Evaluation of breast skin and tissue stiffness using a non-invasive aspiration device and impact of clinical predictors.

A personalized 3D breast model could present a real benefit for preoperative discussion with patients, surgical planning, and guidance. Breast tissue biomechanical properties have been poorly studied in vivo, although they are important for breast deformation simulation. The main objective of our study was to determine breast skin thickness and breast skin and adipose/fibroglandular tissue stiffness. The secondary objective was to assess clinical predictors of elasticity and thickness: age, smoking status, body mass index, contraception, pregnancies, breastfeeding, menopausal status, history of radiotherapy or breast surgery. Participants were included at the Montpellier University Breast Surgery Department from March to May 2022. Breast skin thickness was measured by ultrasonography, breast skin and adipose/fibroglandular tissue stiffnesses were determined with a VLASTIC non-invasive aspiration device at three different sites (breast segments I-III). Multivariable linear models were used to assess clinical predictors of elasticity and thickness. In this cohort of 196 women, the mean breast skin and adipose/fibroglandular tissue stiffness values were 39 and 3 kPa, respectively. The mean breast skin thickness was 1.83 mm. Only menopausal status was significantly correlated with breast skin thickness and adipose/fibroglandular tissue stiffness. The next step will be to implement these stiffness and thickness values in a biomechanical breast model and to evaluate its capacity to predict breast tissue deformations.

"Doctor, how long will it take?" Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury.

BACKGROUND: Flap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors. METHODS: This observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure. RESULTS: 85 patients were included. Median healing time was 48 days (R: 20-406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02). CONCLUSION: After primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.

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.

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.

B3GAT3-related disorder with craniosynostosis and bone fragility due to a unique mutation.

PurposeBased on prenatal suspicion of the combination of radioulnar or radiohumeral synostosis and a peculiar shape of the skull suggestive of craniosynostosis, we report on six patients from four unrelated consanguineous families in whom Antley-Bixler syndrome was suspected during the prenatal period without mutation in genes known to be associated with the syndrome.MethodsMolecular diagnosis involved whole-exome and gene-panel sequencing. RESULTS: All sequenced patients showed a unique homozygous mutation of c.667G>A, p.Gly223Ser (NM_012200) in the beta-1,3-glucuronyltransferase 3 (B3GAT3) gene known to be involved in linkeropathy syndrome. Linkeropathies correspond to a recently identified group of heterogeneous genetic syndromes along a spectrum of skeletal and connective tissue disorders. These patients featured mainly craniosynostosis, midface hypoplasia, bilateral radioulnar synostosis, multiple neonatal fractures, dislocated joints, joint contracture, long fingers, foot deformity, and cardiovascular abnormalities. All died before 1 year of age.ConclusionWe identified a novel B3GAT3-related disorder with craniosynostosis and bone fragility, due to a unique homozygous mutation in B3GAT3. This syndrome should be considered in the prenatal period in light of the severe outcome and as an alternative diagnosis to Antley-Bixler or Shprintzen-Goldberg syndrome.

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.

Inverted Nipple Treatment and Poliglecaprone Spacer.

INTRODUCTION: Nipple inversion is defined as a non-projectile nipple. It is a frequent pathologic condition, in which the whole nipple, or a portion of its, is buried inward towards the lactiferous duct and lies below the plane of the areola. Numerous strategies have been described to correct nipple inversion. All the procedures have the purpose to give a good shape to the nipple, preserving its function and sensitivity, when it is possible. To avoid recurrences and to obtain good aesthetic results, we present a modified percutaneous technique. METHOD: We performed a retrospective study between 2011 and 2016 and included all the cases of inverted nipples treated in our department. Our modified percutaneous technique consists of a minimal incision supported by a percutaneous suture as a temporary spacer to fill the defect caused by releasing the fibro-ductal bands. RESULTS: A total of 41 cases of inverted nipples were corrected in 32 patients. After 1 year of follow-up, no recurrence was observed and all nipples maintained complete eversion. There was only one case of partial unilateral necrosis in a patient who underwent tumorectomy and radiotherapy. All patients were satisfied with the aesthetic outcomes. CONCLUSION: This is a simple, safe and cheap technique that should be considered as a reliable method for long-term correction of nipple inversion. LEVEL OF EVIDENCE IV: 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 .

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.

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.

Postero-Inferior Pedicle Surgical Technique for the Treatment of Grade III Gynecomastia.

INTRODUCTION: Surgical treatment of Grade III gynecomastia generally utilizes mastectomy techniques and free transplantation of the nipple-areola complex. Moreover, with rising obesity rates and the development of bariatric surgery, an increasing demand for correctional surgery for pseudogynecomastia has been observed, which is comparable to Grade III gynecomastia in terms of its surgical management. Here, we describe an innovative technique to deal with these new demands: fascio-cutaneous flap by postero-inferior pedicle. MATERIALS AND METHODS: All patients in the Department of Plastic Surgery from our University Hospital suffering from Grade III gynecomastia or pseudogynecomastia underwent surgery via the postero-inferior pedicle flap technique. Briefly, we performed extensive liposuction of the infero-internal and infero-external mammary quadrants followed by liposuction of the deep tissues of the superior quadrants, except in the area of the pedicle. After removing the skin just above the dermis of the inferior quadrants and performing de-epithelialization of the postero-inferior pedicle flap, the thoracic flap was lowered and the areola transposed. RESULTS: Nine patients underwent surgery between March 2015 and March 2016, and their results were collected prospectively. The mean patient age was 46.6 years, the mean weight was 94.2 kg, and the mean body mass index was 30.8 kg/m2. In addition, the mean operative time was 132 min, the mean liposuction volume was 633 mL, the excised weight was 586 g, and the mean hospitalization and drainage durations were 3.8 days. No major complications occurred, no re-intervention was required, and no recurrence was found. CONCLUSIONS: We report a new operative technique using a postero-inferior pedicle. Its main advantage is preservation of neurovascular function, which makes this a promising technique for patients who wish to maintain nipple sensitivity. This surgery is reliable and reproducible. We recommend it as the first line treatment for Grade III gynecomastia because of its low rate of major complications and favorable functional and esthetic results. LEVEL OF EVIDENCE IV: 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 .

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.

Anatomical basis of the extended TDAP flap: study of its territories of vascularization and its volume.

INTRODUCTION: The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap. MATERIALS AND METHOD: Ten extended TDAP flaps were dissected on 5 fresh human cadavers. Around the classical skin paddle of a TDAP flap, the dissections were performed in a subfascial level, including the muscular fascia and the adipose tissue compartments to increase the volume of the flap. After injection of methylene blue in the thoracodorsal artery, we measured the length and width, the surface and the volume of the coloured flap. RESULTS: The mean sizes of the extended TDAP flap were 24.9 cm × 20.1 cm. The mean surface of the total vascularization zone was 441 cm2. The mean volume of the vascularized flap was 193 ml. CONCLUSION: The thoracodorsal artery perforator via the deep muscular fascial network allows us to harvest a flap of 25 cm × 20 cm with a mean surface of 441 cm² and a mean volume of 193 ml. The extended TDAP flap is a credible option in breast reconstruction.

Treacher Collins syndrome: a clinical and molecular study based on a large series of patients.

PURPOSE: Treacher Collins/Franceschetti syndrome (TCS; OMIM 154500) is a disorder of craniofacial development belonging to the heterogeneous group of mandibulofacial dysostoses. TCS is classically characterized by bilateral mandibular and malar hypoplasia, downward-slanting palpebral fissures, and microtia. To date, three genes have been identified in TCS:,TCOF1, POLR1D, and POLR1C. METHODS: We report a clinical and extensive molecular study, including TCOF1, POLR1D, POLR1C, and EFTUD2 genes, in a series of 146 patients with TCS. Phenotype-genotype correlations were investigated for 19 clinical features, between TCOF1 and POLR1D, and the type of mutation or its localization in the TCOF1 gene. RESULTS: We identified 92/146 patients (63%) with a molecular anomaly within TCOF1, 9/146 (6%) within POLR1D, and none within POLR1C. Among the atypical negative patients (with intellectual disability and/or microcephaly), we identified four patients carrying a mutation in EFTUD2 and two patients with 5q32 deletion encompassing TCOF1 and CAMK2A in particular. Congenital cardiac defects occurred more frequently among patients with TCOF1 mutation (7/92, 8%) than reported in the literature. CONCLUSION: Even though TCOF1 and POLR1D were associated with extreme clinical variability, we found no phenotype-genotype correlation. In cases with a typical phenotype of TCS, 6/146 (4%) remained with an unidentified molecular defect.

Documented cutaneous loxoscelism in the south of France: an unrecognized condition causing delay in diagnosis.

BACKGROUND: Loxoscelism is an envenomation due to a bite by spiders of the genus Loxosceles, very well known on the American continent but unrecognized in Europe. CASE REPORT: We report the case of a 36-year-old woman, without any medical history or treatment, who went to a University Hospital in the South of France, for a painful skin lesion on the internal part of her left thigh, which appeared in the morning and developed rapidly during the day. She was directed to the infectious disease department with a diagnosis of skin infection. In spite of the antibiotics, the lesion increased, with a hemorrhagic central blister, an irregular ecchymotic center, a pale perimeter, and an extensive inflammatory and indurate oedema affecting the whole thigh. There was also a low-grade fever, chills, intense pain and a generalized scarlatiniform exanthema. The lesion was finally diagnosed as cutaneous loxoscelism, then confirmed by collection and identification of a Loxosceles rufescens spider killed by the patient the morning of the occurrence of the lesion. Following an initial symptomatic treatment, the development of a necrotic ulcer justified a delayed surgical reconstruction, after stabilization of the lesion. CONCLUSIONS: Loxosceles bites are usually painless and rarely noticed by patients, often leading to a presumptive diagnosis. Therefore, in the case of a dermonecrotic lesion developing unfavourably with antibiotics, cutaneous loxoscelism should be one of the diagnoses to be considered.

Circumferential Contouring of the Lower Trunk: Indications, Operative Techniques, and Outcomes-A Systematic Review.

BACKGROUND: Increasing obesity prevalence and development of bariatric surgery have led to the development of skin re-draping techniques. Several contouring techniques have been described for treating the circumferential excess of the lower trunk. MATERIALS AND METHODS: We performed a systematic review to summarize surgical indications, operative techniques, peri-operative management (nutritional supplementation, antibiotic prophylaxis, thrombo-prophylaxis), outcomes, complications, patient satisfaction, and impact on quality of life of circumferential contouring of the lower trunk procedures. A systematic review, based on the PRISMA criteria, was conducted using the Pubmed and Cochrane databases. RESULTS: The review included 42 articles and 1748 operated patients. Two studies only were graded as level of evidence II; the others were graded as levels III to V. The most frequently reported indication was massive weight loss. All the described techniques derived either from belt lipectomy or lower bodylift. Belt lipectomy resulted in a posterior scar situated at the waistline and allowed a better correction of hip back rolls, whereas lower bodylift was more effective on buttock and lateral thigh ptosis. The most reported complication was wound dehiscence. Patient satisfaction and quality of life scores were high in all studies. CONCLUSIONS: This review included a majority of low-level evidence studies that limit extrapolability of the results. Future randomized prospective studies may generate stronger evidence, with a standardization of surgical indications and operative techniques. 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 .

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.

Are There Factors Predictive of Postoperative Complications in Circumferential Contouring of the Lower Trunk? A Meta-Analysis.

BACKGROUND: The massive weight loss patient may require a circumferential contouring of the lower trunk. OBJECTIVES: To summarize the complication rates and explore the possibility of predictive risk factors for complications. METHODS: We performed a systematic review using the PubMed and Cochrane databases to identify published articles on the topic. Random effects meta-analyses and meta-regression were conducted to synthesize the data gathered. RESULTS: The analysis included 28 studies and 1380 patients. All but one were retrospective cohorts or case studies. Circumferential contouring of the lower trunk resulted in 37% [95%-CI 30%; 44%] overall complications; 17% [95%-CI 12%; 24%] wound dehiscences; 4% [95%-CI 3%; 5%] skin necrosis; 5% [95%-CI 3%; 9%] infections; 3% [95%-CI 2%; 4%] hematomas; 13% [95%-CI 9%; 18%] seromas; 12% [95%-CI 7%; 21%] scar irregularities; 3% [95%-CI 2%; 5%] thromboembolism; and 5% [95%-CI 3%; 8%] revisions for complications. Lower body lift-related techniques were associated with a higher rate of overall complications than belt lipectomy-related techniques (P = .002). No difference in complication rate was shown when performing a gluteal augmentation with flap. Due to insufficient data reported in the studies, risk factors for postoperative complications could not be assessed. CONCLUSIONS: The whole literature provides very low reliable information. Confusion factors could not be ruled out to explain the increased complications rate for the lower body lift compared to the belt lipectomy. This finding needs to be confirmed in randomized trials. Collaborative efforts must be made to improve the evidence level of our practices and to serve patients in an optimal way. LEVEL OF EVIDENCE: 3 Therapeutic.

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.