the significance of our review and its contribution to the facial aesthetics field, promoting well-informed clinical decisions. 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 .

Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis.

INTRODUCTION: The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains. AIM OF THE STUDY: To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician. METHODS: A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I2 and the QUADAS-2 tool was used to assess bias of the studies. RESULTS: This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries. CONCLUSION: Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.

Augmented Reality-Assisted Design of Local Flaps: A New Practical and Educational Tool in the Field of Plastic Surgery.

ABSTRACT: Augmented reality (AR) is a new and promising technology that has been incorporated into several aspects of our everyday life, including surgery. Examples of its application throughout various fields of surgery, although most of them are in experimental stage, have already been demonstrated and published. In this article, we describe the utilization of AR to design effectively and accurately surgical flap markings just with the help of an AR-compatible mobile phone and a low-cost application. We believe that, due to its ease of use, AR will play a pivotal role to the education and the training in the field of plastic surgery and burns, and other surgical specialties alike.

Alternative physical treatments for deep venous thrombosis prophylaxis in surgical patients: a systematic review.

INTRODUCTION: Venous thromboembolism (VTE) represents a major cause of morbidity and mortality. A variety of novel physical therapies have been proposed for patients in whom standard prophylaxis, including early mobilisation, is contraindicated. This article presents a systematic literature review of alternative physical treatments for VTE prophylaxis, focusing on surgical and trauma patients. METHODS: Following protocol registration in PROSPERO, a systematic review was conducted in accordance with PRISMA. MEDLINE and EMBASE databases were searched for all studies indexed before 27th of July 2019. Two authors independently screened these articles. Data gathering for eligible articles was also undertaken in parallel by two authors. A formal risk of bias assessment was conducted for each study along with an assessment on the quality of the evidence using the GRADE framework. RESULTS: A total of 272 abstracts were identified. After exclusion of duplicates and non-eligible articles, 10 publications were reviewed in detail. Two studies involving electrostimulation, another using a portable intermittent compression device and one study using postoperative calf massage reported a statistically significant reduction in the incidence of deep venous thrombosis when used in conjunction with LMWH. The remaining six articles did not show any significant benefits. DISCUSSION: All studies reporting significant benefits have methodological flaws, with a high risk of bias. The evidence base informing alternative physical treatments as prophylactic measures in VTE is limited. Our data suggest that the use of these physical modalities can be beneficial in patients who also received LMWH, whilst these alone are of no benefit. LEVEL OF EVIDENCE: II - Systematic Review Systematic Review Registration Number PROSPERO CRD42019133684.

Is the use of a powered dermatome an aerosol-generating procedure (AGP)? Implications for personal protection against COVID-19 virus.

INTRODUCTION: Many healthcare workers have contracted SARS-CoV-2 during the pandemic, many cases of which have resulted in severe illness and death. No studies have assessed the potential for powered dermatomes to generate aerosol, an essential technique in burns and plastic surgery. The primary aim of the present study was to capture video footage to illustrate the potential for a powered dermatome to generate significant spray and hence aerosol. METHODS: We utilised a simulated skin graft harvest experimental method. Fluorescein-stained saline was used with ultraviolet (UV) backlighting to demonstrate fluorescent spray from a popular brand of air-powered dermatome. Ultra-slow-motion (960 frames/s) video was used to demonstrate the oscillation of the dermatome blade and the origin within the machine of any spray generated, and the extent of spray generated. RESULTS: The key finding from this study is the captured video footage linked with this paper. Droplets of various sizes are seen spraying out from the leading edge at the sides where the blade oscillates. UV backlighting provides a clear demonstration of the dermatome generating fine spray. CONCLUSION: Our study demonstrates that powered dermatome usage is likely to generate aerosol from blood or blood-contaminated fluid, but does not demonstrate or quantify to what extent this may be clinically relevant in terms of viral transmission potential. We suggest ways to reduce the risk of spray from dermatomes including limiting donor-site bleeding and avoiding a wet donor area. LAY SUMMARY: A dermatome is a device used by surgeons to harvest split skin grafts (SSGs). SSGs are an essential component of burns and reconstructive plastic surgery. Aerosol-generating procedures (AGPs) have implications for transmission of viruses including COVID-19. It has not previously been formally assessed whether use of a dermatome should be classified as an AGP. This study uses a fluorescent dye in the context of simulated surgery using a dermatome to see if any, and how much, fine spray is generated from the device and also utilises ultra-slow-motion videography to see how any spray may be generated. At the heart of this study is the included video footage that demonstrates considerable fine spray generation which suggests it is best to assume that dermatomes are likely to generate some degree of aerosol depending on the clinical scenario and how it is used. However, this information does not translate to providing any information about the risk of transmission of the virus from using a dermatome, especially in relation to COVID-19, and separate research would be required to answer this.

Facial synkinesis outcome measures: A systematic review of the available grading systems and a Delphi study to identify the steps towards a consensus.

INTRODUCTION: Facial synkinesis is characterised by abnormal and unintentional co-contractions of facial muscles caused by aberrant facial nerve healing, usually as a sequalae of facial palsy. The aim of this project is to propose a consensus for reporting this condition in the literature to facilitate the conduction of primary and secondary evidence studies, considering that no previous research has inquired in to this matter. METHODS: A systematic literature search was performed in MEDLINE and EMBASE databases, considering all the published articles on facial synkinesis. Studies that used a particular measuring system for this condition were included. Two authors independently assessed these articles focusing on the grading instruments utilised. The most commonly used instruments were analysed, and their basic components were incorporated in a modified Delphi survey, which was sent to a panel of experts. RESULTS: The systematic literature search retrieved 502 articles, of which 159 met the inclusion criteria. The two most commonly mentioned instruments were the House-Brackmann Scale and the Sunnybrook Facial Grading System. These were then followed by the Yanagihara scale, the Synkinesis Assessment Questionnaire, the eFace system and the Facial Clinimetric Evaluation. The modified Delphi study concluded that an ideal grading system for facial synkinesis should not only include a clinician-based evaluation of symmetry and signs of synkinesis, but also patient-reported symptoms. CONCLUSIONS: Considering the characteristics of the studies found in the literature, the Sunnybrook Facial Grading System fits best with the ideal synkinesis measuring instrument described by the panel of experts. However, in order to satisfy the need to include patient-reported outcomes, the use of the Facial Clinimetric Evaluation as an adjunct to the Sunnybrook Facial Grading System is proposed.

Structural plasticity of 4-α-helical bundles exemplified by the puzzle-like molecular assembly of the Rop protein.

The dimeric Repressor of Primer (Rop) protein, a widely used model system for the study of coiled-coil 4-α-helical bundles, is characterized by a remarkable structural plasticity. Loop region mutations lead to a wide range of topologies, folding states, and altered physicochemical properties. A protein-folding study of Rop and several loop variants has identified specific residues and sequences that are linked to the observed structural plasticity. Apart from the native state, native-like and molten-globule states have been identified; these states are sensitive to reducing agents due to the formation of nonnative disulfide bridges. Pro residues in the loop are critical for the establishment of new topologies and molten globule states; their effects, however, can be in part compensated by Gly residues. The extreme plasticity in the assembly of 4-α-helical bundles reflects the capacity of the Rop sequence to combine a specific set of hydrophobic residues into strikingly different hydrophobic cores. These cores include highly hydrated ones that are consistent with the formation of interchain, nonnative disulfide bridges and the establishment of molten globules. Potential applications of this structural plasticity are among others in the engineering of bio-inspired materials.