Effect of corticosteroids on ischemia-reperfusion injury of deep inferior epigastric perforator flap after re-exploration for anastomosis thrombosis: A prospective randomized trial.

Patients undergoing breast reconstruction with the deep inferior epigastric perforator (DIEP) flap are at risk of arterial and venous thrombosis, necessitating flap salvage surgery. However, this carries the risk of ischemia-reperfusion injury (IRI) and potential significant partial or complete flap loss. The objective of this study was to evaluate the potential benefit of corticosteroids in reducing IRI related complications in DIEP flaps that are returned to the operation theater for attempted salvage after venous or arterial failure. A double-blinded prospective randomized study was conducted between January 2012 and January 2023 on patients scheduled for secondary unilateral breast reconstruction using the DIEP flap technique. Patients were included if they developed post-operative venous or arterial flap thrombosis and experienced DIEP flap IRI following operative take-back and anastomosis revision. The treatment group (TG) received a 5-day course of corticosteroids, while the control group (CG) did not receive any specific treatment. Forty-six patients were enrolled in the study. In the CG, two cases of total flap loss and eight cases of partial flap necrosis were observed, while the TG had only 1 case of partial flap necrosis (p < 0.05). The complete resolution of clinical signs of IRI occurred within 13 ± 2.1 days for the TG and 21 ± 3.5 days for the CG (p = 0.00001). The TG had a significantly shorter hospital stay (11.13 ± 0.38 days) compared with the CG (15.47 ± 1.27 days; p < 0.0001). Targeted corticosteroid therapy following a salvage procedure for vascular thrombosis in DIEP flaps has shown promise as an effective treatment for subsequent IRI. This approach may be considered as a viable option for managing IRI in free flaps. However, further studies involving a larger number of patients are required to substantiate our hypothesis.

The dataset of duplex ultrasound assessment of the internal mammary artery in women with unilateral mastectomy followed by radiotherapy for breast cancer.

Adjuvant radiotherapy for breast cancer may involve some incidental exposure of the ipsilateral internal mammary artery to ionizing radiation. However, the relevant evidence is limited and inconsistent. The dataset presented in this article contains the information used to assess the effects of accidental radiation exposure on the internal mammary artery in patients with unilateral total mastectomy followed radiotherapy for breast cancer. The study population consists of two groups: the irradiated group and the control group. The left and right internal mammary arteries were assessed through the second intercostal spaces using a computed sonography system (Vivid S6; GE, Tirat Carmel, Israel) equipped with a 5.5 - 11 MHz transducer. The recorded parameters were the diameter, time-averaged maximum velocity, and blood flow of the internal mammary artery. The dataset contains two files of data: a raw and an analyzed data. The raw data file contains the individual information of each participant, including demographic characteristics and the parameters of the internal mammary artery duplex ultrasound imaging. The analyzed data file was made up of R Markdown, a markup language of R. The results of data analysis were presented in the related research article which has been accepted for publication in the Annals of Vascular Surgery. The dataset presented in this article may be reused for further studies in which the internal mammary artery is considered as potential donor or recipient vessels for a vascular bypass or free flap anastomosis.

International consensus recommendations on face transplantation: A 2-step Delphi study.

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

Duplex Imaging Assessment of the Internal Mammary Arteries in Women after Unilateral Mastectomy and Radiotherapy for Breast Cancer.

BACKGROUND: The effects of incidental radiation exposure on internal mammary arteries remain unclear. The present study was designed to test the hypothesis by comparing diameter and blood flow of the irradiated and nonirradiated internal mammary arteries, using Duplex ultrasound imaging. METHODS: The study was designed as a single-center, transversal, comparative study. The main outcomes were diameter and volumetric blood flow of the internal mammary arteries. The Wilcoxon rank-sum test was used to assess the differences between the irradiated and nonirradiated internal mammary arteries with regard to the diameter and volumetric blood flow. RESULTS: The diameter (median [interquartile range]) of the irradiated internal mammary arteries (0.170 mm [0.160, 0.180]) was smaller than that of the contralateral nonirradiated ones (0.180 mm [0.170, 0.200], P < 0.0001) and that of the internal mammary arteries in the control group (0.180 mm [0.170, 0.190], P < 0.0001). Similarly, blood flow (median [interquartile range]) of the irradiated internal mammary arteries (52.4 ml/min [37.78, 65.57]) was smaller than that of the contralateral nonirradiated ones (62.7 ml/min [46.87, 84.17], P < 0.0001), as well as of the left (56.7 ml/min [46.88, 72.58], P = 0.02) and the right internal mammary arteries in the control group (61.0 ml/min [47.47, 74.52], P = 0 0.0009). CONCLUSIONS: The data indicate that the irradiated internal mammary arteries in patients with a history of total mastectomy followed by radiotherapy for breast cancer had significantly smaller diameter and blood flow compared to the nonirradiated internal mammary arteries.

Necrotising soft-tissue infections.

The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially life-threatening infections in their career. Despite advances in care, necrotising soft-tissue infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. In particular, failure to suspect necrotising soft-tissue infections, fuelled by poor awareness of the disease, promotes delays to first surgical debridement, amplifying disease severity and adverse outcomes. This Review will focus on practical approaches to management of necrotising soft-tissue infections including prompt recognition, initiation of specific management, exploratory surgery, and aftercare. Increased alertness and awareness for these infections should improve time to diagnosis and early referral to specialised centres, with improvement in the prognosis of necrotising soft-tissue infections.

Analysis of Predictive Factors for Successful Vascular Anastomoses in a Sheep Uterine Transplantation Model.

Uterine transplantation is becoming an increasingly realistic therapeutic for uterine infertility. Surgical training on large animal models such as sheep is a prerequisite for establishing a program in humans. The objective of our study was to analyze the predictive factors for successful vascular anastomoses. We performed 40 autotransplants that involved end-to-side anastomoses from the uterine to the external iliac vessels. We analyzed vessel results in terms of success or failure; a total of 78.7% of arterial and 82.9% of venous anastomoses were successful in the immediate postoperative period. In multivariate analysis, independent factors associated with immediate successful vein anastomoses were as follows: a short warm ischemia time (<2 h, OR = 0.05; 95% CI [0.003−0.88], p = 0.04), the absence of any anastomotic complications (OR = 0.06; 95% CI [0.003−0.099], p = 0.049), and their realization by a vascular surgeon (OR = 29.3; 95% CI [1.17−731.9], p = 0.04). Secondly, we showed that an increase in lactate levels greater than 2.72 mmol/L, six hours after reperfusion was predictive of failure, with a sensibility of 85.7% and a specificity of 75.0%. In order to perfect the management of vascular anastomoses by a vascular surgeon, training on animal models and in microsurgery are mandatory in establishing a uterine transplantation program in humans.

Validation of an Instrumented Hammer for Rhinoplasty Osteotomies: A Cadaveric Study.

Background: Osteotomies during rhinoplasty are usually based on surgeon's proprioception to determine the number, energy, and trajectory of impacts. Objective: The first objective was to detect the occurrence of fractures. The second objective was to determine when the thicker frontal bone was encountered by the osteotome. Materials and Methods: An instrumented hammer was used to measure the impact force during lateral osteotomies on nine human anatomic specimens. A prediction algorithm was developed using machine learning techniques, to detect the occurrence of fractures, and the proximity of the osteotome to the frontal bone. Results: The algorithm was able to predict the occurrence of fractures and the proximity to the frontal bone with a prediction rate of 83%, 91%, and 93% when allowing for an error of 0, 1, and 2 impacts, respectively. The location of the osteotome in the frontal bone was predicted with an error of 7.7%. Conclusion: An osteotomy hammer measuring the impact force when performing lateral osteotomies can predict the occurrence of fractures and the proximity to the frontal bone, providing the surgeon with instant feedback.

Functional Cerebral MRI Evaluation of Integration of Breast Reconstruction into the Body Schema.

BACKGROUND: The objective of breast reconstruction (BR) is to erase the after-effects of total mastectomy by allowing patients to restore their breast shape. The aim of our study was to investigate the body map integration of different types of BR using functional magnetic resonance (fMRI). PATIENTS AND METHODS: We prospectively enrolled all women undergoing BR for breast cancer to the Remasco study (NCT02553967). Participants were categorized into four groups according to the standard of care they required: immediate BR (IBR), delayed BR (DBR), flap (autologous), or implant BR. Each patient performed sensorimotor tasks during the fMRI acquisition. RESULTS: Data of 38 patients were analyzed. We identified the cingulate region as the area of interest in the brain. In the case of DBR, the brain area activated during palpation of the total mastectomy scar (before BR) was different from the brain area activated during palpation of the reconstructed breast (Brodmann areas 31 versus 32). Palpation of the native breast and reconstructed breast activated the same Brodmann area 32. Comparing the brain activation signal during palpation of the native breast and the reconstructed breast did not reveal any significant difference in the overall population (P = 0.41) or in the groups: autologous (P = 0.32), implant (P = 0.10), IBR (P = 0.72), or DBR (P = 0.10). CONCLUSIONS: This experimental study allowed us to describe and understand the brain plasticity processes that accompany BR. The results suggest that the reconstructed breast is integrated into the body schema, regardless of the type of BR or the timing.

Spontaneous Lymph Flow Restoration in Free Flaps: A Pilot Study.

BACKGROUND: Oncologic excision and trauma can be responsible for major defects and lymphedema. Free flaps are commonly used for reconstruction. We aimed to determine if lymphatic flow between flap and recipient site can be restored without lymphatic surgery. METHODS: 15 free flaps were performed in different patients in our center. Infrared-based lymphography was used to plan surgery. Indocyanine green (ICG) was injected in the flap's subdermal tissue and also at the edges of the skin defect. Circumferential lymphatic channels were marked 5 min after the ICG injection. Fluorescent images were recorded with an infrared camera system. The flap inset was obtained by putting side to side the flap markings and the recipient site markings. Infrared-based lymphography was performed on every patient one year after surgery. Spontaneous lymph flow restoration was judged positive if lymphatic connections were observed between the flap and the recipient site. RESULTS: seven free ALT and eight DIEP flaps were performed. All ALT flaps were designed following the limb axis which is the lymphatic axiality. Spontaneous lymph flow restoration was observed for the seven ALT flaps. Eight DIEP flaps were designed upside down and one was designed following the lymph axiality. Spontaneous lymph flow restoration was only observed for the one designed following the lymph axiality. CONCLUSIONS: designing reconstructive free flap regarding lymph axiality seems to improve spontaneous lymph flow restoration between flap and recipient site without any specific lymphatic surgery.

Anatomical subject validation of an instrumented hammer using machine learning for the classification of osteotomy fracture in rhinoplasty.

Osteotomies during rhinoplasty are usually based on the surgeon's proprioception to determine the number and the strength of the impacts. The aim of this study is to determine whether a hammer instrumented with a force sensor can be used to classify fractures and to determine the location of the osteotome tip. Two lateral osteotomies were realized in nine anatomical subjects using an instrumented hammer recording the evolution of the impact force. Two indicators τ and λ were derived from the signal, and video analysis was used to determine whether the osteotome tip was located in nasal or frontal bone as well as the condition of the bone tissue around the osteotome tip. A machine-learning algorithm was used to predict the condition of bone tissue after each impact. The algorithm was able to predict the condition of the bone after the impacts with an accuracy of 83%, 91%, and 93% when considering a tolerance of 0, 1, and 2 impacts, respectively. Moreover, in nasal bone, the values of τ and λ were significantly lower (p < 10-10) and higher (p < 10-4) than in frontal bone, respectively. This study paves the way for the development of the instrumented hammer as a decision support system.

Long-term quality of life in necrotizing soft-tissue infection survivors: a monocentric prospective cohort study.

BACKGROUND: Compared to other life-threatening infection survivors, long-term health-related quality of life (QOL) of patients surviving necrotizing soft-tissue infections (NSTI) and its determinants are little known. In this monocentric prospective cohort including NSTI survivors admitted between 2014 and 2017, QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36), the Hospital Anxiety and Depression (HAD), the activity of daily living (ADL), instrumental ADL (IADL) scales and the Impact of Event Scale-Revised (IES-R). The primary outcome measure was the SF-36 physical component summary (PCS). NSTI patients were compared according to intensive care unit (ICU) admission status. ICU survivors were matched on SAPS II with non-NSTI related septic shock survivors. RESULTS: Forty-nine NSTI survivors were phone-interviewed and included in the study. Median PCS was decreased compared to the reference population [- 0.97 (- 2.27; - 0.08) SD]. Previous cardiac disease was the only variable associated with PCS alteration [multivariate regression coefficient: - 8.86 (- 17.64; - 0.07), p = 0.048]. Of NSTI survivors, 15.2% had a HAD-D score ≥ 5 and 61.2% an IES-R score ≥ 33. ICU admission was not associated with lower PCS [35.21 (25.49-46.54) versus (vs) 41.82 (24.12-51.01), p = 0.516], but with higher IES-R score [14 (7.5-34) vs 7 (3-18), p = 0.035] and a higher proportion of HAD-D score ≥ 5 (28.6 vs 4.0%, p = 0.036). Compared to non-NSTI septic shock-matched controls, NSTI patients had similar PCS [33.81 (24.58; - 44.39) vs 44.87 (26.71; - 56.01), p = 0.706] but higher HAD-D [3.5 (1-7) vs 3 (1.5-6), p = 0.048] and IES-R scores [18 (8-35) vs 8 (3-19), p = 0.049]. CONCLUSIONS: Long-term QOL in NSTI survivors is severely impaired, similarly to that of non-NSTI septic shock patients for physical compartments, but with more frequent depressive and/or post-traumatic stress disorders. Only ICU admission and previous cardiac disease were predictive of QOL impairment.

Analysis of blood parameters and molecular endometrial markers during early reperfusion in two ovine models of uterus transplantation.

The dissection of the veins is the trickiest step of Uterine transplantation (UTx). Performing the anastomosis of a single uterine vein could bring a therapeutic benefit and simplification of surgery and serve for managing unilateral venous thromboses. The objectives of this project were to evaluate the expression of early markers of ischemia-reperfusion and to compare findings following one or two vein anastomoses. Orthotopic uterine auto-transplantations were performed on an ovine model with anastomosis of either two (group 1) or one utero-ovarian veins (group 2). Blood gases, histology and ischemia- reperfusion markers transcripts (PTGS2, IL6, IL8, SOD2, C3, BAX/BCL2 and TLR4) were analyzed as well as PTGS2 protein expression using Western Blot and fluorescence immunolocalization on endometrial biopsies after 3h of reperfusion. Ten ewes were included in the experimentation, 4 were in group1, 3 in group 2, the others being sham operated controls. No significant differences were observed between the two phenotypes. Based on these results, the anastomosis of one single uterine vein appears to be an approach consistent with short-term graft survival. Further experiments will be needed to confirm the reliability of this approach, especially the long-term follow-up of the uterine graft including its ability to support gestation to term.

Using an impact hammer to perform biomechanical measurements during osteotomies: Study of an animal model.

Osteotomies are common surgical procedures used for instance in rhinoplasty and usually performed using an osteotome impacted by a mallet. Visual control being difficult, osteotomies are often based on the surgeon proprioception to determine the number and energy of each impact. The aim of this study is to determine whether a hammer instrumented with a piezoelectric force sensor can be used to (i) follow the displacement of the osteotome and (ii) determine when the tip of the osteotome arrives in frontal bone, which corresponds to the end of the osteotomy pathway. Seven New Zealand White rabbit heads were collected, and two osteotomies were performed on their left and right nasal bones using the instrumented hammer to record the variation of the force as a function of time during each impact. The second peak time τ was derived from each signal while the displacement of the osteotome tip D was determined using video motion tracking. The results showed a significant correlation between τ and D (ρ2 = 0.74), allowing to estimate the displacement of the osteotome through the measurement of τ. The values of τ measured in the frontal bone were significantly lower than in the nasal bone (p<10-10), which allows to determine the transition between the nasal and frontal bones when τ becomes lower than 0.78 its initial averaged value. Although results should be validated clinically, this technology could be used by surgeons in the future as a decision support system to help assessing the osteotome environment.

Face transplantation: A longitudinal histological study focusing on chronic active and mucosal rejection in a series with long-term follow-up.

The 2007 Banff working classification of skin-containing Tissue Allograft Pathology addressed only acute T cell-mediated rejection in skin. We report the longitudinal long-term histological follow-up of six face transplant recipients, focusing on chronic and mucosal rejection. We identified three patterns suggestive of chronic rejection (lichen planus-like, vitiligo-like and scleroderma-like). Four patients presented lichen planus-like and vitiligo-like chronic rejection at 52 ± 17 months posttransplant with severe concomitant acute T cell-mediated rejection. After lichen planus-like rejection, two patients developed scleroderma-like alterations. Graft vasculopathy with C4d deposits and de novo DSA led to subsequent graft loss in one patient. Chronic active rejection was frequent and similar patterns were noted in mucosae. Concordance between 124 paired skin and mucosal biopsies acute rejection grades was low (κ = 0.2, p = .005) but most grade 0/I mucosal rejections were associated with grade 0/I skin rejections. We defined discordant (grade≥II mucosal rejection and grade 0/I skin rejection) (n = 55 [70%]) and concordant (grade≥II rejection in both biopsies) groups. Mucosal biopsies of the discordant group displayed lower intra-epithelial GranzymeB/FoxP3 ratios suggesting a less aggressive phenotype (p = .08). The grading system for acute rejection in mucosa may require phenotyping. Whether discordant infiltrates reflect a latent allo-immune reaction leading to chronic rejection remains an open question.

Bacteriological and mechanical impact of the Sterrad sterilization method on personalized 3D printed guides for mandibular reconstruction.

Surgical cutting guides are increasingly used for maxillofacial reconstruction. They are usually provided by laboratories. In recent years, surgical teams have published studies on the possibility of manufacturing their own cutting guides thanks to 3D printers. The object of this study is to analyze the impact of the sterilization on the surface of those personalized models and to assess the effectiveness of sterilization. Using the data from high-resolution CT scan of patient, 3D models were generated through computerized assisted design and fabricated with a 3D printer using Acrylonitrile Butadiene Styrene (ABS). For the sterilization, a Sterrad method was used. In order to evaluate the effectiveness of sterilization, 3D models were artificially contaminated with several bacterial reference strains, sterilized and finally cultured. The surfaces and mechanical modifications were analyzed before and after sterilization with infrared spectrometry, surface contact angle, extensometer, scanning electron microscopy and atomic force microscopy. Ten models of different shapes and 24 samples were fabricated, sterilized and analyzed. The 3D models were designed in 48 h, printed in an average of 122 min and underwent a 47 min cycle of sterilization. All experimentally contaminated 3D models were negative in culture, with at least, a six log reduction of the initial inoculum. The hydrophobicity and roughness of the surface suffered few changes. The reproducibility of this procedure was proved by identical results in the three sterilization rounds. Using Sterrad process for the sterilization of ABS printed material doesn't represent a bacterial risk for the patient. It is a feasible and safe innovative reconstructive method that can save time particularly for oncological cases.

Using an Impact Hammer to Estimate Elastic Modulus and Thickness of a Sample During an Osteotomy.

Performing an osteotomy with a surgical mallet and an osteotome is a delicate intervention mostly based on the surgeon proprioception. It remains difficult to assess the properties of bone tissue being osteotomized. Mispositioning of the osteotome or too strong impacts may lead to bone fractures which may have dramatic consequences. The objective of this study is to determine whether an instrumented hammer may be used to retrieve information on the material properties around the osteotome tip. A hammer equipped with a piezo-electric force sensor was used to impact 100 samples of different composite materials and thicknesses. A model-based inversion technique was developed based on the analysis of two indicators derived from the analysis of the variation of the force as a function of time in order to (i) classify the samples depending on their material types, (ii) determine the materials stiffness, and (iii) estimate the samples thicknesses. The model resulting from the classification using support vector machines (SVM) learning techniques can efficiently predict the material of a new sample, with an estimated 89% prediction performance. A good agreement between the forward analytical model and the experimental data was obtained, leading to an average error lower than 10% in the samples thickness estimation. Based on these results, navigation and decision-support tools could be developed and allows surgeons to adapt their surgical strategy in a patient-specific manner.

Impact of a multidisciplinary care bundle for necrotizing skin and soft tissue infections: a retrospective cohort study.

BACKGROUND: Necrotizing skin and soft tissue infections (NSTIs) require both prompt medical and surgical treatment. The coordination of multiple urgent interventions by care bundles has improved outcome in other settings. This study aimed to assess the impact of a multidisciplinary care bundle on management and outcome of patients with NSTIs. METHODS: Patients with NSTIs admitted between 2006 and 2017 were compared according to admission before or after bundle implementation (2012-2013). This bundle consisted mainly in (1) the creation of a multidisciplinary task force; (2) management guidelines on empirical antibiotics, intensive care unit admission criteria, a triage algorithm to accelerate operating room access; and (3) an active communication policy. Patient recruitment and management were compared between pre- and post-implementation periods. Main outcome was day 60-censored hospital survival. RESULTS: Overall, 224 patients were admitted: 60 before, 35 during, and 129 after bundle implementation. Admission after implementation was associated with increased yearly admissions (10 [8-13] vs 30 [24-43] patients/year, p = 0.014) and decreased mortality (30 vs 15%, HR = 0.49 [0.26-0.92]; p = 0.026) but was no longer a protective factor for mortality after adjustment on confounding factors (adjusted HR = 0.90 [0.43-1.88], p = 0.780). There was no significant difference regarding time to surgery (0 [0-1] vs 0 [0-1] days, p = 0.192) or rate of antibiotic treatment within 24 h (98% vs 99%, p > 0.99). CONCLUSIONS: Implementation of a multidisciplinary care bundle for NSTIs was feasible, but in a retrospective study from an already experienced center was not associated with significantly increased survival after adjustment.