Ultrasonic elastography for the prevention of breast implant rupture: Detection of an increase with stiffness over implantation time.

Breast implants are widely used after breast cancer resection and must be changed regularly to avoid a rupture. To date, there are no quantitative criteria to help this decision. The mechanical evolution of the gels and membranes of the implants is still underinvestigated, although it can lead to early rupture. In this study, 35 breast explants having been implanted in patients for up to 17 years were characterized by ex vivo measurements of their mechanical properties. Using Acoustic Radiation Force Impulse (ARFI) ultrasound elastography, an imaging method for non-destructive mechanical characterization, an increase in the stiffness of the explants has been observed. This increase was correlated with the implantation duration, primarily after 8 years of implantation. With an increase of the shear modulus of up to a factor of nearly 3, the loss of flexibility of the implants is likely to lead to a significant increase of their risk of rupture. A complementary analysis of the gel from the explants by mass spectrometry imaging (MSI) and liquid chromatography coupled to high resolution mass spectrometry (LC-HRMS) confirms the presence of metabolites of cholesterol originating from the breast tissues, which most likely crossed the membrane of the implants and most likely degrades the gel. By observing the consequences of the physical-chemical mechanisms at work within patients, this study shows that ultrasound elastography could be used in vivoas a quantitative indicator of the risk of breast implant rupture and help diagnose their replacement.

Maxillary and total nasal reconstruction with a scapulo dorsal perforator flap.

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

Aging of non-implanted Natrelle™ gel breast implants.

This study questions the aging of non-implanted breast prostheses for a period of 9-60 months. Every 6 months, two non-implanted Natrelle™ prostheses were tested to measure the strength at break, the elongation at break, and the thickness of the shell. Then, the breaking stress was calculated from the preceding quantities. All these quantities were observed by separating the samples taken from the anterior and posterior sides of the prostheses. One-way ANOVA analyses (analysis of variance) were performed to define the influence of aging duration, lot membership, and side. In addition, the elongation at break and the thickness of the shell showed significant variations as a function of aging regardless of the side but without any trend emerging. For other quantities, there were significant disparities between the anterior and posterior sides of the prostheses, differences between prostheses from different lots, and similarities between prostheses from the same lot. Finally, the thickness is an important parameter. Since manufacturing is a manual process, it is necessary to check the thickness, which must be homogeneous on both sides. Always weaker on the anterior side than on the posterior side, it influences the mechanical properties. We recommend, like other studies, that its control be part of the quality controls during manufacturing.

Musculocutaneous flap of the medial head of the triceps brachii: pedicled flap to cover the posterior cubital region.

INTRODUCTION: The medial head of the triceps brachii flap is already described as a local muscular or as a free flap. It allows coverage of defects of the posterior cubital region. The aim of this study was to describe the vascular anatomy of the musculocutaneous medial triceps brachii pedicled flap. METHODS: Eleven fresh-frozen upper limbs (6 come from women and 5 from men) were proximally injected with Indian ink agar solution. The medial head of the triceps brachii muscle was dissected and the superior ulnar collateral artery (SUCA) was isolated with its collaterals. The collateral arteries were dissected to determine whether there were septocutaneous or musculocutaneous arteries for vascularization of the skin in front of the medial head. Lengths of those collaterals arteries were measured. RESULTS: The average number of collaterals arteries from the SUCA supplying the medial head of the triceps brachii is 4.5 (from 3 to 6 arteries). Among these collaterals' arteries, there are one average 1.5 (0.6-4.5) septocutaneous arteries and 3 (1-4.8) musculocutaneous arteries. DISCUSSION AND CONCLUSION: A musculocutaneous flap with the medial head of the triceps brachii muscle can be described with the muscle. The SUCA gives perforator arteries musculocutaneous and septocutaneous for the vascularization of the triceps brachii medial head. The use of local pedicled flap with similar tissue maximizes healing with a minimal morbidity of the donor site. This study demonstrated the feasibility of the medial head triceps brachii musculocutaneous flap to cover defect of the posterior aspect of the elbow.

Cleft Alveolar Bone Graft Materials: Literature Review.

INTRODUCTION: Since the early stages of alveolar bone grafting development, multiple types of materials have been used. Iliac cancellous bone graft (ICBG) remains the gold standard. DESIGN/METHODS: A review of literature is conducted in order to describe the different bone filling possibilities, autologous or not, and to assess their effectiveness compared to ICBG. This review focused on studies reporting volumetric assessment of the alveolar cleft graft result (by computed tomography scan or cone beam computed tomography). RESULTS: Grafting materials fall into 3 types: autologous bone grafts, ICBG supplementary material, and bone substitutes. Among autologous materials, no study showed the superiority of any other bone origin over iliac cancellous bone. Yet ICBG gives inconsistent results and presents donor site morbidity. Concerning supplementary material, only 3 studies could show a benefit of adding platelet-rich fibrin (1 study) or platelet-rich plasma (2 studies) to ICBG, which remains controversial in most studies. There is a lack of 3-dimensional (3D) assessment in most articles concerning the use of scaffolds. Only one study showed graft improvement when adding acellular dermal matrix to ICBG. Looking at bone substitutes highlights failures among bioceramics alone, side-effects with bone morphogenetic protein-2 composite materials, and difficulties in cell therapy setup. Studies assessing cell therapy-based substitutes show comparable efficacy with ICBG but remain too few. CONCLUSION: This review highlights the lack of 3D assessments in the alveolar bone graft materials field. Nothing dethroned ICBG from its position as the gold standard treatment at this time.

[Pasteurellosis breast implant infection: A case report and literature review]. / Pasteurellose sur un implant mammaire ? : à propos d'un cas et revue de la littérature.

Breast implant infection is a potential complication after surgery. This case reports an unusual infection. A patient undergoes a skin sparing mastectomy for a carcinoma with an immediate breast implant reconstruction. Few days after, she consults for pain, erythema and fluctuating breast collection. The implant is removed and a lavage is done. Bacteriological cultures yield Pasteurella Multocida. She has close contact with cats. Her cat scratches a drain. It looks crucial to educate patients before they go back home. Correct postoperative cares and avoid pets are important to prevent complications.

Use of the Propeller Lumbar Perforator Flap: A Series of 32 Cases.

Lumbosacral substance defect is a challenge in reconstructive surgery because few coverage solutions are available in this anatomical region. Lumbar artery perforator flaps (LAPs) have been progressively developed and make it possible to solve very complex situations. We report a multicenter study on LAP performed to treat medium and low lumbar defects of various etiologies, to highlight the versatility of this flap as well as its robustness and reproducibility. METHODS: Between 2012 and 2019, 32 LAPs were performed in the Toulouse and Strasbourg University hospitals. Etiologies of the defects encountered were diverse: chronic wounds following neurosurgery, oncodermatology, burn sequelae, and ballistic injury. All LAPs were used in their pedicled form, turned as propeller, and combined or not with other flaps. RESULTS: We treated 31 patients with 32 LAPs. Average flap size was 14.3 cm (range 8-26) × 6.5 cm (range 5-10), and average arc of rotation was 131.3 degrees (range 70-180 degrees). Only 4 patients (12.9%) presented partial necrosis, but required no other covering procedure because secondary healing was sufficient. No coverage failure was reported. Average follow-up duration was 9.7 months (range 1-18). CONCLUSIONS: In the case of lumbosacral defects of various etiologies, propeller LAP is a reliable and efficient surgical procedure, offering the advantage of low donor site morbidity. The reconstructive surgeon should propose this technique to patients as a first-line option where surgery is indicated.

Decrease of Thrombosis in Microsurgical Anastomoses: The Use of Intraoperative Pure Intraluminal Unfractionated Heparin.

BACKGROUND: Unfractionated heparin has anticoagulant properties by catalyzing antithrombin III, which inactivates coagulation enzymes. Used in microsurgery, it would prevent the occurrence of thrombosis during microsurgical anastomoses. The objective of this study was to evaluate the role of intraoperative irrigation of the vascular lumen with pure sodium heparin to prevent vascular thrombosis after end-to-end microsurgical anastomoses. METHODS: End-to-end anastomoses were performed on rats by 21 operators. Three surgical sites were studied (cervical, femoral, and rat tail). The first vessel was irrigated with physiological salt solution (0.9%) before, during, and before the end of the anastomosis. Whenever possible, the contralateral vessel was irrigated with pure unfractionated heparin 5,000 UI/mL. The primary endpoint was the occurrence of thrombosis 60 minutes after anastomosis. RESULTS: From November 2015 to April 2018, 247 anastomoses were performed on 229 arteries and 18 veins. One hundred twenty-five anastomoses were irrigated with physiological salt solution, 122 with pure unfractionated heparin. A 60-minute thrombosis was found on 31 anastomoses (25%) irrigated with physiological salt solution compared with 16 anastomoses (13%) irrigated with heparin, that is, a decrease in the thrombosis rate of 2.6 (p = 0.01). CONCLUSION: The use of pure unfractionated heparin in intraoperative lumen irrigation during microsurgical end-to-end anastomoses reduces the rate of vascular 60-minute thrombosis compared with physiological salt solution irrigation. It is an effective intraoperative procedure for the prevention of microsurgical thrombosis.

[Assessment of patient satisfaction following nipple-areolar complex tattooing after breast reconstruction.] / Évaluation de la satisfaction des patientes ayant bénéficié d'un tatouage de la plaque aréolomamelonnaire après reconstruction mammaire.

INTRODUCTION: Nipple-areolar complex tattooing often completes the breast mound reconstruction process after cancer surgery. However, there have been few studies evaluating patient satisfaction with this technique. OBJECTIVE: To assess patients' esthetic satisfaction with the results of tattooing performed by nurses. METHOD: Ninety-eight women participated in the study. Overall satisfaction with reconstruction and satisfaction with the tattoo's color, dimension, position, and form were determined using questionnaires completed by patients and a professional jury. RESULTS: 97% of patients reported overall satisfaction with the results of nipple-areolar reconstruction. The satisfaction rate with the tattoo's color was 67%, with dimension 96%, with form 95%, and with position 94%. The satisfaction rates of the jury were as follows: nipple-areolar reconstruction 79%; color 52%; dimension 77%; form 75%; and position 69%. DISCUSSION: On the whole, the patients were satisfied with the results one year after tattooing and their satisfaction rate was higher than that of the jury's. Only 6.1% of women required a second tattoo because of discoloration. CONCLUSION: Nipple-areolar complex tattooing has a high rate of patient esthetic satisfaction and can be performed by a trained nurse without the need for hospital admission.

Complex abdominal wall defect reconstruction using a latissimus dorsi free flap with mesh after malignant tumor resection.

PURPOSE: Extended and full-thickness abdominal wall defects are commonly reconstructed using free flaps. Published surgical outcomes involving the latissimus dorsi (LD) free flap procedure are limited and are less numerous than those with free flaps involving the thigh. The aim of this report was to describe the immediate and long-term evaluation of complex abdominal wall reconstruction using a LD free flap with mesh. PATIENTS AND METHODS: Between 2005 and 2013, nine patients with extended malignant tumors of the abdominal wall underwent surgeries. After the surgical resection, the mean defect size was 385 cm2 (range: 190-650 cm2 ). Full-thickness abdominal wall reconstruction was performed with a combination of LD free flaps and meshes. The immediate and long-term outcomes were assessed regarding the complications, sustainable strength of the abdominal wall and cancer recurrence. RESULTS: The meshes measured 927 cm2 in average (range: 500-1036 cm2 ). Eight Parietex Composite® and 1 Bard Collamend Implant® were used. No donor site complications occurred, and complete LD flap survival was achieved without partial necrosis or thrombosis. One obese patient who received a porcine dermis mesh developed an eventration four days postoperatively and exhibited a limited amount of abdominal skin necrosis around the flap. Two patients died from cancer evolution. After a mean follow-up of 60.4 months (range: 29-94 months), clinical evaluation of the abdomen revealed 2 patients without anomalies, 4 cases of abdominal bulging without functional discomfort and 1 case of major abdominal distension. CONCLUSIONS: Complex abdominal reconstruction with LD free flap and mesh allows extended satisfactory coverage with a low incidence of flap and donor site complications. However, patients should be advised of the significant risk of abdominal bulging. © 2014 Wiley Periodicals, Inc. Microsurgery 37:38-43, 2017.

Incidence of breast implant rupture in a 12-year retrospective cohort: Evidence of quality discrepancy depending on the range.

BACKGROUND & OBJECTIVE: The majority of studies assessing the rupture rate of breast implants were performed by the breast implant manufacturing industry with questionable independence. After repetitive removals of ruptured implants from the same model, our team decided to assess the rupture rate and the estimated risk thereof for most of the silicone gel-filled implants we have used since they regained market approval in France in 2001. METHODS: Our study is a retrospective cohort of 809 patients operated in our University Hospital from 2001 to 2013 for cosmetic or reconstructive goals. We could track 1561 implants, 90% of them from the same manufacturer, Allergan (Irvine, CA, USA). For each of those, we gathered their exact reference, date of implantation, surgical approach, status, last follow-up visit or the eventual date, and cause of removal. RESULTS: Of 225 explanted devices, only 27 were ruptured, all from the Allergan brand. Risks of removal for rupture were estimated: 0.5% at 1000 days, 6% at 2000 days, and 14% at 3000 days. Risks were significantly different between the models from this same manufacturer. One of the range of macro-textured round implants showed risks of removal for rupture of 33% at 3000 days compared to 6% for the anatomically shaped range. CONCLUSIONS: These results suggest a qualitative discrepancy among the different ranges of breast implants of a single manufacturer within the same timeframe of implantation. To determine the in vivo lifespan of the implants that we use more precisely and sooner, we suggest that each removed implant should be analyzed for wear and tear, independently from the industry.

The Transverse Musculocutaneous Gracilis Free Flap: Virtual Animation-Assisted Dissection and Application in Breast Reconstruction.

The transverse musculocutaneous gracilis free flap is a valuable choice for autologous tissue, unilateral or bilateral breast reconstruction. This procedure is an excellent and customized option for immediate or delayed breast reconstruction in patients with small to moderate size breasts. Few descriptions of flap dissection and breast mound shaping are available. In this first educational video, the authors report the original dissection of the transverse musculocutaneous gracilis free flap used for breast reconstruction. Virtual animations insist on surgical key points and relevant details of the harvesting of the flap.

Erratum: Distal Radius Isoelastic Resurfacing Prosthesis: A Preliminary Report.

[This corrects the article DOI: 10.1055/s-0035-1556855.].

Robotically assisted harvest of the latissimus dorsi muscle: A cadaver feasibility study and clinical test case.

The applications of robotic surgery have quickly spread into a variety of surgical fields. Interest in robotic endoscopic surgery is high because of the small size of the incisions, cosmetic advantages, less invasive surgical techniques, decreased scar tissue, shorter duration of hospitalization and increased cost-effectiveness. We will describe an anatomical feasibility study and a clinical test case of robotically assisted pedicled transposition of the latissimus dorsi muscle.

The transverse musculo-cutaneous gracilis flap for breast reconstruction: How to avoid complications.

BACKGROUND: The transverse musculocutaneous gracilis (TMG) flap has become a common solution for breast reconstruction. However, the safe skin paddle limits are not yet understood. In this study, we attempted to address this issue based on our experiences with inferior and posterior skin paddle extension. METHODS: Forty-four breast reconstructions with TMG flaps performed between November 2010 and January 2014 were analyzed retrospectively. For the first 20 cases, the flap skin paddle was extended 3 cm posteriorly to the middle thigh (group 1). For the next 20 flaps (group 2), the posterior tip was limited to this line, whereas more fat was recruited inferiorly. In the four cases of group 3, the skin flap was extended posteriorly with a second vascular pedicle from the profunda artery perforator (PAP) flap. The weights and the dimensions of the flaps, operating durations, and postoperative complications of the entire series were analyzed. Groups 1 and 2 were statistically compared. RESULTS: Flap complications were statistically more frequent in group 1 compared with group 2 (45 vs. 0%, P = 0.0012); 40% posterior flap tip necrosis was observed in group 1. Conversely, donor site complications were statistically more frequent in group 2 than in group 1 (40 vs. 5%, P = 0.019) with 35% inner thigh dehiscence. In the TMG with extended PAP flap group, the operating duration was 77 min longer compared with the rest of the series with no donor site complications. In one case, limited necrosis occurred at the anterior skin tip. CONCLUSIONS: Harvesting the posterior portion of the TMG up to the middle of the posterior thigh may lead to partial flap necrosis. Extending subcutaneous fat removal under the inferior skin incision may increase the risk of donor site complications. Adding a second vascular pedicle from the PAP flap may improve posterior TMG tip perfusion at the expense of a longer operation.

Complex posterior thoracic wall reconstruction using a crossover combined latissimus dorsi and serratus anterior free flap.

Radical resection of an extended malignant sarcoma of the chest wall requires full-thickness thoracic chest wall reconstruction. Reconstruction is tedious in the case of posteriorly located tumours, because the ipsilateral pedicled myocutaneous latissimus dorsi flap is involved and hence not usable for soft tissue coverage. We report an original case of a left giant dorsal chondrosarcoma originating from the 11th costovertebral joint. After extended resection and skeletal reconstruction, soft tissue coverage was achieved with an original contralateral free flap encompassing both latissimus dorsi and serratus anterior muscles. The flap pedicle was anastomosed to the ipsilateral thoracodorsal vessels.

Evaluation of success of alveolar cleft bone graft performed at 5 years versus 10 years of age.

BACKGROUND AND PURPOSE: Although alveolar cleft bone grafting is the most widely accepted approach, controversies remain on the operative timing. METHODS: A consecutive retrospective series of 28 patients who received alveolar bone grafting was examined and divided into 2 groups depending on the age at the time of bone graft. Group A (14 patients) was operated at a mean age of 5.2 years [range, 4-7] and Group B (14 patients) at a mean age of 10 years [range, 8.5-13]. All the children were assessed clinically and by Cone Beam Computed Tomography (CBCT) before bone grafting and 6 months post-operatively. Cleft and bone graft dimensions, volumes were assessed using Osirix v.3.9.2. Residual bone graft coefficient (Bone Graft Volume on 6-months Postoperative CBCT/Alveolar Cleft Volume) was calculated. Complications, tooth movement or dental agenesis were also reported. RESULTS: The sample was uniform within both groups, considering cleft forms, pre-surgical fistula rate and cleft volume. Residual bone graft coefficient reached 63.3% in Group A and 46.2% in Group B (p = 0.012). Results of residual bone graft are also influenced by tooth eruption through the graft (p = 0.007 in Group A and p = 0.02 in Group B). CONCLUSIONS: This 3D analysis highlighted higher success of alveolar bone grafts when children are operated earlier around 5 years. LEVEL OF EVIDENCE: Therapeutic study. Level III/retrospective comparative study.

Evaluation of 5-year-old children with complete cleft lip and palate: Multicenter study. Part 2: Functional results.

BACKGROUND AND PURPOSE: Cleft surgery is marked by all the controversies and the multiplication of protocols, as it has been shown by the Eurocleft study. The objective of this pilot study is to start a comparison and analyzing procedure between primary surgical protocols in French centers. METHODS: Four French centers with different primary surgical protocols for cleft lip and palate repair, have accepted to be involved in this retrospective study. In each center, 20 consecutive patients with complete cleft lip and palate (10 UCLP, 10 BCLP per center), non syndromic, have been evaluated at a mean age of 5 [range, 4-6]. In this second part, maxillary growth and palatine morphology were assessed on clinical examination and on dental casts (Goslon score). Speech was also evaluated clinically (Borel-maisonny classification) and by Aerophonoscope. RESULTS: Veau-Wardill-Killner palatoplasty involves a higher rate of transversal maxillary deficiency and retromaxillary. The fistula rate is statistically lower with tibial periosteum graft hard palate closure but this technique seems to give retromaxillary. Malek and Talmant two-stage-palatoplasty techniques reach Goslon scores of 1 or 2. Considering speech, Sommerlad intravelar veloplasty got higher outcomes. CONCLUSIONS: Primary results. Extension to other centers required. The two-stage palatoplasty, including a Sommerlad intravelar veloplasty seems to have the less negative impact on maxillary growth, and to give good speech outcomes. LEVEL OF EVIDENCE: Therapeutic study. Level III/retrospective multicenter comparative study.

Oleogranulomatous Mastitis: A Topical Subject.

Paraffin and petrolatum have been known for more than 100 years as volumizing products. Certain countries still use them despite important complications. The authors report the case of a 39-year-old patient presenting a bilateral oleogranulomatous mastitis. An injection of petrolatum had been realized 2 years ago in Chechnya for cosmetic reasons. Clinically, she presented dense, erythemic, and painful breasts. The radiological examination found diffuse oily cysts. After first abdominal expansion, a bilateral mastectomy with immediate reconstruction was performed. The authors present a literature review about the clinical and radiological data and the possible treatments, and underline the numerous risks of this procedure, which should be strictly forbidden.