Total lower eyelid reconstructions with septal chondromucosal graft and pedicled flap on the superficial temporal artery.

BACKGROUND: Subtotal and total lower eyelid tissue loss after tumour excision is a complex issue for reconstructive surgeons. The anterior and posterior flaps must be restored to avoid compromising the functional and aesthetic prognosis of the eye. This study used a septal chondromucosal graft for the posterior lamella and a fasciocutaneous flap pedicled on the temporal artery for the anterior lamella. METHOD: We conducted a 10-year monocentric retrospective study, including 18 patients who were treated using a septal chondromucosal graft with a temporal artery pedicle flap following tumour excision. We collected demographic and medico-surgical data related to flap survival, absence of ectropion, lagophthalmos and other post-operative complications. The aesthetic outcome was judged using a grading scale during the last follow-up consultation. RESULTS: All grafts and flaps survived, whereas 2 patients required early repeat surgery (1 for ectropion and 1 for graft site haematoma). None of the patients developed lagophthalmos. Two patients had distal flap injuries that healed with local care. All patients were satisfied with the aesthetic outcome at the last follow-up visit. CONCLUSION: Combining a septal chondromucosal graft with a fasciocutaneous flap pedicled to the temporal artery for total lower eyelid reconstruction is a reliable method with satisfactory functional and cosmetic outcomes.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments. METHODS: This randomized, non-inferiority trial enrolled patients who underwent skin excision (>30 cm2), which was left open to heal by secondary intention. They received ALGINATE or NPWT by a centralized randomization. Follow-up was performed weekly until optimal granulation tissue was obtained. The primary outcome was time to obtain optimal granulation tissue for a split thickness skin graft take (non-inferiority margin: 4 days). Secondary outcomes were occurrence of adverse events (AEs) and impact of the treatments on the patient's daily life. RESULTS: ALGINATE and NPWT were applied to 47 and 48 patients, respectively. The mean time to optimal granulation was 19.98 days (95% CI, 17.7-22.3) with ALGINATE and 20.54 (95% CI, 17.6-23.5) with NPWT. Between group difference was -0.56 days (95% CI -4.22 to 3.10). The non-inferiority of ALGINATE versus NPWT was demonstrated. No AE related to the treatment occurred with ALGINATE versus 14 AEs with NPWT. There was no difference in the impact of the treatments on the patient's daily life. CONCLUSION: This trial demonstrates that ALGINATE has a similar healing efficacy to that of NPWT and that is markedly better with regard to patient safety.

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.

Vasodilator response to galvanic current stimulation of the skin accurately detects acetylsalicylic acid intake: A study in 400 vascular patients.

BACKGROUND AND AIMS: The first cause of low-dose acetylsalicylic-acid (ASA) inefficacy is poor adherence to treatment. No non-invasive technique is available to assess ASA intake. Current-induced vasodilation (CIV) was found abolished in healthy volunteers after low-dose ASA intake. We tested clinical characteristics, treatments, and comorbid conditions influencing CIV amplitude in vascular patients. METHODS: CIV was tested in 400 patients (277 males and 123 females, aged 65.4 ±â€¯13.4 years). We focused on clinical characteristics, treatments, and comorbid conditions as covariates of CIV amplitude. We studied the CIV amplitude to covariate relationships with multivariate linear regression and receiver operating characteristics (ROC). RESULTS: The multivariate linear model determined that ASA intake within the last 48 h and the interaction between ASA intake and body mass index (BMI) were the sole covariates associated with CIV amplitude. For the whole population, the area under the ROC curve (AUC) for CIV to predict ASA intake was 0.853 [95% confidence interval (CI): 0.814-0.892]. Considering separately the areas observed for non-obese (BMI ≤30, n = 303) and obese (BMI>30, n = 93) patients, the AUC [95% CI] was 0.873 [0.832-0.915] and 0.776 [0.675-0.878], respectively (p = 0.083). CONCLUSIONS: ASA is the only drug that affects the amplitude of CIV response observed after galvanic current application to the skin of vascular patients. CIV depends on BMI but not age or gender. As such, CIV appears to be a potential objective marker of ASA intake and could facilitate future non-invasive assessments of adherence to ASA treatment.

Central Role of P2Y6 UDP Receptor in Arteriolar Myogenic Tone.

OBJECTIVE: Myogenic tone (MT) of resistance arteries ensures autoregulation of blood flow in organs and relies on the intrinsic property of smooth muscle to contract in response to stretch. Nucleotides released by mechanical strain on cells are responsible for pleiotropic vascular effects, including vasoconstriction. Here, we evaluated the contribution of extracellular nucleotides to MT. APPROACH AND RESULTS: We measured MT and the associated pathway in mouse mesenteric resistance arteries using arteriography for small arteries and molecular biology. Of the P2 receptors in mouse mesenteric resistance arteries, mRNA expression of P2X1 and P2Y6 was dominant. P2Y6 fully sustained UDP/UTP-induced contraction (abrogated in P2ry6(-/-) arteries). Preventing nucleotide hydrolysis with the ectonucleotidase inhibitor ARL67156 enhanced pressure-induced MT by 20%, whereas P2Y6 receptor blockade blunted MT in mouse mesenteric resistance arteries and human subcutaneous arteries. Despite normal hemodynamic parameters, P2ry6(-/-) mice were protected against MT elevation in myocardial infarction-induced heart failure. Although both P2Y6 and P2Y2 receptors contributed to calcium mobilization, P2Y6 activation was mandatory for RhoA-GTP binding, myosin light chain, P42-P44, and c-Jun N-terminal kinase phosphorylation in arterial smooth muscle cells. In accordance with the opening of a nucleotide conduit in pressurized arteries, MT was altered by hemichannel pharmacological inhibitors and impaired in Cx43(+/-) and P2rx7(-/-) mesenteric resistance arteries. CONCLUSIONS: Signaling through P2 nucleotide receptors contributes to MT. This mechanism encompasses the release of nucleotides coupled to specific autocrine/paracrine activation of the uracil nucleotide P2Y6 receptor and may contribute to impaired tissue perfusion in cardiovascular diseases.

Effect of lip closure on early maxillary growth in patients with cleft lip and palate.

IMPORTANCE: Debate continues about the cause of midfacial growth disturbance in patients with facial clefts. OBJECTIVE: To evaluate the functional effect of surgical closure of the lip before palatal closure according to the technique by Delaire on early maxillary growth in patients with complete unilateral cleft lip and palate. DESIGN, SETTING, AND PARTICIPANTS: Twenty-two patients with unilateral cleft lip and palate were studied using plaster casts obtained at the time of cheilorhinoplasty and 6 months later before palatal closure. The interrupted lateral muscles were anatomically repositioned using the surgical technique by Delaire. No patients had received preoperative orthodontic treatment or a passive palatal plate. Cast analyses were performed using a digital caliper. MAIN OUTCOMES AND MEASURES: Landmark positioning was performed 3 times by 2 different examiners to define intraobserver and interobserver differences. The final maxilla dimensions were recorded as the distances between the mean landmark positions. Using the t test, dimensions obtained before palatal closure were compared with dimensions obtained before lip closure. RESULTS: The method allowed good reproducibility. Functional closure of the lip significantly narrowed the transverse anterior cleft areas by -2.36 mm (P < .05). Sagittal variables were increased by 1.68 mm on the nonaffected side and by 1.48 mm on the affected side (P < .05 for both). CONCLUSIONS AND RELEVANCE: Functional closure according to the technique by Delaire narrows the transverse dimensions of the maxilla, while simultaneously preserving initial sagittal growth. LEVEL OF EVIDENCE: 4.

Diathermocoagulation in cutting mode and large flap dissection.

BACKGROUND: The aim of this study was to determine the overall complication rate associated with the use of diathermocoagulation in cutting mode for flap dissection. METHODS: Because of the high rate of complications generally associated with abdominoplasty, a large flap, abdominoplasty, or abdominal dermolipectomy model was chosen. A retrospective review was conducted regarding 647 abdominoplasty procedures, 320 of which were performed with the monopolar diathermocoagulation in the cutting mode and 327 of which were performed with a steel scalpel. The two groups were similar regarding morphologic characteristics, prescriptions, and procedures. In both cases, hemostasis was performed with punctual monopolar coagulation current. Analysis was performed regarding the frequency of major general complications (e.g., deep vein thrombosis and pulmonary embolism), major surgical complications (e.g., acute hemorrhage), and "minor" complications (e.g., postoperative secondary collections or delayed wound healing). RESULTS: In the electrosurgery group, the incidence of noninfectious collections was significantly higher, as was the production of the drains. No difference was seen in terms of reintervention for acute hematoma, postoperative infectious collections, blood loss, hospital stay, or thromboembolic complications. Operations took significantly longer with the steel scalpel. The follow-up was significantly longer in the diathermocoagulation group. CONCLUSIONS: Monopolar diathermocoagulation has already proven its place in the general work of every surgeon. Moreover, this technique remains superior in terms of the rapidity with which surgery can be performed when dissecting large areas. Nevertheless, the higher rate of surgical complications leads to a longer follow-up period that, in part, runs counter to this advantage.

Accelerating protons to therapeutic energies with ultraintense, ultraclean, and ultrashort laser pulses.

Proton acceleration by high-intensity laser pulses from ultrathin foils for hadron therapy is discussed. With the improvement of the laser intensity contrast ratio to 10(-1) achieved on the Hercules laser at the University of Michigan, it became possible to attain laser-solid interactions at intensities up to 10(22) W/cm2 that allows an efficient regime of laser-driven ion acceleration from submicron foils. Particle-in-cell (PIC) computer simulations of proton acceleration in the directed Coulomb explosion regime from ultrathin double-layer (heavy ions/light ions) foils of different thicknesses were performed under the anticipated experimental conditions for the Hercules laser with pulse energies from 3 to 15 J, pulse duration of 30 fs at full width half maximum (FWHM), focused to a spot size of 0.8 microm (FWHM). In this regime heavy ions expand predominantly in the direction of laser pulse propagation enhancing the longitudinal charge separation electric field that accelerates light ions. The dependence of the maximum proton energy on the foil thickness has been found and the laser pulse characteristics have been matched with the thickness of the target to ensure the most efficient acceleration. Moreover, the proton spectrum demonstrates a peaked structure at high energies, which is required for radiation therapy. Two-dimensional PIC simulations show that a 150-500 TW laser pulse is able to accelerate protons up to 100-220 MeV energies.