Randomized comparative study of negative pressure wound therapy versus compression dressing on split-thickness skin grafts of the lower limbs in an elderly population.

INTRODUCTION: Failure to adequately secure the skin graft to the lower limbs recipient bed can result in loss of the graft. Our objective was to compare the healing of split-thickness skin grafts three weeks postoperatively, using either negative pressure wound therapy (NPWT) or conventional compression bandaging. METHODS: In this multicenter randomized controlled study, patients with tissue loss ranging from 50 cm2 to 600 cm2 on the lower limbs and treated with split-thickness skin grafts were included in three French hospitals. A digital photographic evaluation was performed at 3 weeks. RESULTS: During 9 years, 70 patients were included in the study and allocated to a treatment group. The grafted area was similar in both groups. Loss of graft was significantly reduced in the NPWT group with 14.6 cm2 compared to 29 cm2 in the control group (p = 0.0003). The hospital stay was also significantly reduced in the NPWT group, at 4 days versus 6.5 days in the control group (p = 0.0284). In the NPWT group, 60% reported pain compared to 22.9% in the control group (p = 0.0048). CONCLUSIONS: The use of NPWT dressings improves skin graft take by reducing necrosis, improving the graft's adherence to the recipient site, and reducing hospital length-of-stay.

Time to return to work after total trapeziometacarpal prosthesis.

OBJECTIVES: This study assessed return to work and prosthesis survival after trapeziometacarpal prosthesis surgery. MATERIAL AND METHODS: A multicenter retrospective study was carried out on patients operated on between 2002 and 2020. All working patients who had undergone trapeziometacarpal prosthesis surgery were included. Return to work was defined as resuming the same full-time position. Postoperative events and their specific treatment and failure to return to work were reported. RESULTS: 240 prostheses in 211 patients were included. The complications rate was 7.5%, with 97% prosthesis survival. 94.3% of patients returned to work, at a mean 48 days (range, 29-210 days; SD, 22.7 days), with no significant difference according to age. Twelve patients did not return to work, half of whom because of prosthetic complications. CONCLUSION: Trapeziometacarpal arthroplasty enables most patients to return to work within 6 weeks. In this series, the prosthetic survival rate was 97%.

In vivo evaluation of Adipose-Derived Stem Cells (ADSCs) using Nanofat technique and chitosan conduit for peripheral nerve defect repair.

INTRODUCTION: Nerve autograft is the gold standard for reconstruction of peripheral nerve loss. The alternative is the interposition of a synthetic regeneration conduit. The purpose of the study was to evaluate the in vivo feasibility and interest of Adipose-Derived Stem Cells (ADSCs) using the Nanofat technique and chitosan conduit for peripheral nerve defect repair. MATERIAL AND METHODS: In vivo, after the creation of a 10 mm defect of the sciatic nerve, 2 groups were defined according to the nerve repair in rats: "chitosan" group (n = 10) and "chitosan and ADSCs" group (n = 10) with a clinical and paraclinical evaluation at 7 weeks. RESULTS: The in vivo results seem to show that the adjunction of ADSCs was favorable clinically, histologically and functionally compare to a chitosan reconstruction alone. DISCUSSION: Peripheral nerve repair with defect using a chitosan conduit associated with ADSCs would constitute a surgical alternative in a single surgical step.

Reporting Criteria for Clinical Trials on Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review and Recommendations.

Medication-related osteonecrosis of the jaw (MRONJ) is a complication caused by anti-resorptive agents and anti-angiogenesis drugs. Since we wanted to write a protocol for a randomized clinical trial (RCT), we reviewed the literature for the essential information needed to estimate the size of the active patient population and measure the effects of therapeutics. At the same time, we designed a questionnaire intended for clinicians to collect detailed information about their practices. Twelve essential criteria and seven additional items were identified and compiled from 43 selected articles. Some of these criteria were incorporated in the questionnaire coupled with data on clinical practices. Our review found extensive missing data and a lack of consensus. For example, the success rate often combined MRONJ stages, diseases, and drug treatments. The occurrence date and evaluation methods were not harmonized or quantitative enough. The primary and secondary endpoints, failure definition, and date coupled to bone measurements were not well established. This information is critical for writing a RCT protocol. With this review article, we aim to encourage authors to contribute all their findings in the field to bridge the current knowledge gap and provide a stronger database for the coming years.

Rapidly spreading deep dissecting hematoma occurring 1 month after a minor trauma: A case report.

A deep dissecting hematoma is the most serious complication of dermatoporosis, consisting of a rapidly expanding blood collection that splits the hypodermis from the muscle fascia. A several-week time lapse between a minor trauma-induced superficial hematoma and its sudden evolution into a rapidly spreading deep dissecting hematoma is unusual. We report the case of a 70-year-old woman with long-term oral anticoagulation and dermatoporosis who suddenly developed a rapidly spreading right-leg deep dissecting hematoma 1 month after minor trauma, for which a surgical debridement and drainage were performed. Only local care and absorbent dressings were used to manage the post-operative wound, and within 4 months, the wound had healed. In this report, we emphasize the importance of preventing deep dissecting hematoma in patients who are at risk as well as the need to weigh the benefits and risks of anticoagulants when dermatoporosis cutaneous signs are present. A limb-threatening deep dissecting hematoma may develop suddenly, even weeks after a minor impact. In order to prevent skin necrosis from occurring, caregivers, patients, and carers must be able to identify this condition early on.

What is the best technic to dislodge Staphylococcus epidermidis biofilm on medical implants?

BACKGROUND: Bacterial biofilm can occur on all medical implanted devices and lead to infection and/or dysfunction of the device. In this study, artificial biofilm was formed on four different medical implants (silicone, piccline, peripheral venous catheter and endotracheal tube) of interest for our daily clinical and/or research practice. We investigated the best conventional technic to dislodge the biofilm on the implants and quantified the number of bacteria. Staphylococcus epidermidis previously isolated from a breast implant capsular contracture on a patient in the university hospital of Dijon was selected for its ability to produce biofilm on the implants. Different technics (sonication, Digest-EUR®, mechanized bead mill, combination of sonication plus Digest-EUR®) were tested and compared to detach the biofilm before quantifying viable bacteria by colony counting. RESULTS: For all treatments, the optical and scanning electron microscope images showed substantial less biofilm biomass remaining on the silicone implant compared to non-treated implant. This study demonstrated that the US procedure was statistically superior to the other physical treatment: beads, Digest-EUR® alone and Digest-EUR® + US (p < 0.001) for the flexible materials (picc-line, PIV, and silicone). The number of bacteria released by the US is significantly higher with a difference of 1 log on each material. The result for a rigid endotracheal tube were different with superiority for the chemical treatment dithiothreitol: Digest-EUR®. Surprisingly the combination of the US plus Digest-EUR® treatment was consistently inferior for the four materials. CONCLUSIONS: Depending on the materials used, the biofilm dislodging technique must be adapted. The US procedure was the best technic to dislodge S. epidermidis biofilm on silicone, piccline, peripheral venous catheter but not endotracheal tube. This suggested that scientists should compare themselves different methods before designing a protocol of biofilm study on a given material.

Tips and Tricks and Clinical Outcome of Cryopreserved Human Amniotic Membrane Application for the Management of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Pilot Study.

Medication-related osteonecrosis of the jaw (MRONJ) is a complication of certain pharmacological treatments such as bisphosphonates, denosumab, and angiogenesis inhibitors. There are currently no guidelines on its management, particularly in advanced stages. The human amniotic membrane (hAM) has low immunogenicity and exerts anti-inflammatory, antifibrotic, antimicrobial, antiviral, and analgesic effects. It is a source of stem cells and growth factors promoting tissue regeneration. hAM acts as an anatomical barrier with suitable mechanical properties (permeability, stability, elasticity, flexibility, and resorbability) to prevent the proliferation of fibrous tissue and promote early neovascularization at the surgical site. In oral surgery, hAM stimulates healing and facilitates the proliferation and differentiation of epithelial cells in the oral mucosa and therefore its regeneration. We proposed using cryopreserved hAM to eight patients suffering from cancer (11 lesions) with stage 2-3 MRONJ on a compassionate use basis. A collagen sponge was added in some cases to facilitate hAM grafting. One or three hAMs were applied and one patient had a reapplication. Three patients had complete closure of the surgical site with proper epithelialization at 2 weeks, and two of them maintained it until the last follow-up. At 1 week after surgery, three patients had partial wound dehiscence with partial healing 3 months later and two patients had complete wound dehiscence. hAM reapplication led to complete healing. All patients remained asymptomatic with excellent immediate significant pain relief, no infections, and a truly positive impact on the patients' quality of life. No adverse events occurred. At 6 months of follow-up, 80% of lesions had complete or partial wound healing (30 and 50%, respectively), while 62.5% of patients were in stage 3. Radiological evaluations found that 85.7% of patients had stable bone lesions (n = 5) or new bone formation (n = 1). One patient had a worsening MRONJ but remained asymptomatic. One patient did not attend his follow-up radiological examination. For the first time, this prospective pilot study extensively illustrates both the handling and surgical application of hAM in MRONJ, its possible association with a collagen sponge scaffold, its outcome at the site, the application of multiple hAM patches at the same time, and its reapplication.

Pectoral Plane Block versus Local Anesthetic Infiltration in Breast Implant Augmentation Surgery: A Retrospective Study.

BACKGROUND: Pectoral plane blocks are routinely used in analgesia for patients undergoing dual-plane breast augmentation with implants. Local anesthetic infiltration is a simple alternative technique with the same aim. The authors evaluated both techniques. METHODS: In this single-center retrospective study, patients received pectoral plane block (ropivacaine 0.2%, 10 ml for pectoral plane I; 20 ml for pectoral plane II) or local anesthetic infiltration. The primary outcome measure was pain, according to the visual analogue scale, at 24 hours after surgery. Secondary outcomes included the measure of pain at 1, 2, 6, and 12 hours after surgery; total opioid consumption at 24 hours; and opioid side effects. RESULTS: Eighty-one patients were finally recruited: 37 in the pectoral plane group and 44 in the local anesthetic infiltration group. Patient characteristics were comparable between the two groups. At 24 hours after surgery, the local anesthetic infiltration group showed a decrease in pain, with a visual analogue scale score of 0.7 versus 1.5 in the pectoral plane group ( p = 0.007). There was no difference in visual analogue scale score between the two groups at 1, 2, 6, or 12 hours after surgery. The duration of anesthesia was increased in the pectoral plane group, with 153 minutes versus 120 minutes in the local anesthetic infiltration group ( p < 0.001). There was no difference in rescue morphine consumption between the two groups. CONCLUSIONS: The authors found that local anesthetic infiltration had a superior analgesic effect at 24 hours after surgery for dual-plane breast implant augmentation compared with pectoral plane block. These findings are a good indication that the local anesthetic infiltration technique is at least as effective as pectoral plane block while being safe, fast, and easy to use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Surgical Application of Human Amniotic Membrane and Amnion-Chorion Membrane in the Oral Cavity and Efficacy Evaluation: Corollary With Ophthalmological and Wound Healing Experiences.

Due to its intrinsic properties, there has been growing interest in human amniotic membrane (hAM) in recent years particularly for the treatment of ocular surface disorders and for wound healing. Herein, we investigate the potential use of hAM and amnion-chorion membrane (ACM) in oral surgery. Based on our analysis of the literature, it appears that their applications are very poorly defined. There are two options: implantation or use as a cover material graft. The oral cavity is submitted to various mechanical and biological stimulations that impair membrane stability and maintenance. Thus, some devices have been combined with the graft to secure its positioning and protect it in this location. This current opinion paper addresses in detail suitable procedures for hAM and ACM utilization in soft and hard tissue reconstruction in the oral cavity. We address their implantation and/or use as a covering, storage format, application side, size and number, multilayer use or folding, suture or use of additional protective covers, re-application and resorption/fate. We gathered evidence on pre- and post-surgical care and evaluation tools. Finally, we integrated ophthalmological and wound healing practices into the collected information. This review aims to help practitioners and researchers better understand the application of hAM and ACM in the oral cavity, a place less easily accessible than ocular or cutaneous surfaces. Additionally, it could be a useful reference in the generation of new ideas for the development of innovative protective covering, suturing or handling devices in this specific indication. Finally, this overview could be considered as a position paper to guide investigators to fulfill all the identified criteria in the future.

Case report of osteomyelitis of the mandible in osteopetrosis and management considerations.

INTRODUCTION AND IMPORTANCE: Osteopetrosis is a poorly known and probably underdiagnosed pathology. It is caused by various genetic abnormalities resulting in osteoclast dysfunction. Functional and aesthetic consequences have a major impact on the patient's quality of life. Ten percent of osteopetrosis cases develop osteomyelitis that usually involves the mandible. Management of this complication remains complex and often unsatisfactory. CASE PRESENTATION: We report a case of a 62-year-old woman with osteopetrosis, complicated by mandibular osteomyelitis with intra-oral bone exposure and submental fistulas. Management was performed with antibiotic therapy and surgical necrotic resection. This cured the fistulas but the bone exposure persisted. DISCUSSION: This case report highlights the difficulty of achieving complete healing of osteomyelitis in osteopetrosis. Antibiotic therapy, surgical management, or even hyperbaric oxygen therapy are required, but must be adapted to the case. A free flap procedure is undesirable but, when it is necessary, a bone marrow transplant could be considered to restore osteoclast function. CONCLUSION: The management of mandibular osteomyelitis in patients with osteopetrosis must adapt to the situation and severity. To avoid most cases of osteomyelitic complications in patients suffering from osteopetrosis, we propose that a preventive strategy of better dental care should be considered.

Assessment of Somatosensory Reorganization by Functional Magnetic Resonance Imaging After Hand Replantation.

INTRODUCTION: Amputation of the hand is a rare and extremely intense trauma. Replanting and allografting after this type of injury require a major reorganization of the brain. Brain plasticity, though better known in the context of disorders of the central nervous system, is just as indispensable when the extremities are damaged. MATERIALS AND METHODS: A 17-year-old patient underwent replantation of the nondominant hand after transmetaphyseal amputation after traumatic injury. After 18 days in hospital and subsequent treatment in a physical rehabilitation center, the patient attended clinical and radiology follow-up sessions over the next 2 years. RESULTS: The management of this patient led to an excellent functional outcome in conjunction with successful social and professional reintegration. Electromyography at 18 months confirmed nerve regrowth. Functional magnetic resonance imaging was done at 2 years to evaluate cerebral plasticity. Motor function, largely dependent on the primary motor area, is aided by the addition of secondary and accessory motor areas for both simple and complex movements. A change in sensory information is stimulation in its own right hemisphere and increases solicitation of the contralateral precentral and postcentral gyrus. CONCLUSIONS: There seems to be a real reversible dynamic plasticity under the balance of inhibitory and excitatory influences exerted on the cortical neurons. Any disruption of this balance requires the brain to adapt to the new circumstances to reestablish the hand as a functioning part of the body.

Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa.

BACKGROUND: The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author's (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa. METHODS: This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered. RESULTS: The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent). CONCLUSIONS: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The cervicofacial lift under pure local anaesthesia diminishes the incidence of post-operative haematoma.

The cervicofacial lift is a frequently performed procedure in plastic surgery. It is the reference technique for facial rejuvenation and restoration of the oval form of the face and it is essential to treat excess skin. One of the most frequent complications of this procedure is the formation of haematomas. The aim of this article is to analyse the incidence of bleeding in the standard cervicofacial lift carried out under pure local anaesthesia. The entire operation, including liposuction and tightening of the SMAS, can be done under local anaesthesia. A total of 1500 patients, who have undergone cervicofacial lift under pure local anaesthesia between November 1995 and January 2016, were included in the study. The incidence of early bleeding (in the first 15 days following the operation) was recorded and analysed. Pre- intra- and post-operative monitoring of the arterial blood pressure revealed stable pressure in the peri­operative period. The mean difference in blood pressure when comparing the intra-operative to the post-operative periods was 7 mmHg for the systolic BP [range from 3 to 25] and 4 mmHg [range from 2 to 12] for the diastolic BP, with lower mean values in the post-operative period. We identified nine bleeding events in 1500 patients (0.6%). The cervicofacial lift under pure local anaesthesia does not radically modify the surgical technique. It allows better control of arterial blood pressure of patients throughout the surgical procedure and avoids fluctuations in blood pressure, which is one of the main causes of bleeding and haematoma formation. The infiltration of xylocaine adrenaline combined with the absence of hypotensive general anaesthesia diminishes the incidence of haematoma and ensures an early return home for the patients.

Impact on Breastfeeding According to Implant Features in Breast Augmentation: A Multicentric Retrospective Study.

BACKGROUND: Exclusive breastfeeding is highly recommended by the World Health Organization during the first 6 months of life. In parallel, breast augmentation with implants is one of the most performed operations in aesthetic surgery. OBJECTIVE: The goal of our study was therefore to analyze the potential impact of aesthetic breast implants on breastfeeding. STUDY DESIGN: A retrospective study was carried out in 3 French university hospitals. The main inclusion criterion was adult women of childbearing age (18-50 years old) with bilateral breast hypoplasia. Some features of the surgery, such as the operative indication, the surgical approach, the implant position against the pectoral muscle, and implants features (material, volume, profile), were collected. We conducted a survey by phone about childbirth after the procedure. If the women had children after surgery, we asked them if they breastfed and the characteristics of breastfeeding. RESULTS: In total, 1316 patients received breast implants in the 3 centers from January 2011 to October 2016 and met our inclusion criteria. We included 1073 patients; 998 women had breast implants with no pregnancy. Among the 75 patients (7%) who gave birth after the surgery, 51 wanted to breastfeed (68%). The patients with a retroglandular implant were significantly less able to breastfeed compared with the patients with retromuscular implants (P = 0.0005). No difference was found for age, the type of surgery, the surgical approach, and the shape or type of implant between the successful breastfeeding group and failed breastfeeding group. CONCLUSION: A woman with aesthetic breast implants has a 75% chance of breastfeeding if desired, regardless of the type and the volume of the implant and the surgical approach. She has an 82% probability of breastfeeding with retromuscular implants and 17% with retroglandular implants.

Monitoring of Myocutaneous Flaps by Measuring Capillary Glucose and Lactate Levels: Experimental Study.

INTRODUCTION: In surgery, certain defects require reconstruction with a microsurgical flap. The free flap failure rate varies between 2% and 5%. Vascular thrombosis is the most frequent complication and represents 15% to 73% of failures. The success rate of salvage therapy is greater when salvage surgery is early. Currently, clinical monitoring is the criterion standard but many noninvasive or minimally invasive techniques have been developed to improve early diagnosis of complications of vascular thrombosis. The aim of our experimental study was to compare clinical assessments with measurements of capillary glycemia and lactatemia during the monitoring of free flaps. MATERIALS AND METHODS: Myocutaneous latissimus dorsi flaps with skin paddles were created in pigs under general anesthesia. For each animal, 2 flaps were created (right and left) using the same technique. Four groups were made: group 1 (no flap ligation: control group), group 2 (flap with permanent ligation of the artery), group 3 (flap with permanent ligation of the two veins), group 4 (flap with transient ligation of the artery and 2 veins for 1 hour). The postoperative monitoring protocol consisted of monitoring the clinical, biological (glucose and lactate), and histological parameters. RESULTS: Eight animals were operated on and sixteen flaps were created. Each flap was clinically and biologically tested 25 times. Clinical, biological, and histological monitoring showed significant variations between the groups. The analysis of variance of capillary glycemia and lactatemia showed statistically significant difference between control group and group 2 (P < 0,0001), group 3 (P < 0,0001), or group 4 (P < 0,0001). There were no histological abnormalities after transient ligature at different times contrary to permanent ligature. DISCUSSION-CONCLUSION: Measuring capillary levels of lactate and glucose associated with clinical monitoring may shorten the time to diagnosis of flap failure. Ultimately, this will save lives and achieve better functional and aesthetic results.

Similarities between induced membrane and amniotic membrane: Novelty for bone repair.

Previous clinical studies have shown the efficacy of a two-stage surgical procedure - the induced membrane (IM) technique - for reconstruction of large bone defects or bone non-union. The first stage involves radical debridement and insertion of a cement spacer into the bone defect. The second stage, performed weeks to months later, consists of removing the spacer while leaving the foreign body membrane induced by the cement in place, and then filling the cavity with bone autograft. The IM has been shown to (1) act as a protective physical barrier by preventing bone autograft resorption and (2) act as a bioreactor by promoting healing through revascularisation and growth factor secretion, and by concentrating mesenchymal stem cells (MSC) with osteogenic properties. New solutions to reduce this surgical procedure to a single step are being explored, for example by using an IM-like bioactive and protective barrier inserted into the bone defect at the same time as bone graft.

Fresh and in vitro osteodifferentiated human amniotic membrane, alone or associated with an additional scaffold, does not induce ectopic bone formation in Balb/c mice.

The human amniotic membrane (hAM) has been successfully used as a natural carrier containing amniotic mesenchymal stromal cells, epithelial cells and growth factors. It has a little or no immunogenicity, and possesses useful anti-microbial, anti-inflammatory, anti-fibrotic and analgesic properties. It has been used for many years in several indications for soft tissue repair. We previously reported that hAM represents a natural and preformed sheet containing highly potent stem cells, and could thus be used for bone repair. Indeed, native hAM possesses pre-osteoblastic potential that can easily be stimulated, even as far as mineralization, by means of in vitro osteogenic culture. However, cell culture induces damage to the tissue, as well as to cell phenotype and function. The aim of this study was to evaluate new bone formation by fresh and in vitro osteodifferentiated hAM, alone or associated with an additional scaffold presenting osteoinductive properties. Moreover, we also aimed to determine the effect of in vitro hAM pre-osteodifferentiation on its in vivo biocompatibility/tissue degradation. Results showed that neither fresh nor osteodifferentiated hAM induced ectopic bone formation, whether or not it was associated with the osteoinductive scaffold. Secondly, fresh and osteodifferentiated hAM presented similar in vivo tissue degradation, suggesting that in vitro hAM pre-osteodifferentiation did not influence its in vivo biocompatibility.