Can probiotic gargles reduce post-tonsillectomy morbidity in adult patients? A pilot, triple-blind, randomised, controlled trial and feasibility study.

OBJECTIVE: This study aimed to determine the efficacy of probiotic gargles compared with placebo gargles on reducing post-tonsillectomy morbidity in adults. METHOD: This was a triple-blind, randomised, controlled trial and feasibility study. Thirty adults underwent elective tonsillectomy and were randomly assigned to receive either probiotic or placebo gargles for 14 days after surgery. Daily pain scores and requirement of analgesia were measured for 14 days post-operatively. Secondary outcomes assessed probiotic safety and tolerability and the feasibility of the trial. RESULTS: The probiotic group experienced less pain at rest on day 2. However, the amount of oxycodone (5 mg) tablets used was greater in the probiotic group compared with placebo. There were no statistically significant differences in the frequency of adverse effects between both groups. This trial was feasible. CONCLUSION: This pilot study suggested that probiotic gargles do not reduce post-tonsillectomy pain or bleeding, highlighting the importance of pilot and feasibility studies in clinical research.

A surgical view on the treatment of Madelung's disease.

Benign symmetrical lipomatosis (Madelung's disease) is a rare condition of unclear aetiology characterized by numerous, unencapsulated lipomatous deposits. The only effective treatment is by surgical intervention; however, there is no consensus in the optimal approach. We present the case of a patient who required staged, multi-modality treatment to achieve disease quiescence. The case highlights the usefulness of magnetic resonance imaging as a tool for assessment as well as preoperative planning.

A randomized 'N-of-1' single blinded clinical trial of barbed dermal sutures vs. smooth sutures in elective plastic surgery shows differences in scar appearance two-years post-operatively.

BACKGROUND: Barbed sutures have unidirectional circumferential shallow barbs, which distribute tension throughout the wound and close wound securely without the need to tie knots. OBJECTIVES: We compare two different methods of wound closure in elective plastic surgical cases: barbed 3/0 V-Loc™180 suture and smooth 3/0 Maxon™ sutures, both polyglyconate monofilament synthetic absorbable sutures. We assessed the aesthetic long-term results with a minimum two year follow up. METHODS: This is a prospective, randomized controlled study with internal control. A single surgeon performed all cases. Patients who underwent elective operations that involved long wound closure were enrolled in the study. Each patient acted as their own internal control with half their wound being sutured with 3/0 V-Loc™180 barbed suture and the other half with smooth 3/0 Maxon™ deep dermal sutures and then a subcuticular skin closure. In both groups, the superficial fascial system was closed with 1 Vicryl interrupted sutures on both sides. Long-term cosmesis was evaluated using the modified Hollander cosmesis score by review of standardized postoperative photographs by 9 blinded plastic surgeons and specialist registrars. RESULTS: The study reports on 33 female patients. The time taken for wound closure was significantly reduced using the barbed suture (p < 0.001). There was no difference in the complication ratio in either group. Two-year aesthetic outcome was significantly superior when using the barbed suture (p = 0.0075). CONCLUSION: Barbed sutures closure of long wounds is faster and produces a better long-term aesthetic outcome than smooth sutures.

Comparing breast-reduction techniques: time-to-event analysis and recommendations.

BACKGROUND: Breast reduction is a common procedure used to improve physical and aesthetic factors associated with breast hypertrophy. This study investigated how surgical technique alone affects the risk factors for complications and profiled differences between techniques. Complications were assessed by the use of time-to-event methods. METHODS: Patient information was extracted from a cohort of 283 patients. Demographic, surgical, and follow-up information was analyzed for patients undergoing surgical procedures using the inferior pedicle Wise pattern (IPWP) and modified Hall-Findlay (MHF) techniques. The patients managed with the IPWP technique were considered control subjects. The failure rates were described using the Kaplan-Meier failure estimator to provide a true estimate of the experienced complication rates. RESULTS: Overall, few differences were noted between the groups except for total tissue removed. The overall failure (complication) rate at 6 months was 18.8%, with 9% of all the patients experiencing a major complication that required operative intervention/revision. As expected, the period with the greatest risk of complication was the first month after surgery. Surgical technique, total tissue removed, and age were nonpredictive of complications. Overall, the IPWP group had significantly more total tissue removed than the MHF group (median difference, 227 g; P=0.002). There was no evidence of a learning curve when an experienced surgeon moved from the one technique to the other. CONCLUSION: At 6 months after surgery, 19% of patients are expected to have experienced a complication. There appears to be few differences in outcomes between the techniques of breast reductions used, and the success or otherwise almost certainly relates to factors independent of surgical technique and includes patient selection, operative skill, and experience. Time-to-event analysis provides a precise assessment and description of the complication profile. 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 at www.springer.com/00266.

Minimally invasive late free flap salvage: indications, efficacy and implications for reconstructive microsurgeons.

One of the most common causes of free flap compromise is microvascular thrombosis. Acland et al describe two described zones of injury: zone 1 the anastomotic site and zone 2 downstream. Factors contributing to zone 1 thromboses include anastomotic irregularities, suture material and platelet adhesion. This often presents in the early postoperative period. Zone 2 however, is less well described and is associated with diffuse microvascular ischaemia. Often, these cases are associated with the use of vein grafts in a delayed reconstructive setting, and present relatively late in their postoperative follow up. There are sporadic reports in the literature of late free flap salvage managed via anastomotic revision, thrombectomy, and the use of thrombolytic agents. We describe the successful use of catheter-directed endovascular urokinase in revascularizing two free flaps which presented in the late postoperative setting. This report demonstrates the safety and efficacy of this technique in free flap salvage. Although late presentation of free flap compromise is uncommon, this report reiterates the importance of long-term surveillance of these patients. It should be remembered, however, that long-term anticoagulation is required, and may not be feasible in certain patient populations. Given that free tissue transfer is often employed when other forms of reconstruction are unavailable, endovascular thrombolysis is a valuable tool for the reconstructive microsurgeon, and its role in early free flap salvage warrants exploration.

Breast reconstruction using permanent tissue expanders.

The breast is a variable organ and as such reconstructive surgeons need to use a variety of reconstructive techniques. Prosthetic reconstruction is a good technique for women who are either unsuitable for or not accepting of autogenous tissue reconstruction. We reviewed the last five years' experience at Monash Medical Centre with permanent tissue expander breast reconstruction. Forty patients underwent reconstruction of 54 breasts. Immediate reconstruction was performed in 70% with an overall average patient age of 45 years. The selection criteria, advantages, and disadvantages of this technique are discussed. Inflation of expanders took an average of 71 days and creation of breast mound (excluding nipple/areolar reconstruction) took an average of 2.3 operations. Overall aesthetic results have been judged to be good to excellent in 81%. Symmetry was more easily achieved in bilateral reconstructions. Capsular contracture rate was Baker Grade I or II in 83%. Minor complications occurred in 17% of patients. We believe that there still exists a significant number of women who are either unsuitable for or not accepting of autogenous tissue reconstruction. It is this group of women who, if well selected, can be reconstructed safely and efficiently by the use of permanent tissue expander breast prosthesis.