Plastic Surgery

Correction to: Optimization of the dermal wrap in inferior pedicle reduction mammoplasty: An Egyptian experience The authors wish to clarify that Dina M. Badwai refers to Dina M. Badawi. The authors apologise for this error.

Management of abnormal deep inferior epigastric vessels in microsurgical breast reconstruction: a report of 3 complex cases Abstract The deep inferior epigastric artery perforator flap is the gold standard in microsurgical breast reconstruction. It is now increasingly offered in patients with previous abdominal scars and in such cases, computed tomography angiography (CTA) is routinely implemented. However, previous injury of the deep inferior epigastric vessels may be difficult to detect with CTA. We report three cases of successful bilateral breast reconstruction, in which a unilateral DIEA was found to be abnormal. In the first two cases, the unilateral DIE vessels were found to be damaged and the flaps salvaged based on the deep superior epigastric artery. In the third patient, previous DIEA injury resulted in vessel recanalization, which was only evident following initial anastomotic failure. In this case, the damaged DIEA segment was subsequently removed and the flap successfully revascularized. All three patients had an uneventful post-operative recovery and all flaps survived with no complications. Based on our experience, we believe that awareness of the potential pitfalls and careful planning for lifeboats are essential to avoid flap loss in such circumstances. Level of Evidence: Level V, therapeutic study.

Surgical fire: principles, risk factors, and prevention

Trigger finger in a hereditary multiple exostoses disease: A unique case report Abstract Trigger finger is one of the most common upper extremity problems seen by hand surgeons. Lesions occupying space in the tendon bed can prevent tendon gliding. We describe a unique case of trigger finger in a patient known for a hereditary multiple exostoses disease where an exostosis in the tendon bed constricted the tendon sheath, leading to triggering and locking. Open surgical treatment was performed by removing of the exostosis which relieved the problem. Level of Evidence: Level V, therapeutic study.

Forehead biconvexity enhancement with fat grafting Abstract Background Frontal biconvexity is a key criterion for an attractive forehead. Fat injection as an effective, safe and reliable method for soft tissue augmentation could be used to enhance forehead contour. We report our experience with combined platelet-rich plasma (PRP) and fat grafting to create or restore frontal biconvexity and to reduce wrinkles. Methods Fifty-seven females and 4 males (mean age, 40.2 years) underwent the combined PRP and fat injection. Fat mixed with PRP on the ratio of 5:1 was injected in small aliquots in the space between the dermis and underlying frontalis muscle. Patient satisfaction with the cosmetic result was evaluated by a questionnaire using pre- and postoperative photos and a four-point grading scale. Results All patients who underwent three injection sessions (n = 5) evaluated the esthetic result as excellent. In patients who had two injection sessions (n = 36), 36% evaluated the result as excellent, 50% as good, and the remaining 5 as moderate. In patients who had a single injection session (n = 15), 27% evaluated the result as excellent, 40% as good, and the remaining 5 as moderate. Concerning frontal wrinkles, 25 of 34 (73.5%) patients reported good improvement and the remaining 9 (26.5%) reported moderate improvement. Conclusion Fat injection combined with PRP should be considered as an effective tool to improve forehead biconvexity. Level of evidence: Level IV, therapeutic study.

Pretarsal roll augmentation with dermal hyaluronic acid filler injection Abstract Pretarsal roll augmentation with dermal hyaluronic acid filler injection focuses on restoring pretarsal fullness. This study aimed to introduce a method of pretarsal roll augmentation with dermal hyaluronic acid filler injection and establish the level of difficulty, safety, and effectiveness of this method. Eighty female patients were enrolled in this study. Hyaluronic acid filler was used to perform pretarsal roll augmentation. Physician and patient satisfaction at 1 month and 4 months after surgery was investigated. The level of satisfaction was graded from points 1 to 5. The patient satisfaction and physician scores were 4.7 ± 1.1 (mean ± standard deviation) points at 1 month and 4.8 ± 0.9 points at 4 months and 4.6 ± 0.9 points at 1 month and 4.8 ± 1.0 points at 4 months, respectively. No major complications were observed. Our technique provided a natural and younger appearance with pretarsal fullness. This technique was easy to perform for the restoration of pretarsal fullness, and it improved periorbital contouring, rejuvenated the pretarsal roll, and provided excellent esthetic results. Level of Evidence: Level V, therapeutic study.

An anatomical study of vascular communications between anterior tibial and peroneal osseosomes and its clinical application in proximal hemiarthroplasty of radiocarpal joint following tumor excision Abstract Background There are speculations that the proximal third fibular osseosomes, supplied by the anterior tibial vessels cannot be reliably recruited on the peroneal vessels supplying fibular diaphyseal osseosomes. Anatomical study by the authors eschewed this speculation and paved way for an evidence-based surgery. Cadaveric dissection, dye injection, and radiological studies revealed existence of a reliable anastomotic musculoperiosteal vessel between these two osseosomes that could effectively recruit the proximal fibular osseosomes on the peroneal vessels. Also, operative tips and tricks for safeguarding these anastomotic vessels were defined by the cadaveric study. Aesthetic and functional outcomes were assessed in five clinical cases, where the fibular heads were harvested reliably on the peroneal pedicle and stable wrist joints were reconstructed following oncological excisions. Methods Based on the evidence from the anatomical study, five clinical cases (three males and two females) affected by stage III GCT (giant cell tumor) of distal radius underwent microvascular fibular head hemiarthroplasty following tumor excision. Average follow-up of the patients was 18 months. Results At the end of follow-up period, all patients had an average MSTS (Musculoskeletal Tumor Society) score of 23. Scores ranged from 21 to 25. Patients had good functional outcomes with 69% average mobility in the reconstructed wrist when compared with the opposite normal wrist. Aesthesis of the reconstructed wrists were acceptable. Conclusion The cadaveric study demonstrated concrete anatomical evidence of existence of an anastomotic musculoperiosteal vessel between anterior tibial and peroneal fibular osseosomes in all the specimens. Clinical study validated the safety of the vascularized proximal fibular hemiarthroplasty on peroneal pedicle. It may be a reliable method for reconstruction of the radiocarpal joint in the post-GCT distal radius excision with good aesthetic and functional outcomes. Level of Evidence: Level V, therapeutic study

Morbidity and mortality in patients undergoing fecal diversion as an adjunct to wound healing: a NSQIP comparison study Abstract Background Fecal diversion for chronic, non-healing wounds improves quality of life, assists in wound healing, and helps to prepare for reconstructive surgery. While commonplace, little has been published regarding the safety of diversion in this patient subgroup. The purpose of this study is to elucidate the morbidity and mortality of fecal diversion for chronic wounds and to identify those patients with disproportionately high perioperative risk. Methods Retrospective analyses were performed using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database and an institutional database. The primary outcome analyzed was 30-day mortality and secondary outcomes included 30-day morbidity and readmission rate. Results Eight hundred fifty-nine patients were identified in the NSQIP database who underwent diversion compared to 3990 who did not. In unmatched data, there were no significant differences in substantial 30-day morbidities. In matched data, diverted patients had a significantly lower perioperative mortality. Fifty-six patients were identified in the institutional review who were diverted for non-healing wounds. Fifty percent of patients with a preoperative ejection fraction of less than 30% died within 30 days of surgery (LR 6.58, p = 0.045). Conclusions The NSQIP review indicates that fecal diversion does not inherently increase 30-day perioperative morbidity or mortality. While 30-day morbidity remains high, the institutional review suggests that patients with cardiac dysfunction contribute to the majority of complications. As such, an ejection fraction less than 30% may be a relative contraindication to immediate diversion. Medical optimization and elective diversion should be considered whenever feasible. Level of Evidence: Level III, risk / prognostic study.

Optimization of the dermal wrap in inferior pedicle reduction mammoplasty: An Egyptian experience Abstract Background Reduction mammoplasty using the inferior pedicle technique has been used for more than five decades. Without doubt, it has many advantages, especially in patients with moderate to severe macromastia. Although the esthetic outcome of reduction mammoplasty in the early postoperative period is usually satisfactory, typical esthetic drawbacks appear during the first year. These drawbacks include bottoming out, loss of superior fullness, box-shaped breasts, poor definition of the infra-mammary fold (IMF), elongation of the vertical scar, star gazing of the nipple-areola complex (NAC) and, of course, the scar burden. Parenchymal reshaping and suspension have been introduced as an additional step to eliminate the drawbacks of the inferior pedicle procedure. Methods This is a prospective study done in a period from March 2016 to March 2018 in Kasr Al-Ainy Hospital (Cairo University hospitals) by the senior author and his team of co-authors. Reduction mammoplasty (Wise pattern) with the inferior pedicle and dermal wrap technique (using two dermal wings) was performed in 20 patients. The distance from the suprasternal notch (SSN) to the NAC was > 30 cm. Results The patients' ages ranged from 28 to 55 years (average age, 39 years). Body mass index (BMI) ranged from 27 to 35 kg/m2 (average BMI, 33.3 kg/m2). The distance between the SSN and NAC ranged from 33 to 45 cm (average distance, 40 cm). The nipples were lifted by 11 to 19.5 cm. The distance from the nipple to the IMF ranged from 18 to 24 cm. This distance was reduced postoperatively to between 9 and 11.5 cm (p value < 0.001). Conclusions Follow-up of the patients revealed that suspension of the breast parenchyma and plication of the dermal flap improved the esthetic results following inferior pedicle breast reduction. The addition of volumetric and geometric adjustment "preoperatively" may significantly improve the results and minimize the operative time of this relatively lengthy procedure (4–6 h for both breasts). Level of Evidence: Level IV, terapeutic study.

Therapeutic breast reduction—are doctors and patients satisfied ? Abstract Background Therapeutic breast reduction (TBR) is an oncoplastic technique that applies breast reduction principles for oncologic purposes. Given that TBR indications have expanded, the purpose of this study is to ascertain the aesthetic outcome of this procedure, and determine how it may be influenced by different surgical techniques and postoperative radiotherapy. Methods A non-randomized cohort study was performed, including breast cancer female patients who underwent breast conserving surgery with TBR. The primary outcome was the esthetic result of the reconstruction, evaluated by both plastic surgeons and patients, at least 12 months after surgery. Results The aesthetic assessment was made in 42 patients. Overall, the clear majority of patients classified the outcome as good or perfect (95.2%), with less than 5% considering the outcome as mediocre. As for plastic surgeons, 83.3% were considered perfect/good outcomes, with 16.7% mediocre results. There were no poor results, neither for the patient nor the surgeon. There were no statistically significant associations between the esthetic result and tumor location nor its relation to the skin-resection pattern. Conclusion Aesthetic outcomes with this technique are promising, even when there is the need for technical modifications and despite the need for adjuvant radiotherapy, making it valuable for tumors in all locations. Level of Evidence: Level III, risk / prognostic study.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com