Total Denervation of the Elbow: Cadaveric Feasibility Study.

PURPOSE: Total elbow arthroplasty for the treatment of patients with severe elbow osteoarthritis is associated with postoperative activity limitations and risk of midterm complications. Elbow denervation could be an attractive therapeutic option for young, active patients. The aim of our study was to assess the feasibility of selective total elbow denervation via 2 anteriorly based approaches. METHODS: Selective total elbow denervation was performed in 14 cadaver elbows by 2 fellowship-trained elbow surgeons. Lateral and medial approaches to the elbow were used. The length of skin incisions and the minimum distance between them were noted. The number of articular branches identified and their respective distances from the lateral or medial epicondyle of the humerus were recorded. RESULTS: The anterolateral and anteromedial approaches allowed for the identification of all mixed and sensory nerves in all 14 cases. The mean number of resultant articular branches per cadaver was 1 for the musculocutaneous nerve, 2 (range, 1-3) for the radial nerve, 1 (range, 1-3) for the posterior cutaneous nerve of the forearm, 2 (range, 1-3) for the ulnar nerve, and 2 (range, 1-3) for the medial antebrachial cutaneous nerve; the collateral ulnar nerve was connected directly to the capsule. The length of the medial and lateral incisions was 15 cm (range, 12-18 cm) and 12 cm (range, 10-16 cm), respectively. The mean minimum distance between the incisions was 7.5 cm (range, 6.7-8.5 cm). CONCLUSIONS: The findings suggest that selective elbow denervation via 2 approaches is feasible. CLINICAL RELEVANCE: Selective elbow denervation via 2 approaches is feasible. Surgeons should target the articular branches of the musculocutaneous, radial, ulnar, and collateral ulnar nerves, posterior cutaneous nerve of the forearm, as well as medial antebrachial cutaneous nerves when carrying out this procedure.

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.

Correcting of Calf Atrophy With a Custom-Made Silicone Implant: Contribution of Three-Dimensional Computer-Aided Design Reconstruction: A Pilot Study.

BACKGROUND: Calf shape is an essential aesthetic parameter of the leg, and calf atrophy can lead to complex problems. The functional consequences of calf atrophy are generally moderate. Prefilled silicone gel implants represent the vast majority of currently placed prostheses, but this technique does not ensure optimal adaptation of the implant shape due to loss of volume. OBJECTIVES: The aim of this study was to describe an innovative procedure for correcting acquired calf atrophy based on 3-dimensional (3D) modeling. METHODS: The study involved 22 patients treated for calf atrophy caused by illness. Implants were made with solid rubber silicone, and 3D reconstructions were created by computer-aided design based on computed tomography scans. The implants were introduced through a horizontal popliteal incision. RESULTS: Forty-one implants were placed. No cases of infection, hematoma, or compartment syndrome were encountered. We experienced 1 case of skin necrosis and 1 case of periprosthetic seroma. In addition, lipofilling was performed in 5 cases. Two patients sought to benefit from a surgical reduction in implant size. CONCLUSIONS: Our innovative procedure to correct calf atrophy with custom solid rubber silicone implants produces a calf shape that better adapts to volume loss than prefilled silicone gel implants. The material maintains its shape and facilitates retrofitting of the prosthesis. There is no risk of hull formation or breakage, and the life span of the implants is limitless. This 3D computer-aided design approach has optimized our reconstructions.

The Perception of Plastic Surgery by Community-Based, Private Practice Nurses: A French National Descriptive Study.

Plastic surgery is a dynamic field but remains poorly understood by general practitioners, medical students, health professionals, and the public. The main health care professionals in the community who are involved in the follow-up of plastic surgery patients are nurses; they help to facilitate wound healing and rehabilitation in the postoperative period. In this study, the authors assessed the medical knowledge and perceptions of plastic surgery by nurses working in the community setting and explored their understanding of classical scenarios commonly encountered in reconstructive surgery. An online survey was designed to assess the demographics of nurses working in the community in France and their knowledge of plastic surgery. This was disseminated to all practicing nurses working outside of hospitals by means of an online social network from the period of April 2019 to June 2019. The survey was completed by 318 nurses. Specific training in plastic surgical nursing will be required to optimize the management of these patients following discharge from hospital. This gap in knowledge may affect patient recovery negatively.

Nonsurgical Treatment of Postburn Hypopigmentation: A Literature Review.

The treatment of postburn hypopigmentation was primarily surgical before the advent of new technologies. Medical devices and therapies are emerging to manage scar sequelae that can be disfiguring and associated with severe psychosocial impact. These innovations have been poorly investigated for hypopigmentation, but they represent a real hope. We reviewed all articles published on Pubmed up to June 2022. Included studies had to specifically focus on treating postburn hypopigmented scars. All articles evaluating transient solutions such as make-up, and articles describing inflammation-linked hypopigmentation with no etiological details or no burn injury history were excluded. Through this review, we have highlighted 6 different types of nonsurgical treatments reported in postburn leukoderma potentially allowing definitive results. Electrophoto-biomodulation or E light (combining intensive pulsed light, radiofrequency, and cooling), topical daylight psoralen UVA therapy, and lasers (fractional lasers using pulse energies or CO2FL devices, lasers-assisted drug delivery as local bimatoprost and tretinoin or pimecrolimus) have been explored with encouraging results in hypopigmented burns. Finally, other promising medical strategies include using FK506, a nonsteroidal anti-inflammatory drug, to induce melanogenesis or using melanocyte-stimulating hormones with fractional laser-assisted drug deliveries, which are expected to emerge soon.

Immunosuppressant drug monitor: A non-invasive device to measure tacrolimus level in the saliva of transplanted patients.

Solid organ and vascularized composite allograft transplantation are pivotal in enhancing both life expectancy and quality of life. However, the significant risk of donor tissue rejection requires lifelong immunosuppressive therapy. Tacrolimus, a common component of immunosuppressive regimens, offers effectiveness in preventing organ rejection but poses challenges due to its narrow therapeutic window and toxicity, making it essential to carefully monitor its concentration. Tacrolimus trough levels are currently measured in blood, requiring frequent blood draws from patients, and results are available after 3 to 6 h. To address the need for a fast, minimally-invasive, and simple method to monitor tacrolimus concentrations, we have assessed a new device for at-home analysis, the Immunosuppressant Drug Monitor (IDM) that can extract, identify and quantify tacrolimus in saliva within 15 min. We included males and females hospitalized at Massachusetts General Hospital Transplant Unit, between the ages of 21 and 65 years, and treated with Tacrolimus. Informed consent, demographic and treatment data were collected. Each subject was asked to provide a 5 mL saliva sample that was de-identified and processed by the IDM, while a 5 mL blood sample was drawn and supplied to the MGH clinical lab for analysis by the current standard, immunoassays. The predicted tacrolimus concentration found in saliva was compared to the blood trough level results. 62 samples from 31 different patients were obtained. The male to female ratio and ethnicity distribution were well balanced. The majority of patients were within 30 days of initiating tacrolimus treatment. After IDM calibration and exclusion, 21 samples were measured by the IDM. Using an exponential function fit, the IDM showed a correlation of R2 = 0.39 between the saliva Test Line absorption and the measured tacrolimus concentration in blood, with an average absolute error of 1.8 ng/mL. Our results demonstrate a clear correlation between blood and saliva measurements. The IDM provided promising results to monitor immunosuppressant drug concentrations in patients after transplantation. Future larger studies will further develop the correlation, and the IDM's potential impact on patient outcomes.

Tissue engineering strategies for breast reconstruction: a literature review of current advances and future directions.

Background and Objective: Mastectomy is a primary treatment for breast cancer patients, and both autologous and implant-based reconstructive techniques have shown excellent results. In recent years, advancements in bioengineering have led to a proliferation of innovative approaches to breast reconstruction. This article comprehensively explores the promising perspectives offered by bioengineering and tissue engineering in the field of breast reconstruction. Methods: A literature review was conducted between April and June 2023 on PubMed and Google Scholar Databases. All English and French articles related to bioengineering applied to the field of breast reconstruction were included. We used the Evidence-Based Veterinary Medicine Association (EBVM) Toolkit 14 checklist for narrative reviews as a quality assurance measure and the Scale for the Assessment of Narrative Review Articles (SANRA) tool to self-assess our methodology. Key Content and Findings: Over 130 references related to breast bioengineering were included. The analysis revealed four key applications: enhancing the quality of the skin envelope, improving the viability of fat grafting, creating breast shape and volume via bio-printing, and optimizing nipple reconstruction through engineering techniques. The primary identified approaches revolved around establishing structural support and enhancing cellular viability. Structural techniques predominantly involved the implementation of 3D printed, decellularized, or biocompatible material scaffolds. Meanwhile, promoting cellular content trophicity primarily focused on harnessing the regenerative potential of adipose-derived stem cells (ADSCs) and increasing the tissue's survivability and cell trophicity. Conclusions: Tissue and bioengineering hold immense promise in the field of breast reconstruction, offering a diverse array of approaches. By combining existing techniques with novel advancements, they have the potential to significantly enhance the therapeutic options available to plastic and reconstructive surgeons.

Optimized Decellularization of a Porcine Fasciocutaneaous Flap.

Reconstructive techniques to repair severe tissue defects include the use of autologous fasciocutaneous flaps, which may be limited due to donor site availability or lead to complications such as donor site morbidity. A number of synthetic or natural dermal substitutes are in use clinically, but none have the architectural complexity needed to reconstruct deep tissue defects. The perfusion decellularization of fasciocutaneous flaps is an emerging technique that yields a scaffold with the necessary composition and vascular microarchitecture and serves as an alternative to autologous flaps. In this study, we show the perfusion decellularization of porcine fasciocutaneous flaps using sodium dodecyl sulfate (SDS) at three different concentrations, and identify that 0.2% SDS results in a decellularized flap that is efficiently cleared of its cellular material at 86%, has maintained its collagen and glycosaminoglycan content, and preserved its microvasculature architecture. We further demonstrate that the decellularized graft has the porous structure and growth factors that would facilitate repopulation with cells. Finally, we show the biocompatibility of the decellularized flap using human dermal fibroblasts, with cells migrating as deep as 150 µm into the tissue over a 7-day culture period. Overall, our results demonstrate the promise of decellularized porcine flaps as an interesting alternative for reconstructing complex soft tissue defects, circumventing the limitations of autologous skin flaps.

Exploring Iodide and Hydrogen Sulfide as ROS Scavengers to Delay Acute Rejection in MHC-Defined Vascularized Composite Allografts.

Vascularized composite allografts (VCA) face ischemic challenges due to their limited availability. Reperfusion following ischemia triggers oxidative stress and immune reactions, and scavenger molecules could mitigate ischemia-reperfusion injuries and, therefore, immune rejection. We compared two scavengers in a myocutaneous flap VCA model. In total, 18 myocutaneous flap transplants were performed in Major histocompatibility complex (MHC)-defined miniature swine. In the MATCH group (n = 9), donors and recipients had minor antigen mismatch, while the animals were fully mismatched in the MISMATCH group (n = 9). Grafts were pretreated with saline, sodium iodide (NaI), or hydrogen sulfide (H2S), stored at 4 °C for 3 h, and then transplanted. Flaps were monitored until clinical rejection without immunosuppression. In the MATCH group, flap survival did not significantly differ between the saline and hydrogen sulfide treatments (p = 0.483) but was reduced with the sodium iodide treatment (p = 0.007). In the MISMATCH group, survival was similar between the saline and hydrogen sulfide treatments (p = 0.483) but decreased with the sodium iodide treatment (p = 0.007). Rhabdomyolysis markers showed lower but non-significant levels in the experimental subgroups for both the MATCH and MISMATCH animals. This study provides insightful data for the field of antioxidant-based approaches in VCA and transplantation.

Superior pedicle reduction mammoplasty: A multivariable analysis of 1306 patients. Risk factors for complications and development of a predictive score.

INTRODUCTION: Breast reduction surgery for hypertrophy is one of the most commonly performed procedures in plastic surgery. This surgery exposes patients to complications well documented in the literature. The objective of this study is therefore to identify the risk factors in order to establish an estimate of the risk of developing complications. We propose the first predictive score of postoperative complications including continuous preoperative variables like Body Mass Index (BMI) and Supra Sternal Notch - Nipple Distance (SSN:N). RESULTS: 1306 patients were analyzed. Multivariable logistic regression showed three independent risk factors : active smoking (OR 6.10 [4.23; 8.78] p < 0.0001), BMI (OR 1.16 [1.11; 1.22] p < 0.0001), SSN:N (OR 1.14 [1.08; 1.21] p < 0.0001). The Rennes Plastic Surgery Score estimating occurrence of postoperative complications was determined, integrating regression coefficient of each risk factor. CONCLUSION: Active smoking, BMI and SSN:N distance are independent preoperative risk factors for the occurrence of breast reduction complications. The Rennes Plastic Surgery Score including the continuous values of BMI and SSN:N allows us to provide to our patients a reliable estimate of the risk of occurrence of these complications. EVIDENCE BASED MEDICINE LEVEL II: Lesser-quality prospective cohort or comparative study; retrospective cohort or comparative study; or untreated controls from a randomized controlled trial.

Outcomes of Autologous Fat Graft Injection(s) in Treating Sequelae of Digital Trauma: A Case Series.

Background: Sequelae of digital trauma, such as painful scars adherent to tendons and bones, pain of neural origin, cold intolerance, skin and pulp atrophy, occur frequently. Autologous fat graft injections is an interesting option to treat these sequelae. The aim of this study is to describe the outcomes of autologous fat graft injections to treat sequelae of digital trauma. Methods: This retrospective study included all adult patients with digital trauma who underwent an autologous fat grafting procedure at our hospital between 2015 and 2019. The procedure was done at least 6 months after the initial trauma. Outcomes were assessed at least 9 months after the injection and included 2-point epicritic discrimination by Weber test (2-PD) and pulp circumference of the affected finger compared with the contralateral finger, a satisfaction questionnaire concerning the improvement of symptoms, aesthetic aspects and pain related to the operation, evaluation of pain by visual analogue scale, quality of life by SF-36 score and quick disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score. We also assessed whether the patients had reintegrated a previously excluded finger. Results: The study included 14 patients. All patients received one session except for one patient who received two sessions. The average 2-PD of the injured finger was 7 mm compared to 3.57 mm for the contralateral finger. There was no difference in pulp circumference between the treated and contralateral fingers. The mean satisfaction score for symptom improvement and aesthetic improvement was 3.36/5, and the mean score for procedure-related pain was 2.36/5. The mean VAS of the patients was 2.91/10, the mean SF-36 was 60.42/100 and the mean QuickDASH was 40.09/100. Five of the nine patients who had a previously excluded finger were able to reintegrate it. Conclusions: Autologous fat transfer seems to offer some benefit in patients with adherent scars and pulp atrophy. It has little effect on neuropathic pain. Level of Evidence: Level IV (Therapeutic).

Targeted partial arthroscopic trapeziectomy with temporary distraction: a retrospective study with 5-year follow-up.

Targeted partial arthroscopic trapeziectomy with temporary distraction is a minimally invasive treatment for trapeziometacarpal osteoarthritis. We performed a retrospective single centre study from March 2011 to May 2022 and included patients with at least 5 years of follow-up. A failure was defined as a patient requiring a second procedure. Of the 28 patients with at least 5 years of follow-up, 23 were reviewed. Five of the 23 patients underwent revision surgery with a 5-year survival rate of 78%. There was a significant improvement in pain and the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. There were three postoperative complications, one with complex regional pain syndrome, and two with hyperesthesia in the distribution of the sensory branch of the radial nerve. Targeted partial arthroscopic trapeziectomy with temporary distraction is a feasible temporary solution for early stage trapeziometacarpal joint osteoarthritis. However, there remains a 20% risk of failure.Level of evidence: IV.

Abdominoplasty and lower body lift surgery improves the quality of life after massive weight loss: a prospective multicenter study.

BACKGROUND: This study was conducted to assess the impact of abdominoplasty and lower body lift surgery following massive weight loss on both the general quality of life and the sexual life of patients. METHODS: We performed a multicenter prospective study on the quality of life after massive weight loss using three scoring questionnaires: The Short Form 36 questionnaire, the Female Sexual Function Index questionnaire, and the Moorehead-Ardelt Quality of Life Questionnaire. Seventy-two patients who underwent lower body lift and 57 patients who underwent abdominoplasty in three centers with pre and post-operative evaluation were included. RESULTS: The mean age of the patients was 43.2 ± 13.2 years. All categories of the SF36 questionnaire were statistically significant at 6 months, and all categories except health change were significantly improved at 12 months post-operative. Overall, the Moorehead-Ardelt questionnaire showed a higher quality of life in general (1.78 ± 0.92 and 1.64 ± 1.03, at 6 and 12 months respectively) and in all domains (self-esteem, physical activity, social relationships, work performance, and sexual activity). Interestingly, global sexual activity improved at 6 months but not at 12 months. Some domains of sexual life improved at 6 months (desire, arousal, lubrication, satisfaction), but only the desire stayed improved at 12 months. CONCLUSION: Abdominoplasty and lower body lift improve the quality of life of patients after massive weight loss as well as the sexual quality of life. This should be an additional valid reason for promoting reconstructive surgery for massive weight loss patients.

Acellular Nipple Scaffold Development, Characterization, and Preliminary Biocompatibility Assessment in a Swine Model.

BACKGROUND: The standard in nipple reconstruction remains the autologous skin flap. Unfortunately, the results are not satisfying, with up to 75% loss of nipple projection over time. Existing studies investigated the use of primates as a source of implants. The authors hypothesized that the porcine nipple can serve as a perfect shape-supporting implant because of functional similarities to the human nipple. A decellularization protocol was developed to obtain an acellular nipple scaffold (ANS) for nipple reconstruction. METHODS: Tissue samples were collected from eight disease-free female Yorkshire pigs (60 to 70 kg) and then decellularized. The decellularization efficiency and extracellular matrix characterization was performed histologically and quantitatively (DNA, total collagen, elastin, and glycosaminoglycan content). In vitro and in vivo biocompatibility was determined by human dermal fibroblast culture and subcutaneous implantation of six ANSs in a single Yorkshire pig (60 to 70 kg), respectively. Inflammation and adverse events were monitored daily based on local clinical signs. RESULTS: The authors showed that all cellular structures and 96% of DNA [321.7 ± 57.6 ng DNA/mg wet tissue versus 11.7 ± 10.9 ng DNA/mg wet tissue, in native and ANS, respectively ( P < 0.001)] can be successfully removed. However, this was associated with a decrease in collagen [89.0 ± 11.4 and 58.8 ± 9.6 µg collagen/mg ( P < 0.001)] and elastin [14.2 ± 1.6 and 7.9 ± 2.4 µg elastin/mg ( P < 0.05)] and an increase in glycosaminoglycan content [5.0 ± 0.7 and 6.0 ± 0.8 ng/mg ( P < 0.05)]. ANS can support continuous cell growth in vitro and during preliminary biocompatibility tests in vivo. CONCLUSION: This is a preliminary report of a novel promising ANS for nipple reconstruction, but more research is needed to validate results. CLINICAL RELEVANCE STATEMENT: Breast cancer is very common among women. Treatment involves mastectomy, but its consequences affect patient mental well-being, and can lead to depression. Nipple-areola complex reconstruction is critical, and existing methods lead to unsatisfactory outcomes.