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.

Superior epigastric artery perforator flap for reconstruction of deep sternal wound infection.

BACKGROUND: The treatment of deep wound sternal infection requires loco-regional pedicled flaps, usually with muscular flaps. Perforator propeller flaps represent the ultimate progress in the history of reconstructive surgery. We report here our experience with the superior epigastric artery perforator (SEAP) flaps to repair sternal defect. PATIENTS AND METHODS: Six patients presenting deep sternal wounds infection were treated with SEAP propeller flap, between March 2015 and June 2017. The mean age was 71.5 (range 53-83) years. The mean length and width of the defect were 16.2 × 7 cm (ranging 8-20 × 4-10). An elliptical skin flap pedicled on the SEAP was harvested in the inframammary fold and rotated up to 90° to cover the defect. RESULTS: All SEAP flaps achieved a successful entire coverage of the defect. The mean size of the skin paddle of the flap was 20.2 × 7.3 cm (ranging 14-27 × 6-9). All flaps were able to provide a complete sternal wound cover. Venous congestion was present in five cases and adequately treated by leech therapy; necrosis was distal in one case, and interesting the entire superficial flap in two cases but with deep tissues remaining viable and able to cover the mediastinum: an infected flap required revision. Satisfyingly, at 2-years postoperative follow-up all-patients were alive with a successful mediastinal cover. CONCLUSIONS: The SEAP Perforator propeller flap is an alternative to muscle flaps to achieve treatment of deep and large sternal wound infection.

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.

Failure rates of artificial dermis products in treatment of diabetic foot ulcer: A systematic review and network meta-analysis.

Diabetic foot ulcer (DFU) is a frequent complication in diabetic patients, occurring in up to 25% of those affected. Among the treatments available to clinicians, the use of bioengineered skin substitutes is an attractive alternative. Artificial dermis functions as a matrix, covering the wound and supporting healing and reconstruction of the lost tissue. This study was aimed at reviewing the use of five regeneration matrices (namely, Integra, Nevelia, Matriderm, Pelnac, and Renoskin) as reported by clinical trials. We searched Medline, Embase, ISI Web of Science, Scopus, and Cochrane Central Register of Controlled Trials databases for relevant studies. Risk of failure rates was analysed by relative risk ratio method and complete ulcer healing was studied using network meta-analysis. Thirteen studies (12 randomized clinical trials and one cohort study) were eligible for analysis. The network meta-analysis based on a single study for Matriderm and 12 studies for other products showed that Matriderm was statistically inferior in achieving complete ulcer healing, as compared to all other products combined. In the second phase analysis, which was limited to three studies using artificial dermis products, there was a 57% reduction in the risk of reepithelialization failure for DFU patients who used Matriderm or Pelnac, compared to those who used Pelnac with basic fibroblast growth factor spray or skin grafting. The data showed an overall low failure rate suggesting that these bioengineered skin products provide a suitable support and microenvironment for healing of DFUs with low ulcer recurrence rates. This systematic review with meta-analysis highlights the pressing need for more studies investigating the safety, efficacy and failure rates of regeneration matrices in the treatment of DFUs.

Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps.

Background The use of distally based neurocutaneous sural flaps (DBNCSF) is one of the most common methods of reconstructing the distal lower leg. However, they have developed a bad reputation because of their propensity for venous engorgement. Venous congestion that can lead to distal necrosis can be prevented by venous supercharging. Using a prospective comparative study, we thus explored the effect of venous supercharging on the reliability of these useful workhorse flaps. Methods We prospectively included 38 patients who received a conventional DBNCSF and 38 patients who received a supercharged version of this flap (sDBNCSF) between January 2012 and July 2016. Results No significant difference was identified between the groups in terms of age, sex, comorbidity, or defect origin. The main reconstruction etiology was traumatic (open fracture, scar disunion, and chronic osteitis). The flap size was noticeably larger in the sDBNCSF group, albeit without significance. The length-width ratio was significantly greater in the sDBNCSF group (6.08 vs. 5.53, p = 0.022). Venous congestion was significantly more common in the non-supercharged group (28.6 vs. 2.6%, p = 0.01), as was coverage failure (23.7 vs. 2.6%, p = 0.035). Conclusion There are significant benefits to using venous supercharging of DBNCSF, when technically feasible. In our experience, venous supercharging increases reliability, allows the raise of larger skin paddles with much narrower pedicles limiting the morbidity of the procedure, and improves the functional and esthetic results.

Free-Flap Reconstruction: What Do Microsurgeons Prefer for Themselves?

Background The recent development of perforator flaps has changed the reconstructive strategy for common integumental defects and has refocused the attention of microsurgeons to donor site morbidity. We asked a representative panel of microsurgeons about the free flap they would use to cover a common integumental defect on their own body to investigate the best free-flap donor sites. Methods In total, 100 practitioners participated in the "FreeFlap4U" study, representing 77.3% of the French national plastic surgery teams practicing microsurgery. To assess changing attitudes, we also compared microsurgeons below 40 years of age (called junior microsurgeons, JMs) with those above 40 years of age (called senior microsurgeons, SMs). Results Perforator flaps were preferred for the first line (JMs) and second line (JMs and SMs) of treatment compared with other flaps. JMs emphasized lower donor site morbidity, whereas SMs favored reliability (p = 0.013) and considered perforator flaps as a second-line treatment. Radial forearm and transverse rectus abdominis flaps were largely dismissed due to high morbidity. Some microsurgeons were influenced by the potential secondary benefit of the integument sample at the donor site. Conclusions Microsurgeons interviewed clearly moved toward perforator flaps, such as the anterolateral thigh, thoracodorsal artery perforator, and superficial circumflex iliac artery types, to cover common integumental defects. In the coming years, we believe that this choice, emitted by the microsurgeons for themselves, will be applied extensively by these surgeons for their patients.

Professional Burnout Among Plastic Surgery Residents: Can it be Prevented? Outcomes of a National Survey.

BACKGROUND: Plastic surgery residencies require significant investments of time and psychological resources. We herein determine the prevalence of burnout syndrome among plastic surgery residents and identify potentially protective factors. METHODS: A national cross-sectional study was conducted among French plastic surgery residents in March 2013. We distributed a validated measure of burnout (Maslach Burnout Inventory) in addition to a general questionnaire collecting sociodemographic and professional information. RESULTS: Fifty-two residents (61%) responded; their mean age was 29 years. A total of 25% and 13.5% of residents scored highly on the depersonalization and high-level emotional exhaustion burnout subscales, respectively, and 48.1% indicated perceived low-level personal accomplishment. The occurrence of a weekly ward round by a senior surgeon (reported by 67.3% of respondents) appears to protect against burnout (P = 0.007); regular staff meetings in the unit (75% of respondents) were also protective because they limited depersonalization (P = 0.048) and promoted personal accomplishment (P = 0.031). The number of hours worked/week was not significantly associated with burnout. Despite these data, 69.2% reported satisfaction with their careers. CONCLUSIONS: Almost one third of plastic surgery residents exhibited a high degree of burnout; the risks were increased by being in the early years of training, feeling dissatisfied with career plans, and working in units in which senior surgeons did not make weekly ward rounds and in which regular staff meetings, which offer the opportunity to discuss cases or problems with other professionals, were not scheduled. Burnout increases the risk of medical errors and suicide among residents. Therefore, we suggest that screening for burnout is essential.

Fluorescein sodium fluorescence microscope-integrated lymphangiography for lymphatic supermicrosurgery.

Microscope-integrated lymphangiography is a useful method in the field of lymphatic supermicrosurgery. Fluorescence based on indocyanine green (ICG) is the most commonly used. Fluorescein sodium is a fluorescent tracer used for retinal and neurosurgical angiography but not yet for lymphatic supermicrosurgery. In this report, we present a case in which the fluorescein sodium fluorescence microscope-integrated lymphangiography was used for assessment of lymphatic drainage pathway and patency in a patient treated for secondary lymphedema by lymphaticovenular anastomoses. Fluorescein sodium fluorescence microscope-integrated lymphangiography was evaluated in a 67-year-old female presented for a Campisi clinical stage IV lymphedema of the upper limb. Transcutaneous guidance and vascular fluorescence were assessed. A comparison with ICG fluorescence was made intraoperatively. Two lymphaticovenular anastomoses were performed and their patency were checked by lymphangiography. Transcutaneous signal was found higher with fluorescein sodium fluorescence. Intraluminal visualization was possible with fluorescein sodium coloration during lymphaticovenular anastomoses. No adverse reaction occurred. The circumferential differential reduction rate of affected limb was 8.1% 3 months after lymphaticovenular anastomoses. The use of fluorescence microscope-integrated lymphangiography with fluorescein sodium may be superior to ICG fluorescence in assistance of lymphaticovenular anastomoses.

π-shaped lymphaticovenular anastomosis: the venous flow sparing technique for the treatment of peripheral lymphedema.

BACKGROUND: Nowadays, lymphaticovenular anastomosis has been recognized as an efficient microsurgical treatment for peripheral lymphedema. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. This is the venous flow-sparing technique, in which the distal endothelial cells are not sacrificed. The purpose of this study is to evaluate the clinical results of π-shaped lymphaticovenular anastomosis in chronic lymphedema of the upper and lower limbs. PATIENTS AND METHODS: From November 2010 to August 2011, 20 patients with a peripheral lymphedema were treated by π-shaped lymphaticovenular anastomosis. A total of 12 patients had a lymphedema of the upper limb and 8 patients had a lymphedema of the lower limb. The mean age of the patients was 57.2 years (range, 44-78 years). The mean duration of lymphedema was 6.2 years (range, 1-23 years). The Campisi clinical stage range 2 to 5 (average, 3.3). Every patient was operated under local anesthesia. Four π-shaped lymphaticovenular anastomoses were performed per limb. RESULTS: The mean caliber of lymphatic vessels used for lymphaticovenular anastomosis was 0.55 mm (range, 0.3-0.8 mm). The mean caliber of subdermal venules was 1.2 mm (range, 0.5-2.1 mm).The average operative time to perform one π-shaped lymphaticovenular anastomosis was 55 minutes (range, 45-65 minutes). A venous backflow was found in 98 lymphaticovenular anastomosis (55.7%). Total 16 patients (80%) had a clinically significant circumferential reduction after surgery. The average volume differential reduction rate was 22.9% (range, 4.9-46.3) (p < 0.001). CONCLUSIONS: π-Shaped lymphaticovenular anastomosis is a supermicrosurgical method with a low morbidity to treat peripheral lymphedema. The procedure can easily be performed under local anesthesia, and the postoperative recovery is short. The results of this series demonstrate a clinical efficiency of the technique to reduce chronic lymphedema of the limbs.EBM level IV.

Small-wave plasty for correction of lip length deficiency: a case report.

BACKGROUND: Lip reconstruction may lead to disappointing results due to secondary deformity and visible scars. The Z-plasty in the Tennison technique is an effective method for repairing the upper lip subunits. The main issue is the visible and ungracious scar. METHODS: A 38-year-old woman was treated for an upper lip deformity secondary to a dog bite injury. At 1 month after a direct suture, a scar contracture with a defect of Cupid's bow and a vermilion height deficiency occurred. A Tennison procedure was chosen to repair the deformity. A small-wave incision procedure also was considered to minimize visibility of the scar. These two techniques were coupled in a small-wave plasty. The small-wave plasty design was performed with a superior flap base (L1) of 7 mm and a circle arc of 10 mm. The superior height (H1) was 3 mm. The middle flap base (L2) was 4 mm, and the circle arc was 6 mm. The middle height (H2) was 2 mm. RESULTS: The surgery time was 55 min with the patient under general anesthesia. The skin healing was completed in 10 days without scar contracture. The upper lip subunits were reconstructed with a regular Cupid's bow and a symmetric vermilion height. The scars were slightly visible at 1 month postoperatively. The results were stable after a follow-up period of 12 months. No revision was needed. CONCLUSION: The small-wave plasty, which couples a Tennison technique with a small-wave incision procedure, is efficient in reconstructing the subunits of the upper lip after a scar contracture deformity. This method should be used for upper lip reconstruction for minimal scar visibility. 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 .

Vacuum-assisted retroauricular full-thickness skin grafting.

The authors describe a vacuum-assisted skin grafting method to optimize graft take in the retroauricular region. This method is demonstrated after skin tumor resection of the retroauricular and mastoid areas.

Vacuum-assisted adipose tissue suction technique (VAST) to optimize fat harvesting.

BACKGROUND: Nowadays, fat grafting is a widespread technique that is commonly used in plastic and reconstructive surgery. The classical fat-harvesting method in which a 10-cc syringe and a 3.0-mm cannula are used, may be time-consuming when a large quantity of adipose tissue is required. We describe a novel technique to optimize fat harvesting, the vacuum-assisted adipose tissue suction technique (VAST), in which disposable sterile components are used. This study compares the adipose tissue harvesting speed and the adipocyte volume between the VAST and the 10-cc-syringe technique. METHODS: From May 2010 to May 2012, a total of 32 patients who had structural fat grafting for breast reconstruction were enrolled in this prospective study. In 16 patients (control group) fat was harvested by the classical 10-cc-syringe technique, and in the other 16 patients (VAST group) fat was harvested by the VAST. Adipose tissue was harvested from the abdomen area in all patients. The volume of harvested adipose tissue was noted every minute during the operative procedure. The operative harvesting speed was calculated for each patient after 5 min. The volume harvested in 5 min was centrifuged, and the remaining adipocyte volume was noted after centrifugation. The operative harvesting speed and the remaining adipocyte rate were compared in both groups. RESULTS: The average volume of harvested adipose tissue was 18.1 ml in the control group and 156.2 ml in the VAST group (p < 0.001). The average harvesting speed was 3.6 ml/min in the control group using a 10-cc syringe and 31.2 ml/min in the VAST group (p < 0.001). The average remaining adipocyte volume, after centrifugation, was 13.5 ml in the control group, and 118.2 ml in the VAST group (p < 0.001). The average remaining adipocyte rate, after centrifugation, was 74.3 % in the control group and 75.4 % in the VAST group (p = 0.27). CONCLUSIONS: Adipose tissue harvesting can be optimized safely by using the VAST before structural fat grafting. Its quickness, low cost, and efficiency make us choose this method in breast reconstruction when a significant volume of adipocytes is required. 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 .

Reconstruction of anterior scalp defect with V-Y advancement flap pedicled on the temporal fascia superficialis.

Reconstruction of scalp defect can call upon several surgical techniques. Direct joining is used whenever possible, but because of the low laxity of the scalp, other approaches are often required. Several types of autoclosing flaps of the scalp have been described in the literature. In this article, we report the advantages of the island flap pedicled on the superficial temporal fascia, as described by Onishi (2005) in a case report for the reconstruction of an anterior scalp defect.

Autologous Gluteal Augmentation with Parasacral Perforator-Pedicled Propeller Flaps.

BACKGROUND: De-epithelialized flaps have been used in gluteal contouring over the last three decades, but most improve the projection rather than the upper quadrants. The authors provide a detailed description of their method of gluteal augmentation using parasacral perforator-pedicled propeller flaps. This technique achieves a volumetric increase and maximal buttock projection at the midlevel and in the medial half of the buttocks. METHODS: Between January and December of 2019, a series of 18 patients on whom a lower body lift with a parasacral perforator-pedicled propeller flap had been performed by the senior author (F.B.) were prospectively evaluated. Postoperatively, the satisfaction rate was assessed using a 10-point analog scale (1 = unsatisfied, 10 = very satisfied) by the patient and by two independent surgeons based on photographs taken 1 year after surgery. RESULTS: Eighteen patients underwent this procedure. Their mean age was 32.2 ± 5.6 years (range, 24 to 40 years). The mean flap length was 20.3 cm, their mean width was 10.4 cm, and the mean thickness was 3.4 cm. The authors noted only two minor complications, one seroma and two skin dehiscences that healed without surgery. The rate of satisfaction as assessed by the patients was 8.3 out of 10 (±1.1), and by surgeons, 7.9 and 8.1. CONCLUSION: This article describes a gluteal autoaugmentation flap technique using parasacral perforator-pedicled propeller flaps to increase projection and volume in the inferomedial gluteal region after lower body lift. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Complications after J Medial Thighplasty following Massive Weight Loss: A Multivariate Analysis of 94 Consecutive Patients.

BACKGROUND: Bariatric surgery has increased the number of patients requiring medial thighplasty after massive weight loss. However, despite the various complications, the procedure improves quality of life. The authors report postoperative complications of vertical J-shaped medial thigh lift in a series of patients and identify preoperative risk factors. METHODS: For almost 5 years, the details of all J medial thighplasties performed by a single surgeon were recorded; detailed medical records were also available. Complications can be major (e.g., need for early surgical revision or readmission) or minor (delayed wound healing). RESULTS: During the study period, 94 patients were treated and only minor complications were recorded (42.5 percent). On multivariate analysis, older age (OR, 1.05; 95 percent CI, 1.01 to 1.10) and a body mass index greater than or equal to 30 kg/m2 (OR, 2.82; 95 percent CI, 1.10 to 7.22) were independent risk factors for postoperative complications. CONCLUSIONS: As with other postbariatric operations, medial thighplasty is associated with significant morbidity, but the risk thereof can be easily established and managed. Specific algorithms for determining the risk of postoperative complications based on age and body mass index are needed to guide preoperative discussions with patients and perform patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.