Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap.

OBJECTIVE: The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. MATERIALS AND METHODS: This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion. RESULTS: Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. CONCLUSION: In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1hour and 45minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.

[Evolution of surgical indications in upper limb functional surgery for tetraplegic patients: Retrospective study of 428 procedures]. / Évolution des indications chirurgicales dans la chirurgie fonctionnelle du membre supérieur chez le patient tétraplégique : étude rétrospective à propos de 428 interventions.

INTRODUCTION: Regarding surgical strategy for upper limb functional rehabilitation in patients with traumatic tetraplegia, there are few publications and the case series are quite small. PATIENTS AND METHOD: We reviewed all traumatic quadriplegic patients, operated one by one surgeon, professor Marc Revol, for functional surgery of the upper limb in the same department from 1989 to 2018. For each patient, we recorded their gender, their group according to the international classification, their age at the time of the first surgical procedure, the length of time between the accident and the first surgery and between two procedures, the average duration of the whole surgical program, and the surgical technique used for the elbow, the wrist, the long fingers and the thumb. RESULTS: We reviewed 158 cases, representing 428 surgical procedures. Some surgical principles have remained unchanged through the years: the hand opening stage comes before the closing one, and systematically includes intrinsic active palliative procedures using lassos; and restoration of long fingers grasping is consistently associated with restoration of thumb gripping and with flexor tendons tenolysis in the lassos region. Other strategic points have evolved over time: restoration of active elbow extension now systematically uses the biceps over the deltoid transfer; brachio radialis (BR) to extensor digitorum communis (EDC) and to extensor pollicis longus (EPL) transfer has been replaced by tenodesis; in groups 2, 3, 4 and 5, the hand opening stage has been consistently associated with the biceps transfer, thus shortening the surgical program to two procedures instead of three for each upper limb; split distal flexor pollicis longus (FPL) tenodesis has replaced thumb arthrodesis; and, whenever it was possible, BR has been spared from group 3 and beyond. CONCLUSION: In groups 2 to 5, the indications have evolved towards the following strategy. The first surgical step includes restoration of elbow extension using biceps transfer and hand opening reinforcement through four lassos, one split distal FPL tenodesis for the thumb, and EDC and EPL tenodesis to the retinaculum. The second surgical procedure consists of restoration of long fingers and thumb flexion using one unique motor (BR or extensor carpi radialis longus), and closed tenolysis of the flexor tendons in case of adhesions in the lassos area.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study.

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Are prostaglandins or calcium channel blockers efficient for free flap salvage? A review of the literature.

The free flap failure rate is less than 5%. The responsible mechanisms of postoperative secondary ischemia are mostly vascular. The main postoperative complication leading to flap failure is thrombosis. Different strategies have been reported to improve the reliability of flaps and decrease the risk of partial or total necrosis: thus, pharmacologic agents have been studied to reduce the risk of microvascular thrombosis. The aim of this review was to evaluate the effect of calcium channel blockers and prostaglandins on free skin flap survival. A systematic review of the literature was performed to identify articles studying the efficacy of calcium channel blockers and prostaglandins on free flap survival. After full text reading, eleven articles were finally included. Eight articles investigated the role of prostaglandins in free tissue transfers, two in rats subjects, one in rabbits, five in humans. Two articles studied the effect of calcium channel blockers on free flaps, one in rats subjects, one in rabbits. One article studied in different groups the effect of calcium channel blockers and prostaglandins on free flaps in rabbits. Literature regarding the efficacy of calcium channel blockers and prostaglandins to salvage free flap is poor and mainly based on animal models. Nevertheless, studies on prostaglandins showed a slight efficiency of these molecules for free flap salvage. Results are less reliable for calcium channel blockers and dependent on the molecule used. In conclusion, there is a lack of evidence to use them in clinical practice.

Reconstruction of an anterior chest wall radionecrosis defect by a contralateral latissimus dorsi flap: A case report.

INTRODUCTION: Soft tissue and bone radionecrosis are rare but serious complications may occur late after radiotherapy. CASE REPORT: We report the case of an 86-year-old woman with a history an infiltrating ductal carcinoma of the left breast, treated by total mastectomy, left axillary dissection and adjuvant radiotherapy. Eighteen years later, the first radionecrosis lesions appeared and grew progressively in a 6-month period. These lesions are deep, involving the anterior aspect of the 4th to the 6th ribs and infiltrating the chest wall to the left cardio-thoracic space communicating largely with the pericardium. During axillary dissection, the neurovascular pedicle of the left latissimus dorsi muscle had been severed. The first part of the operation consisted of performing a left side parietectomy of the thoracic wall with a large resection of pericardial tissue and a small myocardial patch. The second step consisted of repairing the thoracic wall defect with a contralateral musculocutaneous latissimus dorsi flap. CONCLUSION: Due to its significant axis of rotation, the latissimus dorsi muscle flap must be considered in the therapeutic algorithm for covering of contralateral anterior chest wall defects.

[Lumbar artery perforator flap for breast reconstruction]. / Reconstruction mammaire autologue par lambeau perforant lombaire.

Even though DIEP-SIEA flaps or latissimus dorsi musculocutaneous flap are the most frequently used, a wide variety of flaps have been described for autologous breast reconstruction. Concerning the choice of donor-site, the aim is to prevent and to limit the morbidity. That is why the donor-site should be carefully chosen, according to the morphology of the patient. Lumbar artery perforator flap (LAP) is an option for breast reconstruction, but it is not well known and its use is limited. This study summarizes the authors' early experience with free LAP flap for breast reconstruction. Three patients underwent immediate or delayed autologous breast reconstruction using a LAP flap. No vascular by pass was required to lengthen the pedicle. No partial or complete flap necrosis has been reported. There was no surgical donor-site complication. Mean operative time was 7hours. LAP flap can be considered as a good option for autologous breast reconstruction, especially in patients with unfavorable abdominal donor-site, and impossibility to use a DIEP flap.

Surgical approaches in neck dissection: Comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach.

BACKGROUND: Surgical approaches in neck dissection: comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach. METHODS: This single-center retrospective study compares a new transverse incision for cervicotomy to the classical approach described by Paul André in neck dissections. The evaluation criteria were: number of lymph nodes analyzed, operative time, complications, patient satisfaction and aesthetic aspects of the scar. RESULTS: A total of 34 patients were included in this study, from September 2009 until January 2015. The number of lymph nodes analyzed is not affected by this new approach compared to the classical one (P=0.9). The scar has a significantly more discreet appearance in the transverse cervicotomy group (P=0.023) likewise; patient satisfaction is higher in this group (P=0.006). CONCLUSIONS: Aesthetic and functional impairment can be reduced using this new transverse cervical approach hidden in the natural creases of the neck described by Langer.

[Prosthetic genioplasty versus osseous genioplasty in aesthetic chin augmentation: Literature review and knowledge update]. / Génioplasties d'augmentation prothétiques et osseuses, à visée esthétique : revue de littérature et actualisation des connaissances.

Chin augmentation is commonly practiced, whether in microgenia treatment, in cases of orthognathic or cosmetic surgery. Located at the crossroads of many specialties, the technique choice still differs according to the surgeon specialiy. A large number of publications on the subject are available. A comparaison between different surgical methods is therefore possible concerning their indications and their complication. The purpose of this study was to carry out a literature review, with updating knowledge, as well as a synthesis indication regarding aesthetic osseous and alloplastic genioplasty. Despite the generalization of "modern" implants in France, prosthetic genioplasty remains more frequently the source of serious complications (infections, extrusions, bone erosions). Similarly, this technique has much more limited indications than osseous genioplasty, which has the advantage of a better longevity. In order to increase the aesthetic appearance of the chin, osseous genioplasty should be performed more easily and more frequently by surgeons on all sides.

Improving free-flap survival using intra-operative heparin: Ritualistic practice or evidence-base medicine? A systematic review.

INTRODUCTION: The failure rate of free flaps is approximately 5%, mostly due to thrombosis of microvascular anastomosis. A number of pharmacological agents have been tested in order to enhance the patency of microvascular anastomosis and so to as extend the survival of free flaps. One of them is heparin, a very commonly used anticoagulant. However, there exists no consensus on its use in microsurgery as concerns time of introduction (pre-, intra- or post-operative), recommended dosage, or duration of utilization. The aim of this study was to determine whether or not the use of intra-operative heparin, in its systemic or topical forms, can bring about improved survival of free flaps, and if and when it should be recommended in microsurgery. MATERIAL AND METHODS: A systematic review on the PUBMED database enabled us to identify articles evaluating the benefits of intra-operative heparin with regard to free-flap survival. All in all, fifteen articles in animal and human research were selected. RESULTS: As far as animal research is concerned, 9 studies out of 11 showed the superiority of topical intra-operative heparin compared to saline in improving free-flap survival rates through improved patency of the anastomosis. As regards systemic intra-operative heparin, on the other hand, only two trials out of four yielded favorable results. In clinical research in humans, there has been no prospective randomized trial studying the action of topical intra-operative heparin in vessel irrigation of ex-vivo free flaps before vascular repermeabilisation. However, the preliminary results of four trials seem to provide positive arguments for this practice. CONCLUSION: The use of systemic per-operative heparin (intravenous injection) does not improve the survival of free flaps in either animal models or humans. In animal models, however, the use of topical intra-operative heparin (vessel irrigation) has been shown to improve the free-flap survival rate by avoiding thrombosis of microvascular anastomosis. Finally, in clinical studies concerning humans, as of now no prospective randomized trial has proven that use of topical intra-operative heparin to ensure vessel irrigation in ex-vivo flaps is likely to increase free-flap survival. Studies should be conducted to decide whether or not to validate a rather ritualistic practice that consists in irrigating the relevant vessels before anastomosis; does it or does it not improve the patency rate?

[Nipple projection augmentation in breast reconstruction by artificial derm injection]. / Augmentation de la projection du mamelon dans les reconstructions mammaires par injection de derme artificiel.

INTRODUCTION: The reconstruction of the Nipple-Areola Complex (NAC) is the last step and a key part in breast reconstruction. The technique to be used should be chosen as to avoid any complications on previous reconstruction steps. The use of local flaps for NAC reconstruction could be associated with implant exposure especially in the presence of a history of radiation therapy. The pure dermal flap could be indicated for the nipple reconstruction after breast reconstruction by implant after radiotherapy. The limit stay in the nipple hypoprojection. We suggest to assess the increase of the nipple projection, reconstructed by pure dermal flap, by injection of Integra® Flowable Wound Matrix (Integra LifeSciences®, Plainsboro, New jersey). PATIENTS AND METHOD: Nipple projection has been measured among patients enclosed from february to March 2016 reconstructed by pure dermal flap: before, after and also at a 6months term from the injection of Integra® Flowable Wound Matrix. Patient satisfaction and complications have been measured retrospectively. RESULTS: Ten patients with an average of 55years have been enclosed, with an average limit of time of 19months (7 to 33months) between the breast nipple reconstruction by dermal flap and the injection. A volume of 1 to 1.6cc has been injected. A significative increase projection of 2mm at a 6months term has been measured (1.5 to 2.5mm, P<0.01), without complication and a satisfaction rate of 4.5/5. CONCLUSION: The injection of an artificial derm-like Integra® Flowable Wound Matrix seems to be efficient to increase the nipple projection reconstructed by pure dermal flap after a breast reconstruction and moreover, without complications.

[How to make your own custom cutting guides for both mandibular and fibular stair step osteotomies?] / Ostéotomies fibulaires et mandibulaires en marche d'escalier. Comment réaliser ses propres guides de coupe pour les reconstructions maxillofaciales ?

INTRODUCTION: Using tailored cutting guides for osteocutaneous free fibula flap in complex mandibular reconstruction after cancer resection surgery constitutes a substantial improvement. Autonomously conceiving and manufacturing the cutting guides within a plastic surgery department with computer-aided design (CAD) and three-dimensional (3D) printing allows planning more complex osteotomies, such as stair-step osteotomies, in order to achieve more stable internal fixations. METHODS: For the past three years, we have been producing by ourselves patient-tailored cutting guides using CAD and 3D printing. Osteotomies were virtually planned, making the cutting lines more complex in order to optimize the internal fixation stability. We also printed reconstructed mandible templates and shaped the reconstruction plates on them. We recorded data including manufacturing techniques and surgical outcomes. RESULTS: Eleven consecutive patients were operated on for an oral cavity cancer. For each patient, we planned the fibular and mandibular stair-step osteotomies and we produced tailored cutting guides. In all patients, we achieved to get immediately stable internal fixations and in 10 patients, a complete bone consolidation after 6 months. CONCLUSION: Autonomously manufacturing surgical cutting guides for mandibular reconstruction by free fibula flap is a significant improvement, regarding ergonomics and precision. Planning stair-step osteotomies to perform complementary internal fixation increases contact surface and congruence between the bone segments, thus improving the reconstructed mandible stability.

Should we consider the hemi-tip as a proper aesthetic subunit in a nasal reconstruction?

BACKGROUND: Defects involving several aesthetic subunits (ASUs) or lying at the junction of an ASU are challenging and require a complex reconstruction. This study aimed to describe the hemi-tip as a new ASU. MATERIAL AND METHODS: We conducted a retrospective study including patients who underwent a nasal reconstruction for lower nasal pyramid defects according to our modified ASU principle. Patients who suffered from a subtotal alar defect, which also involved <50% of the tip, were reconstructed after excising the remaining tissue of the hemi-tip subunit. An aesthetic evaluation was performed using a patient satisfaction scale and by independent raters. RESULTS: From 2010 to 2014, 21 patients underwent a lower hemi-nose reconstruction. All patients had a full-thickness defect and underwent a reconstruction of the three layers of the nose. Sixty-four percent of our patients were very satisfied, 26% were satisfied, and only 10% were unsatisfied with their nasal tip appearance, with a mean score of 4.4/5. The nasal tip was also rated by independent raters with a mean score of 4.1/5. DISCUSSION: Our results and experience showed that a midline scar between the two hemi-tips is inconspicuous. The majority of the defects involving only one side of the tip would benefit from the hemi-tip ASU reconstruction. CONCLUSION: We have modified the number of ASUs by considering the hemi-tip as a proper subunit.

A new cost-effective and fast method of autologous fat grafting.

Due to the increasing number of fat grafting procedures, several laboratories have developed their own fat processing system (Puregraft(®), LipiVage(®), Viafill(®), etc.), such as closed harvesting systems, centrifugation or washing and filtration devices, or even simple decantation techniques. However, all these tissue-engineering systems are expensive. Our team has developed a simple and fast autologous fat grafting system, useable even for a large volume of lipofilling, and based on low-pressure suction and a sterile closed-system for processing the harvested fat tissue. It is a cost-effective system, as it only costs 9.28Eur (10.52USD) for a 500milliliters autologous fat graft procedure.

Nipple reconstruction after implant-based breast reconstruction in radiated patients: A new safe dermal flap.

INTRODUCTION: After implant-based breast reconstruction, the nipple reconstruction technique must be carefully chosen, especially in patients with a history of radiotherapy. When the contralateral nipple is not available, using a classical dermal-fat local flap may lead to the implant exposure, and consequently, removal. We describe here a simple nipple reconstruction technique, using a strictly dermal local flap and evaluate its complication rate. PATIENTS AND METHODS: All patients who underwent our technique for nipple reconstruction between January 2012 and April 2015 were included in this retrospective study. We described our surgical technique and noted the occurrence of postoperative complications. RESULTS: Forty-nine nipples, in 47 patients with a history of radiotherapy, were reconstructed with our technique. The mean age was 53 years old (range 27-78 years old). The average time between radiotherapy and nipple reconstruction was 42.5 months (range from 4.6 to 274.8 months). The mean follow-up was 30.9 months (range from 6 to 47 months). No implant exposure occurred. Regarding the nipple flap, two partial flap loss and one infection occurred, the whole complication rate was 6.1%. Regarding nipple projection, it was quite low (between 2 and 5 mm) after 6 months, but remained stable. CONCLUSION: Our strictly dermal local flap technique for nipple reconstruction is a safe procedure and represents a good alternative to composite contralateral nipple graft in irradiated patients with an implant-based reconstructed breast.