Is dangling of the lower leg after a free flap reconstruction necessary? Study protocol for a large multicenter randomized controlled study.

BACKGROUND: Within the field of plastic surgery, free tissue transfer is common practice for knee and lower leg defects. Usually, after such free flap reconstruction, patients undergo a dangling protocol in the postoperative phase. A dangling protocol is designed to gradually subject the free flap to increased venous pressure resulting from gravitational forces. Worldwide there are multiple variations of dangling protocols. However, there is no evidence available in the literature that supports the use of a dangling protocol. METHODS: This is a multicenter randomized controlled trial that includes patients with a free flap lower leg reconstruction. The primary outcome is to assess whether a no-dangling protocol is not inferior to a dangling protocol, in terms of proportion of partial flap loss, 6 months after surgery. Secondary objectives are to identify differences in major and minor complications, length of stay, and costs, and to objectify blood gaseous changes during dangling. Furthermore, at 2 years we will assess difference in physical function, infection rates, and osseous union rates. DISCUSSION: The primary outcome of this study will give a more decisive answer to the question of whether a dangling protocol is necessary after a free flap reconstruction of the lower leg. The secondary outcomes of this study will provide a better insight into the physical functions, infection rates, and union rates in these patients. TRIAL REGISTRATION: Central Committee on Research Involving Human Subjects (CCMO), NL63146.041.17. Registered on 11 July 2018. Netherlands Trial Register, NTR7545 . Registered on 10 October 2018.

[A woman with a growing mass close to the fingernail]. / Een drukpijnlijke tumor bij de vingernagel.

A 23-year-old woman had a painful, growing mass close to the nail of her left index finger. The differential diagnosis consisted of acquired digital fibrokeratoma, digital fibromyxoma, periungual fibroma or verruca vulgaris. Surgical excision of the mass was performed, and histopathological analysis revealed a subungual exostosis.

Nutritional deficiencies in gastric bypass patients; incidence, time of occurrence and implications for post-operative surveillance.

BACKGROUND: Post-operative nutritional deficiencies are a common complication following bariatric surgery. The incidence and time of occurrence are not clear, and the efficacy of supplementation remains questionable. Clear guidelines for nutritional follow-up and counselling are needed. METHODS: Preoperative and post-operative deficiencies were determined in a group of 427 gastric bypass patients. The predictive value of preoperative laboratory findings for the development of post-operative deficiencies, the time of occurrence and the effect of supplementation of common deficiencies was studied. RESULTS: Most common preoperative deficiencies were of folic acid (21.3%), vitamin D3 (17.5%) and iron (21.8%). Post-operative, a significant increase in the number of patients with anaemia and deficiencies of ferritin and vitamin B12 was found. Most deficiencies occur between 12 and 15 months post-operatively, but vitamin D3 deficiency occurs significantly earlier at 9.7 months. A preoperative iron, folic acid or ferritin deficiency results in a significant higher risk for developing a post-operative deficiency despite supplementation, and ferritin deficiency occurs significantly earlier in these patients. Oral treatment of post-operative vitamin B12 and vitamin D3 deficiencies was successful in more than 80% of the patients in contrast to oral treatment of anaemia which was only successful in 62.5% of the patients. CONCLUSION: Our study emphasizes the importance of preoperative assessment and treatment of nutritional deficiencies in morbidly obese patients undergoing gastric bypass surgery. Despite limited efficacy, post-operative oral supplementation should be encouraged as it decreases the incidence of deficiencies.

Quality of life long-term after body contouring surgery following bariatric surgery: sustained improvement after 7 years.

BACKGROUND: Bariatric surgery for morbid obesity results in massive weight loss and improvement of health and quality of life. A downside of the major weight loss is the excess of overstretched skin, which may influence the patient's quality of life by causing functional and aesthetic problems. The purpose of the current study was to evaluate the patient's quality of life long-term after body contouring following bariatric surgery. METHODS: Quality of life was measured with the Obesity Psychosocial State Questionnaire in 33 post-bariatric surgery patients 7.2 years (range, 3.2 to 13.3 years) after body contouring surgery. Data were compared with previous assessments 4.1 years (range, 0.7 to 9.2 years) after body contouring surgery of the quality of life at that time and before body contouring surgery. RESULTS: Compared with appraisals of quality of life before body contouring surgery, a significant, mostly moderate to large, sustained improvement of quality of life was observed in post-bariatric surgery patients 7.2 years after body contouring surgery in six of the seven psychosocial domains. A small deterioration occurred between 4.1- and 7.2-year follow-up on two of the seven domains except for the domain efficacy toward eating, which showed a significant improvement. At 7-year follow-up, 18 patients (55 percent) were satisfied with the result of body contouring surgery. CONCLUSIONS: This study indicates a sustained quality-of-life improvement in post-bariatric surgery patients after body contouring surgery. This suggests the importance of including reconstructive surgery as a component in the multidisciplinary approach in the surgical treatment of morbid obesity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complications after body contouring surgery in post-bariatric patients: the importance of a stable weight close to normal.

OBJECTIVE: Body contouring surgery is in high demand following the increase in bariatric surgery. Massive weight loss leads to an excess of lax, overstretched skin causing physical and psychosocial discomfort. Plastic surgical procedures can give rise to an improvement in quality of life, but the relative high complication rate could negatively affect these potential gains. The purpose of this study is to identify predictors of complications in order to optimize outcomes in this patient population. METHODS: Out of a group of 465 post-bariatric patients, 61 patients underwent body contouring surgery following massive weight loss. A total of 43 respondents were reviewed retrospectively for demographic data, pre- and post-operative weight status and co-morbidities. Medical complications were categorized according to the modified Clavien classification. All cases were analyzed for risk factors. RESULTS: A stable weight over a period of at least 3 months prior to body contouring surgery is associated with a significant lower complication rate (odds ratio 0.24; CI 0.07-0.79) and the percentage excess weight loss (odds ratio 0.96; 95% CI 0.92-1.00) was an independent predictor for the occurrence of complications. The overall complication rate was 27.9% with a major complication rate of 8.8%. Most frequent procedures were abdominoplasty (61%) and breast reduction/ mammapexy (25%). CONCLUSION: This study emphasizes the importance to strive for a stable weight close to normal before surgery to minimize the risk of complications. The positive effects of the long-term results of bariatric surgery tolerate the relative high complications rate. Careful pre-operative planning and patient selection are essential to optimize the results of body contouring surgery of post-bariatric patients.

The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life.

BACKGROUND: Massive weight loss following bariatric surgery may lead to an excess of lax, overstretched skin, causing physical discomfort which may affect the patient's quality of life. Whereas the functional and aesthetic deformity is an expected result of massive weight loss, the role of the plastic surgeon in the multidisciplinary approach of the morbidly obese is still unclear. The purpose of the current study is to evaluate the results of reconstructive surgery following weight loss surgery, focusing on the impact on the physical and psycho-social well-being and quality of life of the patients. METHODS: Out of a group of 465 patients, 61 patients underwent reconstructive surgery following weight loss surgery. In 43 respondents, the quality of life after reconstructive surgery was measured by the Obesity Psychological State Questionnaire. Patient satisfaction was evaluated. RESULTS: Reconstructive surgery resulted in a significant improvement in quality of life in patients at a mean interval of 42 months between weight loss and reconstructive surgery. The most frequent procedures were abdominoplasty and breast reconstruction. The relative high complication rate of 27.9% was of no influence on quality of life and the majority of the patients (67%) were satisfied with reconstructive surgery. CONCLUSIONS: This study shows that reconstructive surgery following weight loss after bariatric surgery results in a significant improvement in overall quality of life. Reconstructive surgery should be incorporated in the multidisciplinary care programme following weight loss surgery in the morbidly obese patient.