Intraoperative instillation of ropivacaine during the placement of sub-muscular cosmetic breast implants: Is there a clinical benefit?

INTRODUCTION: The sub-muscular placement of cosmetic breast implants leads to substantial pain due to the muscular distention. The aim of this study was to assess the efficiency of intraoperative ropivacaine instillation to reduce postoperative pain the day after surgery. MATERIAL AND METHODS: We conducted a prospective, controlled, single-blinded study comparing the intraoperative instillation of 7.5mg of ropivacaine through Redon drains with the standard procedure in 72 patients undergoing sub-muscular cosmetic breast augmentation for the first time. RESULTS: Pain at the awakening on postoperative day 1 was 4.8 on a simple numeric pain scale in the treatment group and 5.1 in the control group (P>0.05). On postoperative day 3, pain at awakening was 3.7 in both groups (P>0.05), and on postoperative day 5, pain was 2.8 in the treatment group and 2.7 in the control group (P>0.05). CONCLUSION: Local instillation of ropivacaine in the implant pocket during surgery did not decrease postoperative pain on day 1, day 3 and day 5. From now on, we are able to tell to patients that the postoperative pain after sub-muscular cosmetic breast implants surgery is about 5/10 on postoperative day 1, 4/10 at day 3 and 3/10 at day 5. LEVEL OF EVIDENCE: Level II.

A preoperative cotininury test for abdominoplasty reduces peri-operative complications.

BACKGROUND: Smoking induces complications in plastic surgery, in particular wound healing delays. Despite a 4-weeks' abstinence asking before and after surgery, some patients denied or hid their consumption. The aim of this study was to evaluate the effectiveness of a cotininury detection test in terms of improvement in outcomes after an abdominoplasty. MATERIAL AND METHODS: This retrospective cohort study included patients who underwent an abdominoplasty with umbilical transposition and lipoaspiration. Current smokers were asked to stop smoking 4 weeks before and after surgery. After 2013, we performed a preoperative cotininury test for patients having abdominoplasty, with a cancellation of surgery in case of positive result. We analyzed the test's effectiveness on delayed healing and on other complications. RESULTS: Two hundred and thirty-five patients were included; 80 were tested and 21,3% had a positive test. There was significantly less delayed healing in the "screening" group than in the "no screening": 20,3% versus 41,5% (P=0,002). Alike, complications were significantly less frequent in the "screening" group than in the "no screening": 18,1% versus 42,3% (P<0,001). CONCLUSION: The routine use of the cotininury test in preoperative abdominoplasties significantly reduces risk of delayed healing and other serious complications. It is an objective test, which is simple, quick and non-invasive. Smoking cessation must be at least 4 weeks before and after the surgery. Following medical advice to cease smoking by the surgeon and anesthetist, referral to an appropriate tobacco-addiction specialist clinic may be helpful for the patient who has difficulty stopping smoking.

[Giant recurrent trochanteric pressure sore: A complex medico-surgical care]. / Escarre trochantérienne géante récidivante : une prise en charge médico-chirurgicale complexe.

BACKGROUND: Pressure sores are a frequent complication in spinal injured people. Their treatment is often long and complex. OBSERVATION: We report the case of a 60-year-old man affected with complete paraplegia who developed a right trochanteric pressure ulcer complicated with osteoarthritis of the coxofemoral joint. The treatment was done in three steps. First, a large excision of necrotic tissues and a femoral head-neck resection is performed. Then, the defect is partly covered with a Gluteus Maximus and a Biceps Femoris myocutaneous flaps. Finally, the residual defect is covered with a cutaneous pedicled groin flap called McGregor's flap. Later, the patient showed a right para-scrotal pressure sore on a heterotopic ossification of the ischial tuberosity. DISCUSSION: McGregor's flap is rarely employed for treating trochanteric pressure sores. It was here the only pedicled flap available. It was necessary to autonomize it in order to get enough length and to place a hip external fixation. The para-scrotal pressure sore illustrates the fact that bone resection surgery lifts the weight-bearing zones and can lead to pressure sores in unusual locations. CONCLUSION: The surgical treatment of these "giant" pressure sores requires a perfect collaboration between teams of rehabilitation and several surgical areas. Without a good adherence of the patient, the treatment is doomed to fail.

[Breast reconstruction by latissimus dorsi flap: Towards an evolution of ideas]. / Reconstruction mammaire par lambeau de grand dorsal: vers une évolution des idées.

AIM OF THE STUDY: Breast reconstruction with latissimus dorsi flap and fat grafting is a technique widely used in current practice. Some operators still complain at the lack of final results at the first intervention and the need for repeated lipofilling sessions. The objective of this study was to compare the number of reoperations in patients who underwent reconstruction with latissimus dorsi with prosthesis versus without prosthesis. PATIENTS AND METHODS: We included all patients operated for breast reconstruction with latissimus dorsi flap, with or without prosthesis between 2008 and 2012 in our center. We noted the number of new surgical interventions in these patients on the reconstructed breast. We also noted the average weight of mastectomy in two groups each year. RESULTS: One hundred and eighty-six patients were included in this study. Ninety-one patients underwent reconstruction with latissimus dorsi and prosthesis, and 95 patients reconstruction by latissimus dorsi and fat graft. It has not been demonstrated significant differences in the number of new surgical procedures between the two groups. The average weight of mastectomies in the autologous group has steadily increased over the five years. There was no significant difference in the average weight of mastectomies between the two groups over the last two years. CONCLUSION: For breast reconstruction with latissimus dorsi flap, surgical indications changed in our center to the absence of prosthetic implant, whatever the volume of the breast.

[Use of Extensor digitorum brevis flap in routine reconstructive surgery of lower limbs. Report of more than 50 cases]. / Utilisation du lambeau Extensor digitorum brevis en pratique courante de la chirurgie reconstructrice des membres inférieurs. Une expérience de plus de 50 cas.

The authors report their experience about more than 50 patients with soft tissue defects in the area of the lower leg, of the ankle and of the dorsal aspect of the foot and toes, managed with the Extensor digitorum brevis flap. We have most often performed it with a proximal pedicle. Healing was obtained for all case. Infections of malleola have been treated thank to the better delivery of antibiotics. The donor site shows often delayed healing, but in one case, the harvestment area has presented a complete necrosis, which healed with immobilisation of the ankle with external fixator and dressings. At last, we insist on the fast learning of the procedure and the aim to use it in humanitary mission.

Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon's perspective.

Objective aesthetic criteria are important for patient evaluation and analysis during aesthetic surgeries, while successful aesthetic surgeries must take into account the underlying ethnic differences. The aim of this study is to help surgeons and scientists better plan facial aesthetic surgeries and understand the aesthetic needs according to different patients by reviewing and comparing the current aesthetic principles and preferences in Caucasian and East Asian populations. PubMed and The Cochrane Library were searched using keywords regarding anthropometric measurements. Only original clinical studies and reviews written in English and Chinese and those that focused on the objective assessment of facial aesthetics in Caucasian and East Asian female populations were retained for review. Reference lists of the selected articles were also reviewed for eligible studies. Sixty-five articles that described objective aesthetic criteria in Caucasian and East Asian female populations were found through PubMed, among which 47 included Caucasian populations and 18 included East Asian populations. Compared with White women, East Asian women prefer a small, delicate, and less robust face, lower position of double eyelid, more obtuse nasofrontal angle, rounder nose tip, smaller tip projection, and slightly more retruded mandibular profile. Various differences exist between objective facial aesthetic criteria in Caucasian and East Asian populations. Further studies that focus on the objective aesthetic criteria of facial attractiveness in different ethnicities need to be conducted, especially in Asian countries. Level V: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Injections of platelet-rich plasma for androgenic alopecia: A systematic review.

The aim of this literature review was to evaluate the effects of PRP injections into the scalp of patients with androgenic alopecia. A literature review was conducted using the Pubmed and Google Scholar databases with the search terms "platelet-rich plasma" or "platelet-rich fibrin" and "hair" or "alopecia" or "androgenic alopecia". The publications included had to clinically assess the efficacy of PRP injections in patients with androgenic alopecia. Out of the 32 publications retrieved, 14 publications were included, of which 3 randomized, 4 prospective controlled, 4 prospective uncontrolled and 3 retrospective studies. Seven out of 9 studies reported a significant increase of hair density ranging between 12.3 and 45.9 hairs/cm2, (i.e. 19-31% hairs/cm2). Four studies assessed hair loss with the traction test and found a negative result after treatment in more than 95% of patients. Regarding hair thickness, 1 study reported an increase in hair diameter of 46.4% and 1 reported an increase of 106.4% of the "Hair mass index". Overall, the use of PRP injections in patients with androgenic alopecia seems effective with respect to promoting lost hair regrowth, decreasing hair loss and increasing hair thickness. The effects appear to be progressive from the first injection session, to peak after 3 to 5 sessions and to be attenuated in the absence of further injections. No major adverse effect was reported in the 14 clinical studies.

A modified nasolabial flap for reconstruction of transfixing alar wing defects.

Reconstruction of an entire alar wing is a frequently encountered reconstructive challenge in onco-dermatologic surgery. The aim of this technical note was to describe a surgical technique total for reconstruction of the alar wing, with a modified nasolabial flap with an inferior pedicle associated with a cartilaginous graft. This rapid procedure seems to be a well alternative for elderly people and patients who do not want a forehead flap. The aesthetic and functional outcomes of the donor and recipient sites were satisfactory.

Mandibular reconstruction after cancer: an in-house approach to manufacturing cutting guides.

The restoration of mandibular bone defects after cancer can be facilitated by computer-assisted preoperative planning. The aim of this study was to assess an in-house manufacturing approach to customized cutting guides for use in the reconstruction of the mandible with osteocutaneous free flaps. A retrospective cohort study was performed, involving 18 patients who underwent mandibular reconstruction with a fibula free flap at three institutions during the period July 2012 to March 2015. A single surgeon designed and manufactured fibula and mandible cutting guides using a computer-aided design process and three-dimensional (3D) printing technology. The oncological outcomes, production parameters, and quality of the reconstructions performed for each patient were recorded. Computed tomography scans were acquired after surgery, and these were compared with the preoperative 3D models. Eighteen consecutive patients with squamous cell carcinoma underwent surgery and then reconstruction using this customized in-house surgical approach. The lengths of the fibula bone segments and the angle measurements in the simulations were similar to those of the postoperative volume rendering (P=0.61). The ease of access to 3D printing technology has enabled the computer-aided design and manufacturing of customized cutting guides for oral cancer treatment without the need for input from external laboratories.

Surgical management of necrotizing cellulitis: Results of a survey conducted in French plastic surgery departments.

OBJECTIVE: Necrotizing cellulitis (NC) is a severe infection of the skin and soft tissues, requiring an urgent multidisciplinary approach. We aimed to clarify the surgical management of NC in French plastic surgery departments. PATIENTS AND METHOD: Thirty-two French plastic surgery departments were invited to complete a survey sent by email. Questions focused on diagnostic and therapeutic management of NC in France. RESULTS: Twenty-five plastic surgery departments completed the survey (78%) and each center had a lead plastic surgeon. Overall, 88% of surgeons declared to have managed at least five NC patients within the year. The plastic surgeon was the lead surgical specialist for NC in 80% of cases. Conversely, 76% of interviewed facilities reported not to have any lead medical specialist. Time between surgical indication and surgical management was less than six hours in 92% of cases. Overall, 24% of responding facilities declared that access to the operating room never delayed management. Finally, 80% of facilities declared to be in favor of dedicated care pathways to improve the management of necrotizing cellulitis patients. CONCLUSION: Our study results highlight the heterogeneity of necrotizing cellulitis management in France. The lack of a dedicated care pathway may lead to diagnostic and treatment delays.

DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results.

BACKGROUND: Although some papers have analyzed patient satisfaction after traditional abdominoplasty, studies that have specifically assessed patient satisfaction on abdominal reconstruction after deep inferior epigastric perforator (DIEP) surgery are lacking. AIM: The aim of this study was to assess satisfaction, specifically for abdominoplasty results, in patients who underwent breast reconstruction with a single DIEP flap. METHODS: This retrospective study included 53 consecutive patients who underwent unilateral breast reconstruction with a DIEP flap. The patients were all clinically evaluated during a specific consultation and answered a satisfaction survey based on a four-point scale (unsatisfied, satisfied, happy, and very happy). RESULTS: A total of 50 patients responded to the survey. The average age was 52.3 years. This study revealed that 52% of the patients were happy or very happy with the aesthetic result of their abdomen. A total of 34% of the patients confessed that they preferred their abdomen before surgery. A further analysis of the dissatisfied patients showed particular dissatisfaction with dog-ears (50%), residual abdominal overhang (18%), or the horizontal scar (12%). The average distance between the horizontal scar and vulvar anterior commissure was 10.6 cm. A total of 86% of the patients were happy or very happy with the preoperative counseling. CONCLUSIONS: The authors note the necessity to give detailed preoperative information to explain the final abdominal aesthetic result, which can be quite different from the patient's expectations.

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient.

INTRODUCTION: Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. PATIENTS AND METHODS: Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. RESULTS: The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft. DISCUSSION: All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.