Comparing Mohs micrographic surgery and wide local excision in the management of head and neck dermatofibrosarcoma protuberans: a scoping review

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive cutaneous sarcoma with a propensity for recurrence. Its management, particularly in the head and neck (H&N) region, presents unique challenges. This study aimed to evaluate the effectiveness of Mohs micrographic surgery (MMS) compared to wide local excision (WLE) in treating H&N DFSP and its impact on recurrence rates and tissue preservation. A comprehensive search was conducted in PubMed/MEDLINE, yielding 29 relevant studies. We included studies comparing MMS and WLE in adult patients with H&N DFSP and reporting local recurrence outcomes. Data were analyzed using random effects analysis, with a meta-analysis performed for comparative studies. Analysis of studies demonstrated a lower recurrence for MMS. Comparative analysis of five studies involving 117 patients showed a significantly lower recurrence rate in the MMS group (2%) compared to the WLE group (19%). Margin status varied between studies, with some achieving negative margins at shorter distances. In the management of H&N DFSP, MMS has emerged as a superior surgical technique, consistently associated with reduced recurrence rates and the potential for tissue preservation. The adoption of MMS should be considered for its capacity to achieve negative margins with fewer processing steps, particularly in anatomically complex regions like the H&N.

Management of skin necrosis and wound dehiscence following brown recluse spider bite in the course of breast reconstruction: A case report

Background

Breast reconstruction following mastectomy is a critical component of breast cancer treatment, aimed at improving patient quality of life. However, the management is fraught with potential complications, including skin necrosis and wound dehiscence, which can significantly impact clinical outcomes.

Case Presentation

We report a unique case of a patient, 5 years post-breast reconstruction following mastectomy and radiation therapy, who developed severe skin necrosis and wound dehiscence due to a brown recluse spider bite on the reconstructed breast. The complication necessitated the debridement of skin, removal of the implant, and further reconstruction with a latissimus flap.

Discussion

The case underscores the unusual etiology of spider bite-induced necrosis in breast reconstruction and highlights the challenges and strategic considerations in managing such complications. Upon presentation, the patient's affected breast area showed signs of extensive necrosis and wound dehiscence, directly attributed to the cytotoxic effects of the brown recluse spider's venom. The venom's pathophysiology involves a complex cascade, leading to local and systemic effects. The local effects, marked by dermonecrosis, com- promised skin integrity in this instance. Systemic effects, not observed in this patient but potentially severe, can include hemolysis, coagulopathy, and acute renal failure, highlighting the seriousness of brown recluse spider bites.

Conclusion

In conclusion, this case illustrates the complexities of managing breast reconstruction post-mastectomy complications, particularly those caused by external factors such as brown recluse spider bites. It highlights the need for meticulous attention to unusual etiologies of necrosis and dehiscence, demonstrating the importance of adaptable surgical strategies and a thorough understanding of venom pathophysiology in ensuring successful patient outcomes.

The rat as an animal model in chronic wound research: An update

The increasing global prevalence of chronic wounds underscores the growing importance of developing effective animal models for their study. This review offers a critical evaluation of the strengths and limitations of rat models frequently employed in chronic wound research and proposes potential improvements. It explores these models in the context of key comorbidities, including diabetes, venous and arterial insufficiency, pressure-induced blood flow obstruction, and infections. Additionally, the review examines important wound factors including age, sex, smoking, and the impact of anesthetic and analgesic drugs, acknowledging their substantial effects on research outcomes. A thorough understanding of these variables is crucial for refining animal models and can provide valuable insights for future research endeavors.

Venous thromboembolism risk assessment scale for prediction of venous thromboembolism in inpatients with cancer: A meta-analysis

AIMS

This meta-analysis was conducted to evaluate the validity of the Caprini venous thromboembolism (VTE) risk assessment scale in predicting the risk of VTE in inpatients with cancer.

METHODS

Studies relating to the Caprini VTE risk assessment scale were systematically retrieved from the MEDLINE, EMBASE, Web of Science, Cochrane Library, BIOSIS Previews, EBSCOhost, and China National Knowledge Infrastructure (CNKI) databases up to May 1, 2022. Two reviewers independently conducted data extraction and quality evaluation. MetaDisc 1.4 and Stata 15.0 software were used for data analysis.

RESULTS

We included 10 studies with 23,644 subjects in our analyses. The results showed that the pooled sensitivity (SEN) and specificity (SPE) were 0.59 (95 % CI: 0.55 to 0.63) and 0.57 (95 % CI:0.57 to 0.58), respectively; the pooled diagnostic odds ratio (DOR) was 6.05 (95 % CI: 2.70 to 13.58); and the area under the curve (AUC) of the summary receiver operating characteristic (SROC) curve was 0.76. Subgroup analysis was performed according to ethnicity (Chinese or non-Chinese), study design (prospective/retrospective), Caprini RAM version (2005/2009), and cut-off (≤7 or > 7).

CONCLUSION

The Caprini VTE risk assessment scale has a moderate ability to predict VTE in surgical inpatients with cancer, as well as in Western populations; Caprini 2009 has a stronger predictive ability than 2005, and its predictive power is better if the cut-off value is >7. Future studies in clinical practice and specific specialties are needed to explore the optimal cut-off value of different cancers. This will improve our accuracy in understanding the risk of VTE in inpatients and help promote timely and targeted prevention. In turn, this will reduce the incidence of VTE and improve the quality of life of inpatients with cancer.

Complications and outcomes following injection of foreign material into the male external genitalia for augmentation: a single-centre experience and systematic review

Injection of exogenous material into the penis and scrotum has been performed for augmentation purposes. Complications include cosmetic dissatisfaction, penile necrosis and lymphoedema. We report the complications and outcomes from a single centre with an updated systematic review of the literature. A retrospective review of all cases presenting with foreign substance injection into the genitalia, over a 10-year period was performed. Thirty-five patients with a mean (standard deviation (SD); range) age of 36.9 (±9.1; 22-61) years at presentation were included. The mean (SD; range) time between injection and presentation was 7.8 (±5.8; 1 day-20 years) years. The most common injected substance was silicone (n = 16, 45.7%) and liquid paraffin (n = 8, 22.9%). The penile shaft (94.3%) was the most injected site. The most common presentations were cosmetic dissatisfaction (57.1%) and pain and/or swelling (45.7%). Surgery was required in 32 (91.4%) cases. Primary procedures included local excision and primary closure (n = 19, 59.4%), circumcision (n = 5, 15.6%), excision with a split skin graft or a scrotal flap reconstruction (n = 5, 15.6%). Three (8.6%) patients presented with necrosis and required acute debridement. Overall, 18 patients had more than 1 procedure, and 8 patients required 3 or more procedures. A systematic search of the literature identified 887 articles of which 68 studies were included for analysis. The most common substance injected was paraffin (47.7%), followed by silicone (15.8%). The majority of patients (77.9%) presented with pain, swelling or penile deformity. 78.8% of the patients underwent surgical treatment, which included excision and primary closure with or without the use of skin grafts (85.1% of all procedures), the use of flaps (12.3%) and penile amputation (n = 2). Complications of foreign body injection into the male genitalia can be serious resulting in necrosis and autoamputation. Surgical intervention is often required to excise abnormal tissue to manage pain and improve cosmesis.

Patient-Reported Satisfaction and Health-Related Quality of Life in Patients with Breast Augmentation: A Follow-Up of 6 Months

BACKGROUND

To evaluate the success of a breast augmentation, it is essential to measure outcomes from the patient perspective, because a successful aesthetic result is, in particular, determined by the patient. This study aimed to evaluate patient-reported satisfaction with their breasts, and psychosocial, physical, and sexual well-being in patients undergoing breast augmentation using validated questionnaires.

METHODS

This is a multicenter cohort study based on ongoing routinely collected data. Patient-reported satisfaction and health-related quality of life were assessed with the BREAST-Q augmentation module at intake and 6 months postoperatively.

RESULTS

A total of 1405 patients were included. Large changes in BREAST-Q scores (range, 0 to 100) between intake and 6 months postoperatively were seen in satisfaction with breasts (mean, effect size: +57, 3.8), psychosocial well-being (mean, effect size: +38, 2.1), physical well-being (mean, effect size: -14, -1.2), and sexual well-being (mean, effect size: +44, 2.4). Moreover, improvements in all four scales were not dependent on their intake scores, and all postoperative scores reached similar levels. A decreased physical well-being of the chest was measured after surgery. The satisfaction with breasts scale correlated moderately to strongly with the psychosocial and sexual well-being scale 6 months after surgery. Subgroup analysis based on patient characteristics found no differences in outcomes, except for body mass index.

CONCLUSIONS

Significant improvement in patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being can be seen 6 months after breast augmentation, despite a decline in physical well-being after treatment. Postoperative satisfaction levels did not depend on preoperative scores. These insights can contribute to improving preoperative communication between surgeon and patient regarding the expected outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Clinical efficacy and safety of composite non-cross-linked hyaluronic acid for treating tear trough-lower eyelid bag deformity

BACKGROUND

Tear trough-eye bag deformities may appear in young Asian patients due to the weak support of their facial skeletons. For these patients with better periorbital skin elasticity, the injection may be more suitable than surgery for treating tear trough-lower eyelid bag deformity.

AIMS

Identify the clinical efficacy and safety of non-cross-linked HA in the treatment of tear trough-lower eyelid bag deformity.

METHODS

In this study, we analyzed pre- and postinjection photographs of 55 patients treated with non-cross-linked hyaluronic acid (HA) for tear trough-lower eyelid bag deformity.

RESULTS

The mean [SD] scores of modified Goldberg score suggested that the most significant improvement of preoperative and postoperative scores was in tear trough depression, followed by infraorbital triangular depression, orbital fat prolapse, loss of skin elasticity, and skin transparency. Only transient localized complications were observed, including bruising, swelling, and erythema. There were no serious complications, such as skin necrosis or visual impairment.

CONCLUSIONS

Our study confirmed the beneficial efficacy and minor complications of composite non-cross-linked HA for the treatment of tear trough-lower eyelid bag deformity.

Characterizing the Impact of Facial Rehabilitation on Acute Facial Paralysis

Evidence on facial rehabilitation therapy (FRT) for acute facial paralysis (FP) remains limited. We present a retrospective review of patients with acute FP who have received FRT with physical therapists within 1 year of FP onset as determined by Sunnybrook Facial Grading Scale (SFGS) composite scores. A total of 702 patients with a clinical diagnosis of FP were referred to a university rehabilitation program between January 1, 2015 and January 1, 2022. Seventy-six patients met the criteria, defined as FP diagnosis <12 months before FRT initiation, ≥3 therapy sessions, and sufficient follow-up data. Average number of treatment sessions between SFGS scores was 7.7. History of cancer, sex, number of treatment sessions, and initial SFGS score were correlated with change in SFGS. Time to treatment was not correlated with change in SFGS score. SFGS improved with each additional treatment session (p < 0.01). Each additional point in the initial SFGS was correlated with less change in the final SFGS score (p < 0.01). FRT can provide meaningful improvement in functionality for patients with acute FP, regardless of time to treatment. Furthermore, patients who present with poorer functionality at baseline and those who undergo more treatment are most likely to see SFGS improvement. Research comparing the effect of facial rehabilitation with other treatment modalities and to a control cohort is warranted.

Dexmedetomidine on the interplay of IL-6 and STAT3 pathways in adrenal gland damage-induced scalding burns in rats

Scalding burns are a common form of thermal injury that often leads to systemic complications. Pro-inflammatory cytokines like interleukin-6 (IL-6) and the activation of signal transducer and activator of transcription 3 (STAT3) pathways have been linked to the pathophysiology of organ damage caused by burns. This study aimed to investigate the potential therapeutic effects of dexmedetomidine, an α2-adrenergic receptor agonist with anti-inflammatory properties, on the interplay of IL-6 and STAT3 pathways in adrenal gland damage following scalding burns in rats. Twenty-eight rats were divided randomly into four groups. Rats in group 1 (n=7, control) were given only 0.9% intraperitoneal (i.p.) NaCl. Rats in group 2 (n=7, DEX) were exposed to 25°C water for 17 s on day 1 and received 100 mcg/kg/day dexmedetomidine i.p. for 3 days; for rats in group 3 (n=7, Burn), boiling water of 94°C was applied inside for 17 s. Rats in group 4 (n=7, Burn+DEX) were exposed to 94°C water for 17 s and received 100 mcg/kg/day dexmedetomidine i.p. for 3 days. Adrenal gland tissues were histopathological examined, and STAT3, IL-6, and TUNEL staining were performed using immunohistochemically. Our results revealed that scalding burns increased IL-6 and STAT3 expression in the adrenal glands of rats. Histological analysis demonstrated that dexmedetomidine administration ameliorated adrenal gland damage and reduced inflammatory cell infiltration. Our findings suggest that dexmedetomidine protects the adrenal glands in scalding burns. This protection appears to be mediated, at least in part, by its modulation of IL-6 and STAT3 pathways.

Nasal Deformity Correction in Cleft Lip and Palate Patients by Secondary Rhinoplasty: Patients Satisfactions

AIM OF THE STUDY

To evaluate the degree of patient satisfaction postsecondary rhinoplasty, specifically in cleft patients in Mosul city.

METHODOLOGY

A retrospective comparison questionnaire study was conducted between March and April 2024 among cleft patients who underwent surgical secondary rhinoplasty in Mosul City of Nineveh Province. All cleft patients aged 18 to 40 who underwent secondary rhinoplasty are included in the study. Forty participants respond to a specific questionnaire in 3 time periods (before surgery 3 and 6 months after). Basic demographic information (age, gender, cause of visit, diagnosis, and treatment) is recorded. Questionnaire which conflict the patient's perception presurgery and postsurgery also. The improvement rate and reduction rate of improvement are calculated according to a special equation.Thanks for such comment. The sentences changed as requested with (Six standard questions applied to evaluate the patients' satisfaction postsurgery. Responses are assessed statistically by special equation to detect the improvement rate).

RESULTS

According to age groups, the age between 26 and 30 years have the highest incidence between the cases with 37.5%. Females are highest with (55%). Esthetics are the most common cause. Effective or improvement rate shows positive except for question 6 ( median: 4%). The reduction rate shows positive results.

CONCLUSIONS

Despite being a complicated surgical operation, cleft rhinoplasty can yield symmetry, improved esthetics, and enhanced functioning, including improved breathing, which can be life-changing for patients and fulfilling for the surgeon. Its difficulty stems from the fact that it has required several surgical phases throughout the years, each of which calls for a comprehensive surgical team with a variety of specializations to be addressed for optimal outcomes.

Short-term versus extended chemoprophylaxis against venous thromboembolism in DIEP flap breast reconstruction: A retrospective study of 424 patients

BACKGROUND

Autologous breast reconstruction is considered high-risk for deep vein thrombosis (DVT) and thromboembolism (PE). It is therefore recommended to treat patients undergoing these complex and lengthy procedures with DVT chemoprophylaxis. The optimal anticoagulation protocol is still not established. The objective of our study was to evaluate the need of a prolonged anticoagulation in patients undergoing microsurgical breast reconstruction.

METHODS

This retrospective cohort study compares our former anticoagulation protocol, which was given during the in-hospital stay, with our new protocol consisting of extended anticoagulation until postoperative day 25, in terms of DVT/PE risk reduction. A logistic regression was used to evaluate the risk of DVT/PE between the two groups, while adjusting for several covariates.

RESULTS

Our cohort consisted of 205 patients in the short-term anticoagulation group and 219 in the extended protocol group. Five patients (2.4%) in the short-term anticoagulation group had a DVT/PE event versus 4 patients (1.8%) in the extended protocol group. Logistic regression revealed no difference in the incidence of DVT/PE between the two groups. Similarly, there was no differences in terms of hematoma and infection rate between the two groups. Finally, we found an increased risk of DVT/PE in patients with a Caprini score equal or greater than 8.

CONCLUSION

In our experience, short-term anticoagulation during the hospital stay is equivalent to extended thromboprophylaxis in terms of DVT/PE prevention.

[Versatility of the free serratus flap in microsurgical reconstruction: Evaluation of a series of 100 cases]

In the era of microsurgery and with the more recent advent of flaps, it is interesting to highlight the value of the serratus muscle flap in microsurgical reconstruction. A total of 100 flaps were performed in our department between 2001 and 2022, with 85% of cases in a post-traumatic context (acute or septic). There were 83 male and 17 female patients. The mean age was 40.5years, with extremes ranging from 11 to 76years. The origin of the tissue loss was as follows: acute trauma 73 cases; chronic/septic wound 19 cases; purpura fulminans 2 cases; tumour 6 cases. The size of the loss of substance varied from 15 to 200cm2, with an average of 90cm2. Four different types of flap were used: muscle flap ( 78 cases), musculocutaneous flap (5 cases), costo-osteomuscular flap (13 cases), costo-osteomusculocutaneous flap (4 cases). In all cases where the rib was taken, it was the 8th rib and sometimes the 7th. These vascularised rib flaps were performed for bone loss ranging from 5 to 12cm. In our series, there was a 6% complication rate at the recipient site (3 haematomas, 2 pneumothoraxes and one case of chronic pain). The overall success rate in our series was 82.8%, with only 20% of general complications and 6% of donor site complications, with very little aesthetic scarring or functional damage to the donor site. This flap, which is rarely used, is particularly interesting for limb reconstruction, as all its parameters can be adjusted according to the defect, and the length of its pedicle means that it can also be used to perform anastomoses at a distance from the traumatised area. It also offers the possibility of reconstructing a bony defect with a composite costal harvest.

Inclusion of clinical photographs with general dental practitioner electronic referrals of patients with oral mucosal disease to secondary care: a service review

Introduction This service evaluation reviewed how the inclusion of photographs in dentist referrals to an oral medicine specialist service can improve the service for triage, prioritisation and diagnosis.Materials and methods Data were prospectively collected from e-referrals over a four-month period. Any change in appointment prioritisation resulting from review of photographs at the vetting stage was recorded.Results Only 29.5% (82 of 367) of referrals included a photograph. Of these, 5% were 'rejected with advice' since the photograph indicated the patient did not require a secondary care appointment. Additionally, 14% of all referrals were upgraded in urgency, five of which were due to concerns of malignancy, and three of five were upgraded solely based on the photographs as they showed features of possible malignancy, where the written element of the referral did not describe nor raise such concerns.Discussion and conclusions Including a photograph with a referral can often make up for inaccurate or insufficient written content, allowing appropriate and safe prioritisation, especially where the referrer has failed to recognise possible malignancy. Photographs can also prevent unnecessary referral upgrades, ensure an appointment is necessary and can be invaluable as a baseline comparator.

Thrombosis in the perforasome in idiopathic purpura fulminans with anti-protein S antibodies: Anatomical and clinical evidence to improve management

Idiopathic purpura fulminans (IPF) is a rare and severe form of purpura fulminans caused by acquired protein S deficiency. It can lead to severe thrombotic complications, such as large skin necrosis and amputation. The lesions almost exclusively affect the lower limbs, and their distribution is similar among patients with IPF, unlike classical purpura fulminans lesions. Our hypothesis is that vascular structures called perforasomes may be involved in IPF, possibly caused by protein S deficiency. We analyzed all case reports and case series published in the literature that provided sufficient data for an anatomical study of limb injuries. For precise localization of areas of necrosis, we examined each case using descriptions and images to determine whether they overlapped with vascular territories that include perforasomes. We analyzed twelve cases from the literature and identified six vascular territories: the anterolateral, anteromedial, and posterior territories of the upper leg, as well as the anterolateral, anteromedial, and posterolateral territories of the lower leg. For each territory, we described the most probable vascular damage and the corresponding perforasome. IPF is a complex multifactorial disease in which a direct involvement of perforating arteries may be suspected and taken into account in the surgical of lesions.

Reduction Mammoplasties: Risk Factors and Early Complications-About 1442 Cases

BACKGROUND

Breast reduction surgery is a widely performed plastic surgery procedure. The incidence of such complications has been steadily decreasing in recent years but is still nonetheless 5.6%. The primary aim of this study was to analyze the incidence of the main postoperative complications of breast reduction surgery. In addition, we identified cause-and-effect links between complications and characteristics of the patients, such as smoking, age, weight resection, BMI, and wound drainage.

MATERIALS AND METHODS

This retrospective study was performed on a population of 1442 women who underwent breast reduction surgery between January 2016 and October 2022 in the plastic surgery unit at Saint-Louis Hospital, Paris, France. At the follow-up examination, we evaluated the patients for complications.

RESULTS

The average resection weight was 1297.7 g in a population for which the average BMI was 28.9. We found 19.9% rate of total complications, of which 3.5% were major complications. We found that only the resection weight was a risk factor for complications.

DISCUSSION

The main strength of our study is the size of our sample. The large number of patients allowed us to conduct numerous analyses and obtain significant results despite the rarity of certain events. This large cohort was also responsible for the high statistical power of our results.

CONCLUSION

The risk of developing a postoperative infection was 7.5% for resections of less than 2.4 kg, increasing to 13.9 % when greater than that. Thus, the administration of prophylactic antibiotic therapy to affected women to reduce the risk of infection is a distinct consideration. For the other factors, while none of them appeared to promote the occurrence of adverse events and, therefore, do not formally contraindicate breast reduction surgery, some preventive measures still strike us as being relevant, such as blade drainage, weight loss, diabetes control, and smoking cessation.

LEVEL OF EVIDENCE III

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 .

A Biological Approach to Periorbital Aesthetics in Caucasian Females: A Review of the Literature

The face plays an important role in human interactions, and the periorbital region is particularly important for recognition and attractiveness. There are several studies on the beauty of the periorbital region with a variety of methodologies, but few articles consider the attractiveness factors derived from evolutionary psychology such as symmetry, dimorphism, age and average, neoteny, and facial expression. The aim of this study was to identify periorbital attractiveness criteria in Caucasian females based on experimental studies and to interpret them in the light of studies on biological attractiveness factors. A review of literature was conducted with PubMed, the Cochrane Library Database, and EMBASE. Studies published after March 20, 2022, were analyzed, and no date limit was applied to reference papers. The search strategy was focused on 3 main concepts: attractiveness AND evaluation AND facial feature of periorbital region. A total of 780 articles were identified with this search strategy; 534 were excluded based on title and abstract and another 110 after full text assessment. Eighteen articles were finally included in the analysis. The main factors identified were an ascending intercanthal axis and eyebrow axis, a regular pretarsal plate and a well-defined upper lid crease, no scleral show, and an open eye fissure exposing the upper half of the iris. In our review we were able to identify objective anthropometric characteristics linked to biological attractiveness criteria that may be helpful in preoperative planning and assessment of the periorbital region of patients.

LEVEL OF EVIDENCE: 3

Role of V-Y flap reconstruction in vulvar cancer patients: multicenter retrospective study

OBJECTIVE

To assess if the use of a V-Y reconstructive flap after excisional radical surgery positively influences the surgical outcomes in patients with vulvar cancer.

METHODS

This was a multicenter, retrospective, controlled study. Surgical outcomes and complication rates of women with invasive vulvar cancer who underwent radical surgery and vulvar reconstruction and those who underwent radical surgery without the reconstruction step were compared. Only patients who underwent bilateral or unilateral V-Y advancement fascio-cutaneous flaps were included in the reconstruction group. Univariate and multivariate logistic regression models were used to analyze predicting variables for their association with complication rates.

RESULTS

Overall, 361 patients were included: 190 (52%) underwent the reconstructive step after the excisional radical procedure and were compared with 171 (47.4%) who did not undergo the reconstructive step. At multivariate analysis, body mass index >30 kg/m2 (odds ratio (OR) 3.36, p=0.007) and diabetes (OR 2.62, p<0.022) were independently correlated with wound infection. Moreover, increasing age (OR 1.52, p=0.009), body mass index >30 kg/m2 (OR 3.21, p=0.002,) and International Federation of Gynecology and Obstetrics (FIGO) stages III-IV (OR 2.25, p=0.017) were independent predictors of wound dehiscence. A significant reduction in the incidence of postoperative wound complications among patients who underwent V-Y reconstructive flaps was demonstrated. This was correlated more significantly in women with lesions >4 cm.

CONCLUSIONS

The adoption of V-Y flaps in vulvar surgery was correlated with reduced surgical related complications, particularly in vulnerable patients involving large surgical defects following excisional radical procedures.

Breast reconstruction through exclusive lipomodeling or in addition to a flap: Current status in Franche-Comté

INTRODUCTION

Breast reconstruction after cancer surgery through lipomodeling can be performed alone or in combination with a flap. Our objective is to describe the proportion of techniques used on patients who underwent autologous reconstructive surgery after tumorectomy or mastectomy in Franche-Comté.

MATERIALS AND METHODS

A bicentric retrospective observational study was conducted between October 2017 and December 2021 (NCT06101732), including three groups: those who underwent exclusive lipomodeling reconstruction after mastectomy (1) or in addition to a flap (2), and those who underwent exclusive lipomodeling reconstruction after tumorectomy (3). Socio-demographic, medical, and surgical data were collected and recorded in a specially designed software.

RESULTS

Two hundred and fifty-one lipomodeling procedures were performed on 91 patients. In group 1, the average transferred volume was 1191mL with an average number of sessions of 4.4 spreads over 19.4months. In group 2, the average transferred volume was 676mL with an average operative time of 2.5 spread over 16.1months. In group 3, the average transferred volume was 223mL with an average number of sessions of 1.5 spreads over 6.2months. Regarding postoperative complications, 11% had cysts of fat necrosis, 4.4% had infections, and 2.2% had hematomas.

CONCLUSION

Lipomodeling is a technique that has clearly established itself in the field of breast reconstructive surgery. It results in a few complications and improves the final aesthetic outcome whether used exclusively or in addition to a flap.

Biomechanically based Fu's subcutaneous needling treatment for senile knee osteoarthritis: protocol for a randomized controlled trial

INTRODUCTION

Fu's subcutaneous needling (FSN) is a new type of acupuncture that uses subcutaneous tissue to oscillate from side to side to improve muscle pathology status and can be effective in treating Knee osteoarthritis. Nonetheless, whether the clinical effect is similar to that of most commonly used drugs is unclear. Thus, this study aims to determine the pain-relieving effect and improvement in the joint function of the FSN therapy by comparing it with that of a positive control drug (celecoxib). Furthermore, this clinical trial also aims to evaluate the effect of FSN on gait and lower limb muscle flexibility, which can further explore the scientific mechanisms of the FSN therapy.

METHODS AND ANALYSIS

This study is a randomized, parallel-controlled, single-center prospective clinical study that includes 60 participants, with an FSN group (n = 30) and a drug group (n = 30). The Fu's subcutaneous needling (FSN) group undergo the FSN therapy 3 times a week for 2 weeks, while the drug group receives 0.2 g/day oral celecoxib for 2 weeks, with a follow-up period of 4 weeks after the completion of treatment. The primary outcome is the difference in the visual analog scale score after 2 weeks of treatment compared with baseline. The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, joint active range of motion test, three-dimensional gait analysis, and shear wave elastic imaging technology analysis in lower limb muscles are also performed to demonstrate clinical efficacy.

ETHICS AND DISSEMINATION

The trial is performed following the Declaration of Helsinki. The study protocol and consent form have been approved by the Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine. All patients will give informed consent before participation and the trial is initiated after approval. The results of this trial will be disseminated through publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT06328153.

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications

INTRODUCTION

The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment.

METHODS

A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes.

RESULTS

The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant.

CONCLUSION

The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers.

LEVEL OF EVIDENCE III

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 .

Role of hydrogen sulfide in dermatological diseases

Hydrogen sulfide (H2S), together with carbon monoxide (CO) and nitric oxide (NO), is recognized as a vital gasotransmitter. H2S is biosynthesized by enzymatic pathways in the skin and exerts significant physiological effects on a variety of biological processes, such as apoptosis, modulation of inflammation, cellular proliferation, and regulation of vasodilation. As a major health problem, dermatological diseases affect a large proportion of the population every day. It is urgent to design and develop effective drugs to deal with dermatological diseases. Dermatological diseases can arise from a multitude of etiologies, including neoplastic growth, infectious agents, and inflammatory processes. The abnormal metabolism of H2S is associated with many dermatological diseases, such as melanoma, fibrotic diseases, and psoriasis, suggesting its therapeutic potential in the treatment of these diseases. In addition, therapies based on H2S donors are being developed to treat some of these conditions. In the review, we discuss recent advances in the function of H2S in normal skin, the role of altering H2S metabolism in dermatological diseases, and the therapeutic potential of diverse H2S donors for the treatment of dermatological diseases.

The Effects of Gender-Affirming Hormone Therapy on Quality of Life: The Importance of Research on Youth

Gender-affirming hormone therapy (GAHT) plays a significant role in the medical care of transgender individuals, helping to align their physical characteristics with their gender identity. While numerous studies have investigated the impact of GAHT on adults, research focusing on its effects on the quality of life (QoL) of transgender youth is limited. In this opinion paper, we aim to address selected challenges associated with gender-affirming medical care, such as (1) the necessity for evidence-based youth gender-affirming medical care, (2) the urge to explore different approaches to gender-affirming medical care diversely in transgender youth research, and (3) understanding the challenges of the detransition process (which refers to stopping or reversing gender-affirming medical or surgical treatments), as well as suggest possible solutions for meaningful progress. Notably, the available evidence underlines a positive impact of GAHT on various aspects of QoL of transgender youth, such as mental health and social functioning, by alleviating gender dysphoria, improving body satisfaction, and facilitating appearance congruence (the degree to which an individual's physical appearance represents their gender identity). However, challenges related to methodological limitations, as well as ethical considerations, and several sociocultural factors highlight the need for further research to better understand the long-term effects of GAHT on the QoL of transgender youth. Ethical considerations, such as ensuring informed consent and weighing potential benefits against risks, are pivotal in guiding healthcare decisions. Additionally, navigating these ethical responsibilities amid sociocultural contexts is crucial for providing inclusive and respectful care to transgender youth. Addressing these research gaps is, therefore, crucial to developing successful healthcare programmes, raising awareness, and promoting the holistic well-being of transgender youth through comprehensive and affirming care.

French national survey on breast cancer care: caregiver and patient views

PURPOSE

To improve the quality of care for patients with breast cancer, an analysis of the health-care pathway, considering feedback from both health-care practitioners (HCPs) and patients, is needed.

METHODS

Between 2020 and 2022, we conducted a survey at French breast cancer centers and analyzed information from questionnaires completed by HCPs and patients. We collected information on center organization, diagnostic processes, treatment decisions and modalities, supportive care, patient advocacy groups, and work issues.

RESULTS

Twenty-three breast cancer centers were included and questionnaires completed by 247 HCPs and 249 patients were analyzed. The centers closely followed the legal French framework for cancer treatments, which includes formal diagnostic announcements, multidisciplinary tumor boards, personalized treatment summaries, and supportive care access. HCPs and patients were satisfied with the time to diagnosis (≤ 2 weeks as evaluated by 75% of patients), time to surgery (mean 61 days), time between surgery and chemotherapy (mean 47 days), and time between surgery and radiotherapy (mean 81 days). Fertility preservation counseling for women under 40 years of age was systematically offered by 67% of the HCPs. The majority (67%) of the patients indicated that they had received a personalized treatment summary; the topics discussed included treatments (92%), tumor characteristics (84%), care pathways (79%), supportive care (52%), and breast reconstruction (33%). Among HCPs, 44% stated that reconstructive surgery was offered to all eligible patients and 57% and 45% indicated coordination between centers and primary care physicians for adverse effects management and access to supportive care should be improved, for chemotherapy and radiotherapy, respectively. Regarding patient advocacy groups, 34% of HCPs did not know whether patients had contact and only 23% of patients declared that they had such contact. For one-third of working patients, work issues were not discussed. Twenty-eight percent of patients claimed that they had faced difficulties for supportive care access. Among HCPs, 13% stated that a formal personalized survivorship treatment program was administered to almost all patients and 37% almost never introduced the program to their patients. Compliance to oral treatments was considered very good for 75-100% of patients by 62% of HCPs.

CONCLUSIONS

This study provides an updated analysis of breast cancer care pathways in France. Overall, the initial processes of diagnosis, announcement, and treatment were swift and were in agreement with the best care standards. No barriers to accessing care were identified. Based on the study findings, we proposed several strategies to improve the quality of care for patients in supportive care, coordination with primary care physicians, reconstructive surgery, and fertility preservation access.

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways.

SUMMARY

In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

Innovative technique for managing extreme relapsing bilateral pseudoangiomatous stromal hyperplasia (PASH) in a young woman: A case report highlighting a novel intervention in reconstruction

INTRODUCTION

Pseudoangiomatous stromal hyperplasia (PASH) is a rare breast stromal lesion that typically manifests clinically as a palpable unilateral, painless lump that is freely movable and has a rubbery or firm consistency. The diagnosis can be confirmed by a core needle biopsy (CNB) or surgical excision. Treatment options include medical treatment with hormonal management for asymptomatic patients or local excision and breast reduction in rare cases.

CASE PRESENTATION

We reported the case of a 24-year-old woman with a history of taking contraceptive pills for about a year. Examination revealed extremely enlarged, sore, and swollen breasts, particularly the right side, marking her third PASH relapse. The patient underwent a surgical skin-reducing mastectomy (SRM) using a novel technique with an immediate prepectoral implant covered by a dermal flap to reconstruct the breast shape due to the large PASH lesions and aiming for optimal cosmetic outcomes. The procedure was complication-free with no recurrence after 18 months of follow-up.

DISCUSSION

Mastectomy followed by immediate implantation offers benefits such as prompt restoration of breast shape with fewer surgeries.

CONCLUSION

This case report highlights the successful use of immediate implantation in reconstructing large recurrent benign breast diseases. The outcomes indicate that immediate implantation shows promise as a suitable choice for carefully selected patients managing large, relapsing bilateral benign breast diseases. However, due to common complications such as infection and implant loss, it is not generally recommended for benign lesions. The decision should be made on a case-by-case basis, considering the size, recurrence, and individual suitability.

Unexpected location of a pilonidal sinus

Pilonidal sinus disease is typically located in the sacrococcygeal area, although it has been described in other locations. We present a rare case of pilonidal sinus on the scalp and its management.

The versatility of the scapular free flap: A workhorse flap? A systematic review and meta-analysis

BACKGROUND

The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction.

METHODS

A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection.

RESULTS

A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2.

CONCLUSION

The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.

Venous Thromboembolism after DIEP Flap Breast Reconstruction: Review of Outcomes after a Postoperative Prophylaxis Protocol

BACKGROUND

Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens.

METHODS

A new chemoprophylaxis protocol was introduced starting in March of 2019 that involved 2 weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at the authors' institution between January of 2014 and March of 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence.

RESULTS

Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared with patients discharged with prophylaxis (3.7% versus 0%; P = 0.03). Notably, zero patients in the VTE prophylaxis group developed a deep venous thrombosis or pulmonary embolism. In addition, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 ( P = 0.0002).

CONCLUSION

The authors demonstrate the successful implementation of a 2-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Is smoking a risk factor for complications following total ankle arthroplasty? A meta-analysis

BACKGROUND

Smoking has long been recognized as a risk factor for impaired wound and bone healing, particularly in the context of ankle and foot surgery. Despite numerous studies exploring the association between smoking and complications following ankle replacement, there remains significant inconsistency in their findings. Therefore, this meta-analysis study aims to elucidate whether smoking increases the rate of complications after total ankle arthroplasty (TAA), providing valuable insights for clinical management.

METHODS

A comprehensive systematic search was conducted in the PubMed, Embase, and Wiley databases to identify relevant English studies on the influence of smoking on postoperative complications following ankle replacement without any restrictions on publication dates. The quality of the included studies was assessed using the Newcastle-Ottawa Scale. Random-effect models were used to calculate odds ratios (OR) and 95 % confidence intervals (CI). This study adhered to PRISMA guidelines for transparent reporting and was registered with PROSPERO.

RESULTS

The analysis incorporated data from 12 retrospective cohort studies, totaling 17331 subjects, 2580 of whom were smokers and 791 complications following TAA. The findings revealed a statistically significant disparity in wound-related complications (OR: 2.26; 95 % CI: 1.13-4.50; P = .02), particularly evident in current smokers with an OR of 3.30 (95 % CI: 2.12-5.14; P < .00001). However, we lacked sufficient evidence to substantiate an association between smoking and complications related to the prosthesis (OR: 1.09; 95 % CI: 0.77-1.53; P = .64) or systemic complications (OR: 1.18; 95 % CI: 0.10-14.13; P = .90) following TAA.

CONCLUSIONS

Smoking, especially current smoking, is associated with increased wound complication risk post-operation for total ankle arthroplasty. Despite a lack of definitive evidence on the optimal timeframe for smoking cessation before surgery, discontinuing smoking appears to be a prudent measure to mitigate these complications.

Platelet-Rich Plasma for Treatment of Hair Loss Improves Patient-Reported Quality of Life

This study explores the psychological impact of platelet-rich plasma (PRP) treatment for hair loss. PRP, an autologous plasma enriched with platelets, has gained recognition in aesthetic and regenerative medicine for its potential to facilitate tissue healing and regeneration through the release of growth factors. However, concerns arise regarding the lack of standardized protocols for PRP preparation and characterization, including platelet counts and active substance concentrations. Additionally, the concentration of leukocytes and the platelet-to-leukocyte ratio in PRP are crucial factors that can affect treatment outcomes. Further analysis is necessary to establish reliable conclusions about the applications of PRP. LEVEL OF EVIDENCE V: 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 .

Contributors to post-operative venous thromboembolism risk after breast cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals.

METHODS

This study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed.

RESULTS

Thirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE.

CONCLUSION

The incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction.

Feasibility of perforator flaps in Day surgery. A retrospective study through a two-years' experience

BACKGROUND

Day surgery is developing and its popularity is increasing for a variety of reasons: economic constraints, changes in professional practices, a greater adhesion of the patient. In an era of progress in surgical procedures, pedicled-perforator flaps reducing donor site morbidity and avoiding micro-anastomosis could take their place in Day surgery if planned and managed by an experienced team.

METHODS

In the period January 2019 to January 2021, we performed perforator flaps for soft tissue coverage in ambulatory setting. The patients were included retrospectively and data were collected by reviewing the medical records. Major and minor complications were recorded.

RESULTS

The retrospective cohort included 32 surgical procedures in 32 patients. In all cases, perforator flaps were realized for resurfacing soft tissue defects consequent to oncodermatology surgery (84.3%), soft tissue sarcoma surgery (12.5%), invasive ductal breast carcinoma (3.1%). Major complications needing a surgical revision overcame 3/32 times (9.4%). In these cases, a failure requiring the drop off the flap overcame once. The average wound healing time was of 33 days (15-90) and the mean duration of follow-up was 9.6 months (1-22).

CONCLUSION

The low complication rate in our series suggests that this first experience on perforator flaps in outpatient surgery is promising in terms of safety and feasibility. Day surgery could be a practical option for this type of surgical procedures avoiding the conventional department's saturation and allowing the delivery of proper surgical cares.

Mechanical characterization of soft-tissue stiffness during mandibular distraction

The purpose of this study was to determine the stiffness of mandibular soft tissues during mandibular distraction, from the perspective of improving distraction devices such as automated continuous distractors. Uncompleted osteotomy was performed on 11 fresh human hemimandibles via a greenstick fracture, to preserve the uplift of the internal periosteum of the mandibular corpus. In order to replicate continuous distraction, direct measurements were performed through a uniaxial quasi-static tensile test. For all specimens, linear regression was applied to the force-displacement curve for a force region of 10-20 N, and the slope extracted. The mean stiffness was estimated to be 9.12 ± 3.56 N/mm. This study is the first to measure directly the stiffness of the surrounding tissues of the human mandibular corpus, and paves the way to the design of a new generation of distractor devices.

[The therapeutic purpose of plastic surgery]

The acts of plastic surgery consist in providing care to patients and pursue a therapeutic purpose. They benefit from VAT exemption in accordance with European legislation. They appear in the Common Classification of Medical Acts as therapeutic acts, whether or not they are covered by health insurance. To assist the plastic surgeon during the consultation in his role as a medico-surgical expert, we propose a global assessment scale for physical disgraces. This scale specifies the importance of disharmony, its etiology, and considers the patient in his entirety, both biologically and psychosocially. All repercussions are analyzed: physiopathological impact, pain, functional impact on daily life activities, pleasure and sexual activities, psychological, social, and professional impact. Each item is independently rated. Depending on the overall score obtained, the therapeutic nature of the act can be confirmed. The proposed scale is a simple tool that easily and seriously supports the therapeutic nature of our acts. It ensures argued expertise, a reliable and indisputable synthesis. We are, above all, doctors, caregivers, contributing to health as defined by the WHO: "a state of complete physical, mental, and social well-being." We alone are able to judge the therapeutic nature of a service, in agreement with our patients.

Application of Cross-Groin Flap for Coverage of Large Skin and Soft Tissue Defects of the Foot and Ankle in Children

In children with large soft tissue defects of the foot and ankle, it is difficult to cover the wound completely using a local skin flap, and skin grafting of the donor area for repair causes secondary damage. Free skin flaps require good vascular anastomoses and are prone to vascular crises. The authors evaluated the effectiveness and safety of cross-inguinal flaps for the repair of large soft tissue defects of the foot and ankle in children. The records of 15 children who underwent cross-groin flap transplantation between June 2017 and June 2021 were analyzed retrospectively. All the flaps survived without infection, necrosis, or other complications. The flap shape was good, the donor area was sutured directly, and the damage was minimal. This surgical method is simple, effective, and safe and can replace microsurgery, making it suitable for use in primary-level hospitals that are not equipped for microscopic surgery.

An Algorithmic Approach to Dual-System Venous Drainage for DIEP Flap Breast Reconstruction

BACKGROUND

Few studies compared the use of the deep venous system alone versus combined superficial and deep venous drainage in deep inferior epigastric perforator (DIEP) flaps. The objective of this study was to compare DIEP flap breast reconstruction using either the deep venous system alone versus dual-system venous drainage and to propose an algorithm for flap design and orientation and vein selection to facilitate consistent use of dual-system venous drainage.

METHODS

Patients undergoing DIEP flap breast reconstruction between March of 2017 and April of 2021 were reviewed retrospectively. Flaps were divided into 2 groups: deep venous system only (group 1) or dual system (group 2). Outcomes included take-back to the operating room, flap loss and thrombosis, and operative time.

RESULTS

A total of 244 DIEP flaps in 162 patients met inclusion criteria. A total of 130 flaps were included in group 1 (53.3%) and 114 flaps were included in group 2 (46.7%). Sixteen flaps (6.6%) required immediate take-back to the operating room, and take-back rates were not significantly different between groups ( P = 0.606). The flap loss rate was significantly higher in group 1 at 2.5% versus group 2 at 0% ( P = 0.031). Flap thrombosis occurred in 8 flaps (3.3%) and tended to occur more frequently in group 1, but this finding did not reach significance (group 1, 5.4%; group 2, 0.9%; P = 0.071).

CONCLUSIONS

The use of dual-system venous drainage in DIEP flap breast reconstruction decreases the rate of flap loss. The authors' algorithm can be used to guide selection of flap laterality, rotation, and veins and recipient vessels to facilitate routine use of dual-system venous drainage.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Anthropometry and Current Aesthetic Concept of the Lower Third of the Face and Lips in Caucasian Adult Population: A Systematic Review and Meta-Analysis

BACKGROUND

The lack of standardization of the norms and aesthetic concept of the lower third of the face and lips creates challenges in reconstructive surgery and aesthetic procedures. A large-scale, anthropometric measurements summary poses an alternative for establishing universal patterns.

METHODS

A systematic review was conducted by searching PubMed, Embase, Google Scholar and Web of Science using keywords: lip, face, aesthetics, beauty, anthropometry and Caucasian. Seventy records were included in the review and checked in detail in terms of available data.

RESULTS

The study contains a meta-analysis of twelve parameters with sufficient quantitative data-lip width, nose width, facial width, lower third of the face height, midline mandible height, total height of the upper and lower lip, upper and lower vermilion height, cutaneous upper lip height and nasolabial and mentolabial angle.

CONCLUSIONS

The review provides a detailed database of primary anthropometric studies of lips and perioral regions of the healthy Caucasian population. The attractiveness of the region is focused on uniformity of proportions. Notably, results acquired with different methods of measurement are not interchangeable. Despite many published anthropometric studies, systems for conducting the measurements and reporting the results are not sufficiently unified to quantitatively assess meticulous key aesthetic clinical parameters.

LEVEL OF EVIDENCE I

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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Dermatofibrosarcoma Protuberans in "Slow Mohs-tion": Multidisciplinary Approach of A Pediatric Dermatofibrosarcoma Protuberans of the Scalp with Slow Mohs Micrographic Surgery and A Double Rotational-Advancement Scalp Flap

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue sarcoma with primary incidence of 4.1 per million person-years and accounts for 0.1% of all malignancies. In patients under the age of 19, DFSP comprises 6% of cases with an annual incidence of 1 in 1,000,000. It is a slow-growing malignancy with low metastatic potential. However, DFSP is notable for its high rates of local recurrence due to local invasion with its classic "finger-like" projections into normal tissue. We discuss a case of dermatofibrosarcoma protuberans on the scalp of a 14-year-old male with delayed diagnosis, which required extensive resection through slow Mohs Micrographic Surgery (sMMS). This resection created a sizeable scalp defect of nearly 100 cm 2 , which mandated creative reconstruction using a novel double rotational-advancement scalp flap to close the defect while maintaining the patient's hairline for optimal cosmesis.

Ultrasound versus MRI for evaluation of silicone leakage from silicone breast implants

Background

Implant ruptures and gel bleed are not uncommon among women with silicone breast implants. While magnetic resonance imaging (MRI) is traditionally considered the gold standard diagnostic modality, recent studies suggest ultrasound might be an acceptable alternative. This study compares the efficacy of ultrasound and MRI in assessing implant integrity.

Methods

Women with silicone breast implants underwent a breast and axillary ultrasound and MRI on the same day. All tests were assessed by experienced radiologists. The accuracy, sensitivity, and specificity of ultrasound and MRI for implant rupture detection and silicone depositions in axillary lymph nodes were evaluated.

Findings

A total of 104 women participated in the study. The accuracy, sensitivity, and specificity of ultrasound for detecting implant ruptures compared to MRI were 96 %, 95 %, and 96 %, respectively. MRI demonstrated significantly lower sensitivity (44 %) for detecting silicone depositions in axillary lymph nodes compared to ultrasound. A significant association was observed between the presence of enlarged axillary lymph nodes and/or axillary pain and the detection of silicone depositions in axillary lymph nodes on ultrasound (χ2 (1, N = 104) = 5·1, p = 0·024). Six women exhibited silicone depositions in axillary lymph nodes despite having intact first-pair implants, indicative of gel bleed.

Interpretation

Ultrasound is nearly as effective as MRI for detecting breast implant ruptures and is superior for detecting silicone depositions in axillary lymph nodes. We therefore recommend initiating radiological examination in women with breast implants with a breast and axillary ultrasound, proceeding to MRI only if the ultrasound is inconclusive. The prevalence of gel bleed is understudied and its potential adverse health effects might be underestimated. Further research is needed to explore its potential association with development of systemic symptoms.

Biomechanical characterization of cadaveric brachial plexus regions using uniaxial tensile tests

INTRODUCTION

The proximal regions of the brachial plexus (roots, trunks) are more susceptible to permanent damage due to stretch injuries than the distal regions (cords, terminal branches). A better description of brachial plexus mechanical behavior is necessary to better understand deformation mechanisms in stretch injury. The purpose of this study was to model the biomechanical behavior of each portion of the brachial plexus (roots, trunks, cords, peripheral nerves) in a cadaveric model and report differences in elastic modulus, maximum stress and maximum strain.

METHODS

Eight cadaveric plexi, divided into 47 segments according to regions of interest, underwent cyclical uniaxial tensile tests, using a BOSE® Electroforce® 3330 and INSTRON® 5969 material testing machines, to obtain the stress and strain histories of each specimen. Maximum stress, maximum strain and elastic modulus were extracted from the load-displacement and stress-strain curves. Statistical analyses used 1-way ANOVA with post-hoc Tukey HSD (Honestly Significant Difference) and Mann-Whitney tests.

RESULTS

Mean elastic modulus was 8.65 MPa for roots, 8.82 MPa for trunks, 22.44 MPa for cords, and 26.43 MPa for peripheral nerves. Differences in elastic modulus and in maximum stress were statistically significant (p < 0.001) between proximal (roots, trunks) and distal (cords, peripheral nerves) specimens.

CONCLUSIONS

Proximal structures demonstrated significantly smaller elastic modulus and maximum stress than distal structures. These data confirm the greater fragility of proximal regions of the brachial plexus.

Locally advanced breast cancer patients should be cautious about the immediate breast reconstruction after mastectomy: a pooling analysis of safety and efficacy

BACKGROUND

The purpose of this study was to compare safety and efficacy outcomes between immediate breast reconstruction (IBR) and mastectomy alone in locally advanced breast cancer patients.

METHODS

We conducted a comprehensive literature search of PUBMED, EMBASE, and Cochrane databases. The primary outcomes evaluated were overall survival, disease-free survival, and local recurrence. The secondary outcome was the incidence of surgical complications. All data were analyzed using Review Manager 5.3.

RESULTS

Sixteen studies, involving 15,364 participants were included in this meta-analysis. Pooled data demonstrated that patients underwent IBR were more likely to experience surgical complications than those underwent mastectomy alone (HR: 3.96, 95%CI [1.07,14.67], p = 0.04). No significant difference was found in overall survival (HR: 0.94, 95%CI [0.73,1.20], p = 0.62), disease-free survival (HR: 1.03, 95%CI [0.83,1.27], p = 0.81), or breast cancer specific survival (HR: 0.93, 95%CI [0.71,1.21], p = 0.57) between IBR group and Non-IBR group.

CONCLUSIONS

Our study demonstrates that IBR after mastectomy does not affect the overall survival and disease-free survival of locally advanced breast cancer patients. However, IBR brings with it a nonnegligible higher risk of complications and needs to be fully evaluated and carefully decided.

Artificial keloid skin models: understanding the pathophysiological mechanisms and application in therapeutic studies

Keloid is a type of scar formed by the overexpression of extracellular matrix substances from fibroblasts following inflammation after trauma. The existing keloid treatment methods include drug injection, surgical intervention, light exposure, cryotherapy, etc. However, these methods have limitations such as recurrence, low treatment efficacy, and side effects. Consequently, studies are being conducted on the treatment of keloids from the perspective of inflammatory mechanisms. In this study, keloid models are created to understand inflammatory mechanisms and explore treatment methods to address them. While previous studies have used animal models with gene mutations, chemical treatments, and keloid tissue transplantation, there are limitations in fully reproducing the characteristics of keloids unique to humans, and ethical issues related to animal welfare pose additional challenges. Consequently, studies are underway to create in vitro artificial skin models to simulate keloid disease and apply them to the development of treatments for skin diseases. In particular, herein, scaffold technologies that implement three-dimensional (3D) full-thickness keloid models are introduced to enhance mechanical properties as well as biological properties of tissues, such as cell proliferation, differentiation, and cellular interactions. It is anticipated that applying these technologies to the production of artificial skin for keloid simulation could contribute to the development of inflammatory keloid treatment techniques in the future.

Reconstructive surgery for women with female genital mutilation: A scoping review

BACKGROUND

Female genital mutilation (FGM) is a global public health concern. However, reconstructive surgery remains unavailable in many countries.

OBJECTIVES

This scoping review, guided by Joanna Briggs Institute (JBI) principles, explores indications, referral routes, eligibility, care pathways and clinical outcomes of reconstructive surgery for FGM.

SEARCH STRATEGY

Medical Subject Headings (MeSH) terms and subject headings were searched in EMBASE, MEDLINE, SCOPUS, Web of Science and publicly available trial registers.

SELECTION CRITERIA

Any primary experimental and quasi-experimental study addressing reconstructive surgery for FGM, and its impact on women, published before June 2023.

DATA COLLECTION AND ANALYSIS

After removing duplicates from the search results, titles and abstracts were screened and data were extracted. Disagreements were resolved through panel discussion. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram depicts the search results and inclusion process.

MAIN RESULTS

A total of 40 studies were included. Multidisciplinary teams were involved in 40% (16/40) of the studies, and psychosexual counselling was offered in 37.5% (15/40) of studies. Clitoral reconstruction using Foldes' technique was predominant (95%, 38/40). A total of 7274 women underwent some form of reconstruction. Post-surgery improvement was reported in 94% of the cases (6858/7274). The complication rate was 3% (207/7722 women with reconstruction).

CONCLUSIONS

Further research and clinical trials are needed. Although the outcomes suggest improved sexual function and quality of life post-surgery, the evidence remains limited. Advocating surgical reconstruction for survivors of FGM is vital for addressing health disparities and potential cost-effectiveness.

[Functional outcomes and prognostic factors of firearm-related ocular trauma among soldiers in the conflict zones of Cameroon]

PURPOSE

To study prognostic factors and functional visual outcomes of soldiers after firearm-related ocular trauma in the conflict zone.

MATERIALS AND METHODS

A cross-sectional analytical study was carried out from January 2017 to December 2022 in the ophthalmology departments of three military hospitals. Soldiers with firearm-related ocular trauma were selected. Epidemiological and clinical data, prognostic factors and functional outcomes were studied. Statistical analyses were performed using IBM-SPSS version 23.0 software. Univariate and multivariate analyses were performed, and a P-value<0.05 was considered statistically significant.

RESULTS

A total of 162 eyes of 136 patients were included. The mean age was 28.93±6.52 years. All patients were male. Improvised firearms were the most frequent cause (77%). Bilateral involvement was observed in 26 patients (19.1%). The mean visual acuity of the affected eyes was 1.66±1.04logMAR on admission. Closed globe injuries predominated (72%). The most frequent anatomical lesions of the globe were hyphema (23.4%) and vitreous hemorrhage (19.7%). The mean final visual acuity was 1.38±1.17logMAR, and blindness was observed in 50% of eyes. Factors influencing final visual acuity were type of trauma, initial visual acuity, hyphema and vitreous hemorrhage.

CONCLUSION

Blindness due to firearm-related eye injuries in the conflict zone of Cameroon is common. Wearing protective glasses or visors might reduce its frequency.