Short-Scar Latissimus Dorsi With a Lateral Approach: A Game Changer in Breast Reconstruction?

BACKGROUND: In delayed breast reconstruction, the thoraco-mammary cutaneous tissue often shows residual damage from radiotherapy. The fragility of this tissue is associated with a risk of skin necroses of approximately 8% when dissection is performed by reopening of the mastectomy scar. OBJECTIVES: The objective of this study was to adapt the technique of short-scar latissimus dorsi flap surgery with an abdominal advancement flap employing a lateral approach only avoiding re-incision of the mastectomy scar. METHODS: In this retrospective study, the authors performed 150 reconstructions in 146 patients to assess the safety and effectiveness of the short-scar latissimus dorsi technique with lateral approach. The primary outcome was the occurrence of postoperative skin necrosis of the thoraco-mammary area. RESULTS: Of the 150 delayed breast reconstruction procedures performed, none showed skin necrosis of the thoraco-mammary area, and a positive effect on skin trophicity of this area was observed. The resulting patient and surgical team satisfaction were very favorable. CONCLUSIONS: In the authors' practice, this technique changed their paradigm because of good skin safety and effectiveness. It allows reconstruction without a patch-effect in patients with very poor skin quality in whom the thoraco-mammary skin would have been replaced in the past by a skin paddle. Reconstruction would have even be contraindicated. It could also be an alternative to many other more complex and longer techniques of autologous reconstruction.

Internal pudendal perforator artery flap harvesting without pre-operative imaging: Reliability and approach.

Since its initial description in 1996 by Yii and Niranjan, the internal pudendal perforator flap (also known as the Singapore flap, the gluteal fold flap, and the lotus petal flap) has become a workhorse in perineal soft tissue reconstruction. In 2001, Hashimoto described the presence of three to five perforators in the perineal anogenital triangle. The ischial tuberosity has thus become a useful anatomic landmark for the safe boundary of medial dissection during flap elevation, in order to avoid damaging the perforator vessels. The objective of the present study was to evaluate the perforators' positions within the anogenital triangle by using color Doppler ultrasound. In a study of 15 subjects in the lithotomy position, we identified a total of 24 perforator vessels with a diameter greater than 5 mm. We noted the vessels' positions using orthonormal measurements, according to the distance from the midline and the distance on a straight line between the two ischial tuberosities (i.e. consistent bony anatomic landmarks that are independent of the patient's height and body mass index). The mean distance between the ischial tuberosity and the internal pudendal perforator was 27.3 mm. Based on our present results, we consider that routine ultrasound identification and dissection of the perforators is not always required before pudendal flap harvesting. This decreases the operating time and simplifies the flap harvesting procedure.

Early subcutaneous drainage of skin and soft tissue infections in patients with febrile neutropenia: A new treatment option.

OBJECTIVES: Patients with febrile neutropenia presenting a cutaneous portal of entry for an infectious agent are at high risk of death (19-32%). If medical management is well codified, surgical management represents a therapeutic dilemma because the only available option is an aggressive debridement of the infected area which is associated with a high morbidity rate. Our objective was to implement a low-risk technique that is quick to perform and does not delay major surgical debridement if the latter turns out to be necessary. PATIENTS AND METHODS: We performed an early subcutaneous drainage of the infected areas by percutaneous approach in order to avoid the evolution towards skin and subcutaneous necrosis. Five consecutive patients were treated with this technique associated with the recommended medical treatment between March and September 2017. This technique is based on the mechanical concept of the evacuation of the edema from the inflammatory area which would allow a better efficiency of the antibiotic treatment thanks to a better blood perfusion and a higher tissue concentration of antibiotics. RESULTS: Of the 5 patients managed in the department, no skin necrosis occurred, no surgical debridement was necessary, and no patient died during the episode of febrile neutropenia. CONCLUSION: Early subcutaneous drainage by percutaneous approach of an area of skin infection in a patient with febrile neutropenia may be considered as an interesting option. This technique allows without loss of chance for the patient to increase survival and decrease the number of aggressive surgical debridement and their high morbidity.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments. METHODS: This randomized, non-inferiority trial enrolled patients who underwent skin excision (>30 cm2), which was left open to heal by secondary intention. They received ALGINATE or NPWT by a centralized randomization. Follow-up was performed weekly until optimal granulation tissue was obtained. The primary outcome was time to obtain optimal granulation tissue for a split thickness skin graft take (non-inferiority margin: 4 days). Secondary outcomes were occurrence of adverse events (AEs) and impact of the treatments on the patient's daily life. RESULTS: ALGINATE and NPWT were applied to 47 and 48 patients, respectively. The mean time to optimal granulation was 19.98 days (95% CI, 17.7-22.3) with ALGINATE and 20.54 (95% CI, 17.6-23.5) with NPWT. Between group difference was -0.56 days (95% CI -4.22 to 3.10). The non-inferiority of ALGINATE versus NPWT was demonstrated. No AE related to the treatment occurred with ALGINATE versus 14 AEs with NPWT. There was no difference in the impact of the treatments on the patient's daily life. CONCLUSION: This trial demonstrates that ALGINATE has a similar healing efficacy to that of NPWT and that is markedly better with regard to patient safety.

How to Save a Life From Macroscopic Fat Embolism: A Narrative Review of Treatment Options.

Macroscopic fat embolism (MAFE) has grabbed the attention of the plastic surgery community in recent years because of its high mortality rate. Many articles on preventing MAFE during gluteal fat grafting are available in the literature. However, total prevention is difficult: a number of factors, both technical and human, mean that MAFE remains a potential complication. This review was written with the main goal of providing a treatment plan. MAFE shares many similar pathophysiologic and hemodynamic features with massive thrombotic pulmonary embolism (PE), especially the associated cardiopulmonary decompensation. Lessons learned from PE management were used to devise a management algorithm for MAFE. The use of extracorporeal membrane oxygenation and its potential application as a main modality of treatment for MAFE was explored. The lack of evidence in the literature for the treatment of MAFE, and its high mortality, lent urgency to the need to write an article on the management aspect in the form of a narrative review, to ensure that every plastic surgeon practicing gluteal fat grafting is knowledgeable about the treatment aspect of this deadly complication.

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.

Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa.

BACKGROUND: The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author's (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa. METHODS: This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered. RESULTS: The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent). CONCLUSIONS: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Botulinum Toxin versus Placebo: A Meta-Analysis of Prophylactic Treatment for Migraine.

BACKGROUND: The purpose of this study was to assess the efficacy of botulinum toxin in reducing the frequency of migraine headaches. METHODS: The MEDLINE, Embase, and Cochrane Library databases were searched to identify randomized, double-blind, placebo-controlled trials that compared patients receiving botulinum toxin versus placebo injections in the head and neck muscles, for the preventive treatment of migraine. The primary outcome was change in the number of headache episodes per month from baseline to 3 months. RESULTS: There were 17 studies including a total of 3646 patients. Overall analysis reported a tendency in favor of botulinum toxin over placebo at 3 months, with a mean difference in the change of migraine frequency of -0.23 (95 percent CI, -0.47 to 0.02; p = 0.08). The reduction in frequency of chronic migraines was significant, with a mean differential change of -1.56 (95 percent CI, -3.05 to -0.07; p = 0.04). Analysis of chronic migraine frequency was also significant after 2 months. The findings also highlighted an improvement of the patient's quality of life at 3 months in the botulinum toxin group (p < 0.00001). Further adverse events were traced in the botulinum toxin type A group with a statistically significant risk ratio of 1.32 (p = 0.002). CONCLUSIONS: This meta-analysis reveals that botulinum toxin type A injections are superior to placebo for chronic migraines after 3 months of therapy. For the first time, a real benefit in patient quality of life is demonstrated with only few and mild adverse events. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

An Open, Prospective Study to Evaluate the Effectiveness and Safety of Hyaluronic Acid for Pectus Excavatum Treatment.

BACKGROUND: Pectus excavatum (PE) is sometimes associated with psychological and physiological difficulties influencing a patient's quality of life. Treatment with a hyaluronic acid (HA)-based gel may benefit patients and be an alternative to other more invasive treatments. OBJECTIVES: The authors sought to evaluate the effectiveness in terms of satisfaction, duration, and safety of HA gel treatment for PE including impact on quality of life. METHODS: Males ≥18 years having PE without functional problems received HA gel injections (50 - 150 mL) at the site of deformity and in some cases at the medial pectoralis muscle borders to optimize the aesthetic result. Follow-up visits were performed after 1, 3, 6, 12, and 24 months with optional retreatment at the 24-month visit including a 1-month follow-up. Evaluations included Pectus Excavatum Evaluation Questionnaire, patient satisfaction, magnetic resonance imaging, and safety assessments. RESULTS: The treatment significantly improved patients' self-esteem (P < 0.001) and psychosocial function (P ≤ 0.038) throughout the study, as assessed by Pectus Excavatum Evaluation Questionnaire. Patients were satisfied with the aesthetic outcome and considered the treatment mild in terms of level of pain during injection. Treatment effects were maintained up to 24 months and 58% of the HA gel remained at this visit, shown by Magnetic Resonance Imaging measurements. The treatment was well tolerated. CONCLUSIONS: Treatment of PE with HA gel improved patient quality of life related to self-esteem and psychosocial functioning including aesthetically pleasing results. The treatment may also offer benefits in terms of safety and tolerability compared with other treatments.

Inverted Nipple Treatment and Poliglecaprone Spacer.

INTRODUCTION: Nipple inversion is defined as a non-projectile nipple. It is a frequent pathologic condition, in which the whole nipple, or a portion of its, is buried inward towards the lactiferous duct and lies below the plane of the areola. Numerous strategies have been described to correct nipple inversion. All the procedures have the purpose to give a good shape to the nipple, preserving its function and sensitivity, when it is possible. To avoid recurrences and to obtain good aesthetic results, we present a modified percutaneous technique. METHOD: We performed a retrospective study between 2011 and 2016 and included all the cases of inverted nipples treated in our department. Our modified percutaneous technique consists of a minimal incision supported by a percutaneous suture as a temporary spacer to fill the defect caused by releasing the fibro-ductal bands. RESULTS: A total of 41 cases of inverted nipples were corrected in 32 patients. After 1 year of follow-up, no recurrence was observed and all nipples maintained complete eversion. There was only one case of partial unilateral necrosis in a patient who underwent tumorectomy and radiotherapy. All patients were satisfied with the aesthetic outcomes. CONCLUSION: This is a simple, safe and cheap technique that should be considered as a reliable method for long-term correction of nipple inversion. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anatomical basis of the extended TDAP flap: study of its territories of vascularization and its volume.

INTRODUCTION: The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap. MATERIALS AND METHOD: Ten extended TDAP flaps were dissected on 5 fresh human cadavers. Around the classical skin paddle of a TDAP flap, the dissections were performed in a subfascial level, including the muscular fascia and the adipose tissue compartments to increase the volume of the flap. After injection of methylene blue in the thoracodorsal artery, we measured the length and width, the surface and the volume of the coloured flap. RESULTS: The mean sizes of the extended TDAP flap were 24.9 cm × 20.1 cm. The mean surface of the total vascularization zone was 441 cm2. The mean volume of the vascularized flap was 193 ml. CONCLUSION: The thoracodorsal artery perforator via the deep muscular fascial network allows us to harvest a flap of 25 cm × 20 cm with a mean surface of 441 cm² and a mean volume of 193 ml. The extended TDAP flap is a credible option in breast reconstruction.

Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps.

Background The use of distally based neurocutaneous sural flaps (DBNCSF) is one of the most common methods of reconstructing the distal lower leg. However, they have developed a bad reputation because of their propensity for venous engorgement. Venous congestion that can lead to distal necrosis can be prevented by venous supercharging. Using a prospective comparative study, we thus explored the effect of venous supercharging on the reliability of these useful workhorse flaps. Methods We prospectively included 38 patients who received a conventional DBNCSF and 38 patients who received a supercharged version of this flap (sDBNCSF) between January 2012 and July 2016. Results No significant difference was identified between the groups in terms of age, sex, comorbidity, or defect origin. The main reconstruction etiology was traumatic (open fracture, scar disunion, and chronic osteitis). The flap size was noticeably larger in the sDBNCSF group, albeit without significance. The length-width ratio was significantly greater in the sDBNCSF group (6.08 vs. 5.53, p = 0.022). Venous congestion was significantly more common in the non-supercharged group (28.6 vs. 2.6%, p = 0.01), as was coverage failure (23.7 vs. 2.6%, p = 0.035). Conclusion There are significant benefits to using venous supercharging of DBNCSF, when technically feasible. In our experience, venous supercharging increases reliability, allows the raise of larger skin paddles with much narrower pedicles limiting the morbidity of the procedure, and improves the functional and esthetic results.

Free-Flap Reconstruction: What Do Microsurgeons Prefer for Themselves?

Background The recent development of perforator flaps has changed the reconstructive strategy for common integumental defects and has refocused the attention of microsurgeons to donor site morbidity. We asked a representative panel of microsurgeons about the free flap they would use to cover a common integumental defect on their own body to investigate the best free-flap donor sites. Methods In total, 100 practitioners participated in the "FreeFlap4U" study, representing 77.3% of the French national plastic surgery teams practicing microsurgery. To assess changing attitudes, we also compared microsurgeons below 40 years of age (called junior microsurgeons, JMs) with those above 40 years of age (called senior microsurgeons, SMs). Results Perforator flaps were preferred for the first line (JMs) and second line (JMs and SMs) of treatment compared with other flaps. JMs emphasized lower donor site morbidity, whereas SMs favored reliability (p = 0.013) and considered perforator flaps as a second-line treatment. Radial forearm and transverse rectus abdominis flaps were largely dismissed due to high morbidity. Some microsurgeons were influenced by the potential secondary benefit of the integument sample at the donor site. Conclusions Microsurgeons interviewed clearly moved toward perforator flaps, such as the anterolateral thigh, thoracodorsal artery perforator, and superficial circumflex iliac artery types, to cover common integumental defects. In the coming years, we believe that this choice, emitted by the microsurgeons for themselves, will be applied extensively by these surgeons for their patients.

A Systematic Review and Meta-Analysis of Perforator-Pedicled Propeller Flaps in Lower Extremity Defects: Identification of Risk Factors for Complications.

BACKGROUND: Currently, increased interest in the perforator-pedicled propeller flap should not obscure the fact that it is, in reality, a complex procedure requiring experience and monitoring similar to free flaps. Through a meta-analysis, the authors aimed to identify the risk factors of perforator-pedicled propeller flap failure in lower extremity defects. METHODS: The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from 1991 to May of 2014 for articles describing perforator-pedicled propeller flaps in the lower extremity. The study selection met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Fixed-effects models were used. RESULTS: Forty articles complied with the inclusion criteria, representing 428 perforator-pedicled propeller flaps. The most common cause was posttraumatic (55.2 percent). Most of the defects were at the distal third of the lower leg (45.6 percent). The arc of rotation was 180 degrees for 34.3 percent. Complications were found in 25.2 percent, including partial necrosis (10.2 percent) and complete necrosis (3.5 percent). Complete flap survival was found in 84.3 percent. The authors identified three significant risk factors: age older than 60 years (relative risk, 1.61; p = 0.03), diabetes (relative risk, 2.00; p = 0.02), and arteriopathy (relative risk, 3.12; p = 0.01). No significant results were found regarding smoking status other than a tendency (p = 0.06), acute cause (p = 0.59), posttraumatic cause (p = 0.97), distal third of the lower leg (p = 0.66), fascia inclusion (p = 0.70), and pedicle rotation greater than 120 degrees (p = 0.41). CONCLUSION: Age older than 60 years, diabetes, and arteriopathy are significant risk factors of perforator-pedicled propeller flap complications in the lower extremity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.