A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement.

BACKGROUND: Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications. OBJECTIVES: This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution. METHODS: Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis. RESULTS: A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline. CONCLUSIONS: Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

Autologous Gluteal Augmentation with Parasacral Perforator-Pedicled Propeller Flaps.

BACKGROUND: De-epithelialized flaps have been used in gluteal contouring over the last three decades, but most improve the projection rather than the upper quadrants. The authors provide a detailed description of their method of gluteal augmentation using parasacral perforator-pedicled propeller flaps. This technique achieves a volumetric increase and maximal buttock projection at the midlevel and in the medial half of the buttocks. METHODS: Between January and December of 2019, a series of 18 patients on whom a lower body lift with a parasacral perforator-pedicled propeller flap had been performed by the senior author (F.B.) were prospectively evaluated. Postoperatively, the satisfaction rate was assessed using a 10-point analog scale (1 = unsatisfied, 10 = very satisfied) by the patient and by two independent surgeons based on photographs taken 1 year after surgery. RESULTS: Eighteen patients underwent this procedure. Their mean age was 32.2 ± 5.6 years (range, 24 to 40 years). The mean flap length was 20.3 cm, their mean width was 10.4 cm, and the mean thickness was 3.4 cm. The authors noted only two minor complications, one seroma and two skin dehiscences that healed without surgery. The rate of satisfaction as assessed by the patients was 8.3 out of 10 (±1.1), and by surgeons, 7.9 and 8.1. CONCLUSION: This article describes a gluteal autoaugmentation flap technique using parasacral perforator-pedicled propeller flaps to increase projection and volume in the inferomedial gluteal region after lower body lift. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Complications after J Medial Thighplasty following Massive Weight Loss: A Multivariate Analysis of 94 Consecutive Patients.

BACKGROUND: Bariatric surgery has increased the number of patients requiring medial thighplasty after massive weight loss. However, despite the various complications, the procedure improves quality of life. The authors report postoperative complications of vertical J-shaped medial thigh lift in a series of patients and identify preoperative risk factors. METHODS: For almost 5 years, the details of all J medial thighplasties performed by a single surgeon were recorded; detailed medical records were also available. Complications can be major (e.g., need for early surgical revision or readmission) or minor (delayed wound healing). RESULTS: During the study period, 94 patients were treated and only minor complications were recorded (42.5 percent). On multivariate analysis, older age (OR, 1.05; 95 percent CI, 1.01 to 1.10) and a body mass index greater than or equal to 30 kg/m2 (OR, 2.82; 95 percent CI, 1.10 to 7.22) were independent risk factors for postoperative complications. CONCLUSIONS: As with other postbariatric operations, medial thighplasty is associated with significant morbidity, but the risk thereof can be easily established and managed. Specific algorithms for determining the risk of postoperative complications based on age and body mass index are needed to guide preoperative discussions with patients and perform patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Superior epigastric artery perforator flap for reconstruction of deep sternal wound infection.

BACKGROUND: The treatment of deep wound sternal infection requires loco-regional pedicled flaps, usually with muscular flaps. Perforator propeller flaps represent the ultimate progress in the history of reconstructive surgery. We report here our experience with the superior epigastric artery perforator (SEAP) flaps to repair sternal defect. PATIENTS AND METHODS: Six patients presenting deep sternal wounds infection were treated with SEAP propeller flap, between March 2015 and June 2017. The mean age was 71.5 (range 53-83) years. The mean length and width of the defect were 16.2 × 7 cm (ranging 8-20 × 4-10). An elliptical skin flap pedicled on the SEAP was harvested in the inframammary fold and rotated up to 90° to cover the defect. RESULTS: All SEAP flaps achieved a successful entire coverage of the defect. The mean size of the skin paddle of the flap was 20.2 × 7.3 cm (ranging 14-27 × 6-9). All flaps were able to provide a complete sternal wound cover. Venous congestion was present in five cases and adequately treated by leech therapy; necrosis was distal in one case, and interesting the entire superficial flap in two cases but with deep tissues remaining viable and able to cover the mediastinum: an infected flap required revision. Satisfyingly, at 2-years postoperative follow-up all-patients were alive with a successful mediastinal cover. CONCLUSIONS: The SEAP Perforator propeller flap is an alternative to muscle flaps to achieve treatment of deep and large sternal wound infection.

Feasibility and impact of the implementation of a clinical scale-based sedation-analgesia protocol in severe burn patients undergoing mechanical ventilation. A before-after bi-center study.

BACKGROUND: Severe burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients. METHODS: We performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU. RESULTS: Eighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%-38%] and median ABSI was 7 [5-9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2-24] vs. 6 days [2-17] (P=0.3) and 17 days [4-32] vs. 8 days [3-23] (P=0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2-24] in the Intervention phase (P=0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P=0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P=0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P=0.6). CONCLUSION: Scale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilation.

Management of Pilonidal Sinus Disease with the Aesthetically Shaped Parasacral Perforator Flap: Multicenter Evaluation of 228 Patients.

BACKGROUND: The management of pilonidal sinus disease is still not standardized. Currently, the two main procedures are a lay-open excision procedure with secondary healing or coverage with local flaps. The authors present their experience with a one-stage excision-coverage with an innovative parasacral artery perforator flap propeller designed to respect the aesthetic unity of the buttocks. METHODS: Study patients were managed with this procedure in the Toulouse, Montpellier, and Rennes university hospitals between 2012 and 2018. Data were collected on clinical and surgical details, immediate and late postoperative complications, and long-term recurrence. Aesthetic satisfaction was evaluated with a self-evaluation questionnaire. RESULTS: The authors operated on 228 consecutive patients for pilonidal sinus disease with an aesthetically shaped parasacral artery perforator flap. The median patient age was 23.5 years, the median operative time was 46 minutes, the median flap length was 9.3 cm (range, 6.5 to 14 cm), and the median flap width was 4.1 cm (range, 4 to 6.5 cm). There were five distal necroses but no complete flap necrosis. There were six postoperative hematomas, 11 infections, and 18 wound dehiscences. The median follow-up period was 27.9 months. Median hospital length of stay was 4.2 days. Three recurrences of pilonidal sinus disease and six instances of hidradenitis suppurativa were detected. Approximately 82 percent of the women and more than 85 percent of the men were "satisfied" or "very satisfied" with the aesthetic outcome, without significant differences between the sexes (p = 0.901). CONCLUSIONS: The aesthetically shaped parasacral artery perforator flap combines very satisfactory results regarding recurrence and postoperative recovery with cosmetic outcome. This procedure is technically more demanding than other flap procedures, although it is accessible to numerous surgeons as the first-line treatment for pilonidal sinus disease after initial learning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Hidradenitis Suppurativa: A Systematic Review and Meta-analysis of Therapeutic Interventions.

Hidradenitis suppurativa is a chronic inflammatory condition that affects skin regions bearing apocrine glands. Although hidradenitis suppurativa is difficult to treat and cure, the currently available treatments are directed toward managing the lesions and associated symptoms. This review presents an evidence-based outline of the available treatment options. We searched four electronic databases and extracted data from retrieved studies for qualitative or quantitative analysis. Meta-analysis was conducted using the comprehensive meta-analysis software to generate pooled standardized mean differences or risk ratios. Numerous medical treatments are available for hidradenitis suppurativa such as antibiotics, retinoids, antiandrogens, immunosuppressive and anti-inflammatory agents and radiotherapy for early lesions. Adalimumab, an anti-tumor necrosis factor antibody, was superior to placebo in reducing Sartorius score (standardized mean difference = -0.32, confidence interval [-0.46, -0.18], P < 0.0001) and pain (risk ratio = 1.42, confidence interval [1.07, 1.9], P = 0.02), when given weekly (not every other week). Combination therapies (such as antibiotics and hyperbaric oxygen therapy) have been tested, which have shown promising results that are yet to be confirmed. Based on the quality of evidence, the most recommended treatments for hidradenitis suppurativa include adalimumab and laser therapy. Surgery (either by simple excision or complete local excision followed by skin graft) is the first choice for intractable disease presenting in the late stages. However, the evidence on most of these treatments is deficient and further randomized trials are needed to establish the most efficient therapies for hidradenitis suppurativa management.

Management of infected diabetic wound: a scoping review of guidelines.

Background: Various international guidelines and recommendations are available for management of diabetic foot infections. We present a review of the guidelines and recommendations for management of these infections. Methods: A systematic literature search was conducted through MEDLINE, CENTRAL, EMBASE, LILACS, DARE, and national health bodies. Based on the review of fifteen documents, we present details on the importance of suspecting and diagnosing skin, superficial infections, and bone infections in diabetics. Results: The guidelines recommend classifying the infections based on severity to guide the treatment. While antibiotics have shown the best results, other treatments like hyperbaric oxygen therapy and negative wound pressure have been debated. It is suggested that a team of specialists should be in-charge of managing the infected wounds. Infectious Diseases Society of America (IDSA) 2012 guidelines are widely followed world-over. All guidelines and reviews have consistent suggestions on the assessment of the severity of infection, diagnosis, start, selection, and duration of antibiotic therapy. Conclusions: It is reasonable to conclude that the IDSA 2012 guidelines are commonly followed across the world. There is a consensus among the Australian guidelines, Canadian guidelines, IDSA 2012, National Institute for Health and Care Excellence (NICE) 2015, and International Working Group on the Diabetic Foot (IWGDF) 2016 guidelines on the management of infected wounds for patients with diabetes mellitus.

Ongoing Development and Evaluation of a Method of Telemedicine: Burn Care Management With a Smartphone.

In cases involving small burns in patients without a comorbidity or associated pathology, a referral from a surgeon is necessary and sometimes it cannot be ascertained when the patient is not brought in by a specialized team. The purpose of this retrospective study was to evaluate the quality of our method for performing telemedicine. This retrospective study included the 323 patients who were initially treated using the telemedicine system implemented between 2011 and 2016. This procedure only involved patients burned over a small portion of their body's surface area (ie, ≤15%) who were between 15 and 75 years of age and who did not have a major comorbidity. The purpose of the procedure was to evaluate the need for surgery. The initial diagnosis regarding the need for a surgical procedure was accurate in 94.4% (305/323) of the cases. Eleven patients (3.4%) were transferred unnecessarily as they ultimately did not require surgery, and seven patients (2.2%) were ultimately transferred even though the need for surgery was not initially established at the time that the pictures were viewed. No initial errors in the photographic evaluation caused a worsening in the life-threatening, functional, or aesthetic prognoses. We have recently opted to use telemedicine for initial patient management. In 94.4% of cases, the opinion that was provided was accurate. Only 3.2% of the patients for whom outpatient treatment was recommended ultimately underwent surgery without subsequently experiencing the slightest injury due to any delay in therapy. Although it will never replace clinical examination, these results have encouraged us to develop telemedicine based on digital photography.

New techniques for wound management: A systematic review of their role in the management of chronic wounds.

Debridement is a crucial component of wound management. Recent technologies such as hydrosurgery (Versajet), ultrasound therapy (the MIST therapy device), or plasma-mediated bipolar radio-frequency ablation therapy (Coblation) seem to represent interesting alternatives for wound debridement. The purpose of this systematic review was to describe, evaluate, and compare these three recently developed methods for the management of chronic wounds. In January 2016, an electronic database search was conducted of MEDLINE, PubMed Central, and Embase for articles concerning these three innovative methods for the management of chronic wounds. A total of 389 references were identified by our search strategy, and 15 articles were included. We extracted data regarding the number and age of patients, indications, operating time, number of procedures, costs, wound healing time, decrease in exudation, perioperative blood loss, bacterial load, and the occurrence of complications. The 15 articles included studies that involved 563 patients who underwent hydrosurgery (7 studies), ultrasound therapy (6 studies), or Coblation (2 studies). Six randomized controlled trials were included that compared the use of a scalpel or curette to hydrosurgery (2 studies) or ultrasound therapy (6 studies). Hydrosurgery, in addition to being a very precise and selective tool, allows significantly faster debridement. Ultrasound therapy provides a significant reduction of exudation, and improves the wound healing time. No comparative study dedicated to Coblation was identified. Despite the obvious clinical interest of the topic, our review of the current literature revealed a lack of prospective randomized studies comparing these devices with each other or with standard techniques, particularly for Coblation and hydrosurgery.

Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis.

INTRODUCTION: Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?" METHODS: This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I2 index were computed. RESULTS: We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016). CONCLUSION: In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.

Comparison of propeller perforator flap and venous supercharged propeller perforator flap in reconstruction of lower limb soft tissue defect: A prospective study.

INTRODUCTION: In lower limbs, reliability of propeller perforator flaps (PPF) remains uncertain. The main complication is venous congestion, which can lead to distal necrosis. We aim to highlight if venous supercharging of PPF could substantially limit complications in lower limb coverage. METHODS: Between 2011 and 2016, we developed a standardized procedure of venous supercharging in the lower limb reconstruction with PPF using saphenous veins anastomosis. Then, we prospectively compared a consecutive series of 30 PPF to cover lower limbs defect, with a consecutive series of 30 venous-supercharged PPF (vsPPF). Etiologies of trauma, flap harvesting, complications, and outcomes were compared. RESULTS: The etiologies of the defect were acute trauma in 67.6% of reconstruction with PPFs and 60% of reconstruction with vsPPFs (P = 0.826). The average size of the skin paddle was 48.1 ±18.2 cm2 for PPF and 58.9 ±19.5 cm2 for vsPPF, and the average arc of rotation was 126.7° ±33.1 for PPF and 121.3° ±31.9 for vsPPF. The average sizes and rotation arcs between the two flaps were not significantly different (P = 0.031, P = 0.527). The operative time was significantly increased for vsPPF when compared to PPF procedure (128.8 ±8.5 minutes vs. 81.3 ±10.1 minutes, P < 0.001). Venous congestion was significantly higher in PPF with 11 cases than in vsPPF with two cases (36.7% versus 6.7%, P = 0.010). Distal necrosis were significantly higher in PPF with nine cases than in vsPPF with 1 cases (30% versus 3.3%, P = 0.012). Following poor flap evolution, stitches removal was significantly more frequent in PPF with 11 cases than in vsPPF with one case (36.7% vs 3.3%, P = 0.002). Leeches application was significantly more frequent for PPF procedures with nine cases, than for vsPPF with one case (30% vs 3.3%, P = 0.012). The average length of hospital stay for PPF was significantly longer than for vsPPF (8.78 versus 7.11 days, P = 0.026). CONCLUSION: The vsPPF is a reliable alternative to PPF to cover small- and medium-size defect in lower limbs, reducing venous congestion and overall complications.

A Double-Blind, Placebo-Controlled Randomized Evaluation of the Effect of Low-Level Laser Therapy on Venous Leg Ulcers.

This study aimed to determine the effect of low-level laser therapy (LLLT) on chronic venous leg ulcers (VLUs). A double-blinded prospective randomized controlled trial was conducted to compare incidence of complete wound closure, ulcer size and pain reduction in patients randomized to 24 treatments of placebo or LLLT (635 nm) over 12 weeks. Patients presented with a 6-week history of VLUs ranging in size from 5 to 20 cm2. Venous origin was confirmed by Doppler ultrasound and an ankle brachial index of 0.8 or greater. Of 24 patients, 23% of the test group (n = 13) and 18% of placebo group (n = 11) achieved complete wound closure. At 12 weeks, patients in test and placebo groups had a mean surface area reduction of 6.26 cm2 ( P < .0001) and 6.72 cm2 ( P < .005), respectively, and a mean pain score decrease of 43.54 points ( P < .0001) and 25.73 points ( P = .002) respectively. Differences between groups was not statistically significant for wound closure ( P = 1.0) or ulcer size ( P = .80). Mean ulcer pain was significantly reduced from initiation of treatment compared with 4 weeks' follow-up after 12 weeks with LLLT ( P < .01). Within the limitations of the study, LLLT may not have early effects as an adjunctive therapy to wound healing of VLUs, but LLLT may have delayed effects on VLU healing and associated pain, which requires further study.

Failure rates of artificial dermis products in treatment of diabetic foot ulcer: A systematic review and network meta-analysis.

Diabetic foot ulcer (DFU) is a frequent complication in diabetic patients, occurring in up to 25% of those affected. Among the treatments available to clinicians, the use of bioengineered skin substitutes is an attractive alternative. Artificial dermis functions as a matrix, covering the wound and supporting healing and reconstruction of the lost tissue. This study was aimed at reviewing the use of five regeneration matrices (namely, Integra, Nevelia, Matriderm, Pelnac, and Renoskin) as reported by clinical trials. We searched Medline, Embase, ISI Web of Science, Scopus, and Cochrane Central Register of Controlled Trials databases for relevant studies. Risk of failure rates was analysed by relative risk ratio method and complete ulcer healing was studied using network meta-analysis. Thirteen studies (12 randomized clinical trials and one cohort study) were eligible for analysis. The network meta-analysis based on a single study for Matriderm and 12 studies for other products showed that Matriderm was statistically inferior in achieving complete ulcer healing, as compared to all other products combined. In the second phase analysis, which was limited to three studies using artificial dermis products, there was a 57% reduction in the risk of reepithelialization failure for DFU patients who used Matriderm or Pelnac, compared to those who used Pelnac with basic fibroblast growth factor spray or skin grafting. The data showed an overall low failure rate suggesting that these bioengineered skin products provide a suitable support and microenvironment for healing of DFUs with low ulcer recurrence rates. This systematic review with meta-analysis highlights the pressing need for more studies investigating the safety, efficacy and failure rates of regeneration matrices in the treatment of DFUs.

Artiss Sealant®: An Alternative to Stapling Skin Grafts on the Dorsal Side of the Hand and Fingers.

The aim of this study was to evaluate the benefit of using a new slow-setting fibrin sealant compared with staples for adherence of split-thickness skin grafts on the backs of hands and fingers. Staple removal is often painful for patients. Twenty-eight patients were included for a graft total of 34 hands. The authors chose to test this sealant on zones that are often difficult to graft given their varied topographies. Its low concentration of thrombin (4 IU/ml) compared with other sealants provides it with prolonged polymerization time (60 seconds) making it easier to use in this location. All 34 grafts had taken at 5 days postoperatively and no graft required revision surgery. Six of our patients had sealant on one hand and staples on the other hand. All of the patients reported less pain on the sealant hand with a mean visual analog scale inferior to 2.6 times less (Mann-Whitney U test, P = .0035). Eighteen months after treatment, all of the patients had acceptable function and esthetic aspect of their hands with no difference noted between glued or stapled hands. The only notable drawbacks to the use of this sealant are the preparation and application time which is longer than with staples, the need to evacuate small seromas under the graft and obstruction of the drainage points by the sealant. The use of Artiss Sealant enabled us to reduce the amount of care and to decrease the pain because there was no staple removal.