Covering of wound infection in hip arthroplasty with local cutaneous flaps

Total hip arthroplasty is a very common procedure to treat osteoarthritis. One of the complication is the infection which occurs in about 1% of the cases. The manifestation of infection can be poor wound healing with dehiscence and exposition of bone or prosthetic components. Hip arthroplasty infections are difficult to treat. It required an associated multidisciplinary approach with infectiology, orthopedic and plastic surgeries. The study included five patients with hip wound dehiscence after total hip arthroplasty. Coverage after orthopedic surgery was provided by local cutaneous flap. These cutaneous flaps were either a deep inferior epigastric perforator flap (DIEP) or a transposition flap. The orthopedic and the plastic treatment were done at the same time. Two deep inferior epigastric flaps were performed for patients with a deep defect with bone or prosthesis exposure. Four transposition flaps were done in three patients with wound dehiscence but without direct contact with the prosthesis. Three transposition flaps were done from the abdominal wall and one from the posterior thigh. The mean follow up was 18 months, ranging from 10 to 24months. After healing, there was no recurrence of the infection. In all cases, the coverage was obtained. The prosthesis was salvage and the gait was possible. Cutaneous flaps are easy and safe to cover the hip. They are reliable flaps even in patients with multiple co-morbidities. They do not cause sequelae on the recipient site. This study is the first about cutaneous flap for covering hip defects in hip arthroplasty infections.

Satisfaction survey of secondary rhinoplasty among unilateral cleft lip and palate patients

Secondary rhinoplasty on patients with cleft is a challenging procedure, and the most important criterion for evaluating the surgery success is patient satisfaction even if it's subjective.

OBJECTIVES

To evaluate patient satisfaction following secondary cleft rhinoplasty with a specific assessment for patients with Unilateral Cleft Lip and Palate (UCLP).

PATIENTS AND METHODS

Our retrospective cross-sectional study is composed of 29 patients with UCLP with a mean age of 23years old, who underwent secondary rhinoplasty between 2010 and 2021 in our department. The survey was conducted postoperatively using a cleft-nose specific custom designed questionnaire based on the Byrne questionnaire, over the phone. This satisfaction questionnaire comprises six questions about physical appearance and one question about functional aspect. Patients were asked to answer "yes" or "no" or to rate from 0 (no improvement) to 10 (perfect result) depending on the question.

RESULTS

Twenty out of 29 people responded to the questionnaire, representing an answer rate of 69%. The average score given by the patient for nasolabial scar improvement was 7.2/10, and the one concerning global improvement was 8.2/10. All patients would be ready to undergo the same procedure again, knowing the final result. A functional improvement concerning breathing or snoring was reported in 45% of cases. All dorsum or tip issues were improved after surgery (P=0,07).

CONCLUSIONS

Our results demonstrate high patient satisfaction after cleft rhinoplasty, which encourages the continuation of this surgery. We would recommend the use of this simple questionnaire to allow a more accurate evaluation of patient outcomes.

Unilateral cleft nose deformities at adulthood

Secondary rhinoplasty is a challenging procedure, requiring a precise preoperative diagnosis of nasal deformities before correcting them. As there is currently no accepted outcome measurement tool available to assess unilateral cleft lip and palate (UCLP) nose sequelae before secondary rhinoplasty. The goal of this retrospective study is to identify the nose deformities and rate them in an evaluation scale that allows collecting and analyzing cleft nose data. Our retrospective cohort is composed of 29 patients with UCLP, who underwent secondary rhinoplasty between 2010 and 2021 in a cleft center, with a mean age of 23years old. Evaluation of deformities is made from preoperative two-dimensional photography. The assessment photographic tool is a custom-designed scale of 16 items. A binary scoring system is used by two experts to assess nasolabial deformities. The most encountered sequelaes are the alar foot displacement (93%), the enlarged tip (90%) and the nostril horizontalization (86%). The inter-examiner ICC for total rating was calculated at 0.911 and indicated a strong level of reliability that was highly significant (P<0.05). The simplicity, reliability and reproducibility of the proposed assessment system could be interesting for clinicians, in order to diagnose the nasal deformities before surgery, but also to assess postoperative success of a secondary rhinoplasty and thus to compare several surgical techniques.

[A pedicled deep inferior epigastric flap to cover a hip arthroplasty infection]

The deep inferior epigastric perforator (DIEP) flap is a reliable flap mostly used in skin resurfacing after signifiant resection for sarcoma or correction contour deformities. This case is about a pedicled DIEP flap covering the trochanteric region after a total hip arthroplasty infection. A 62years old woman with a BMI at 42kg/m² presents an infected total hip arthroplasty with a cutaneous defect. The hip prosthesis is changed and covered with a pedicled DIEP flap. This original case reports the used of pedicled DIEP flap in hip coverage. This local fasciocutaneous flap covered the hip osteoarticular infection. The limb is salved and the patient can walked again. The success of this surgery is the collaboration between infectious disease specialist, orthopedic surgeon and plastic surgeon.

[Reverse abdominoplasty in the presence of bi-subcostal scar: Technical note]

INTRODUCTION

The presence of horizontal supraumbilical scars increases the risk of vascular complications after a large abdominoplasty. We present here a technique of abdominal dermolipectomy with umbilical transposition called « reverse », in the presence of a bi-subcostal scar.

TECHNICAL NOTE

The reverse abdominoplasty technique consists in uninserting the umbilicus, detaching the supra-umbilical and sub-umbilical soft tissues by assessing the existing bi-subcostal scar in order to pull the skin upwards, and to remove the supra-umbilical excess skin, before bringing the umbilicus back to its proper position.

DISCUSSION

This technique is a good alternative to perform an abdominal dermolipectomy in a patient with a history of bi-subcostal scarring without increasing the risk of abdominal skin necrosis, and without complicating or lengthening the conventional surgical procedure, provided that the upper redraping is achievable with sufficient upper excess skin and laxity.

[Medical photographs: Time saving and data security thanks to a dedicated application]

INTRODUCTION

Medical photography, ubiquitous in plastic surgery, provides essential information to the medical record. Smartphones have become the preferred tool for acquiring these photographs, but cause a data security issue. Furthermore, the management of photographs is frequently manual and time-consuming. The Pixacare software suite has been designed to meet this need in complete security. It includes a mobile application, a web application and a HADS server. The objective of the study was to calculate the time saved by the Pixacare application at the time of data acquisition.

PATIENTS AND METHODS

This prospective and monocentric study was carried out in two steps in order to time the acquisition times with the usual method and with the Pixacare mobile application. Each phase included 89 patients recruited in plastic and maxillofacial surgery consultation with four surgeons. The number of patients and the average number of photographs per patient were comparable for each practitioner in both phases.

RESULTS

The acquisition time of the photographic data was divided by 3.77 (P<0.001). With the usual method, the average acquisition time was 259seconds, compared to 69seconds with the Pixacare application, saving 3minutes and 10seconds per patient.

CONCLUSION

The Pixacare software suite saves the surgeon significant time while ensuring appropriate data security. This study does not take into account the additional time saved by organising medical meetings, the benefits of sharing photographs between healthcare professionals and the efficiency of secure messaging.

[Shape and aesthetic outcome evaluation of transposed umbilicus according to four surgical procedures]

INTRODUCTION

In abdominal plastic surgery, umbilicus is frequently transposed, generating scars and shapes variating with the techniques used. Various umbilical transposition techniques have been described, all of them attempt to reproduce the "ideal" umbilicus. This study aimed to define the shape and the aesthetic results obtained with four different surgical procedures, in order to choose an "ideal" umbilical transposition technique.

PATIENTS AND METHODS

This retrospective study analyzed the characteristics of transposed umbilicus, in 50 patients who had undergone abdominal dermolipectomy for aesthetic reason, after a loss of weight or in breast reconstruction by Deep-Inferior-Epigastric-Perforator. Four surgical procedures were chosen, which differed by their counter-incision shape in the abdominal flap (Y, inverted Y, de-epidermized round with horizontal incision or U), and the deep points position of umbilical docking (along a horizontal or vertical axis). Shape and depth were evaluated by a panel of experts. The global assessment was based on a double evaluation, by the surgical jury and the patients themselves.

RESULTS

The counter-incision type determined the umbilicus shape: triangular for the Y (60%) or inverted-Y (41%), round for the U (52%) and vertical oval (67%) or round (32%) for the de-epidermized circle. The deep points position influenced the umbilicus axis. Regarding the appreciation, the de-epidermized circle had the best results for surgeons in a significant way, and for patients (respectively 72% and 100% satisfied), followed by the inverted-Y (57% and 92%) and Y techniques (55% and 89%) and at last the U (50 and 75%).

CONCLUSION

Horizontal counter incision in a de-epidermized round, with two anchoring points on a vertical axis, generates vertical oval or round shaped umbilicus, considered attractive in the literature, and giving the highest aesthetic satisfaction for both surgeons and patients.

[Concomitant breast surgery with a vertical latero-thoracic incision in continuity with a brachioplasty incision: About twelve (12) cases after massive weight loss]

INTRODUCTION

The need of iterative surgeries, the proximity of two anatomical areas, the combination of an aesthetic surgery with a surgery covered by health insurance are the reasons which motivated the authors to provide a simultaneous procedure on arms and breast in patients achieving massive weight loss. We propose a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision to treat the excess skin and subcutaneous tissue of the lateral chest wall, either by resection, or by increasing the breast with the patients own autologous tissue.

METHODS

Between 2010 and 2017, twelve patients aged between 31 and 56 years, with 42 being the average, have undergone a technique that utilises a vertical continuation of the lateral mastopexy incision superiorly, in continuity with a simultaneous brachioplasty incision: transverse skin incisions and free nipple transplantation for correction of extreme gynaecomastia (2 cases), mastopexy with resection of the excess tissue of the lateral chest wall (8 cases), autologous breast augmentation by the use of intercostal artery perforator flaps (2 cases). Mean body mass index (BMI) was 24kg/m² [23; 32] after average weight loss of 56kg [14; 112] following diet (3 cases) or bariatric surgery (9 cases).

RESULTS

Mean operative time was 4hours [3: 6], mean length of hospital stay was 4 days [2; 9]. We observed one major complication (hematoma) and one minor complication (wound dehiscence). At a mean follow-up of 21 months (ranged from 15 days to 84 months), the lateral flank scarring was well tolerated, with the additional benefit of reducing flank fullness.

CONCLUSION

The extended lateral flank scar allows reducing the excess skin and subcutaneous tissue of the lateral chest wall, while being easily concealable. This technique offers an elegant solution to this excess that used to persist after multistage surgeries.

[Secondary surgery of abdominal dermolipectomies]

The abdominoplasty (AP) is a common type of plastic surgery procedure that removes unsightly and uncomfortable cutaneous and fatty excess from the anterior abdominal wall. In 30% of the cases, the results prove to be insufficient and motivate a request for reintervention which goes from the simple cicatricial revision under local anesthesia to the complete recovery of the procedure. The defects at the origin of the secondary abominoplasty are persistent skin excess, residual fat deposits, scarring malpositions or abnormalities of the umbilicus. The respect of certain technical rules during the primary AP are likely to limit the postoperative defects at the origin of these surgical revisions. When an imperfection of result is found postoperatively, the methodical clinical analysis of the defect will allow in determining the cause and to choose the most adapted corrective solution in order to obtain finally the satisfaction of the patient.

[Surgical revision in case of DIEP failure in breast reconstruction]

INTRODUCTION

Immediate or delayed breast reconstruction by deep inferior epigastric perforant flap (DIEP) is a frequent and widespread autologous breast reconstruction technique that presents a risk of failure inherent in its microsurgical nature. The main objective was to evaluate the interest of surgical revision in case of DIEP failure, the secondary objective was to evaluate the consequences of surgical revision on the subsequent management.

MATERIALS AND METHODS

This is a retrospective monocentric and single-operator analytical study of 167 unilateral DIEPs carried out from 2008 to 2016. Two groups were compared: success of DIEP without revision versus DIEP requiring a revision that resulted in success or failure. After analyzing the failure and recovery rates of DIEP, we compared the transfusion rate, total operating time, hospitalization time, and final breast reconstruction in the two groups.

RESULTS

One hundred and sixty-seven DIEPs were performed from 2008 to 2016 in 167 women, 18 revisions were reported (10.7%), 12 revisions were successfully reported (7.2%) 6 failures were reported after revision (3.6%). Surgical revision allows the flap to be rescued in 67% of cases. Revision increases the risk of blood transfusion by a factor of 12 (OR=12.24 [95% CI=3.74-43.17] P<0.05). Revision or failure doubles the total operating time (281.8min [170-570] vs. 577.8min [285-860] P<0.05) and increases hospitalization time by 2.5days compared to DIEP's initial success (5.74days [4-9] vs. 8.33days [5-17] P<0.05). Fifty percent of patients choose another type of breast reconstruction after DIEP failure.

CONCLUSION

DIEP is a reliable microsurgical breast reconstruction technique, failure can be prevented in two thirds of cases by monitoring and early reoperation.

[Breast reconstruction with free flap of gracilis]

Breast reconstruction with free flap of gracilis has been described since 2004. The procedure consists in harvesting a flap made of the gracilis muscle and a transverse cutaneous paddle originating from the internal root of the thigh. The pedicle of the flap is the main pedicle of the gracilis muscle. After weaning, the vessels are anastomosed to the internal thoracic artery and vein. The modeling of the breast is done by folding the cut points in front of the muscle to obtain the shape of a cone. This surgical technique allows the realization of autologous breast reconstructions of small to medium size, immediate or delayed, unilateral or bilateral.

[Clinical and morphological indications for delayed breast reconstruction]

A full range of breast reconstructions procedures exists and had to be proposed within a surgical team, from the simplest to the most complex. The choice of the technique is simply based on the discussion between the surgeon and the patient during a consultation. A computed tomographic angiography might be required in the case of DIEP flap reconstruction. The surgeon bases his decision on a clinical exam of the breast area, the quality of the tissues and looks for potential flaps or fat donor sites. The patient expresses her expectations in terms of breast volume, form and is clearly informed about potential risks and follow-up. Thus the surgeon could propose the most adequate procedure in the case of the patient, who will take the final decision. The surgeon should ensure to find the most adapted procedure to each individual. A well-determined indication will lead to a truly satisfied patient, which is the main goal of breast reconstruction. We decided to present this dialogue and the path towards the final choice in a fun and original format.

[The reconstruction of the nipple-areolar]

The reconstruction of the nipple-areolar complex is the final stage of breast reconstruction that restores the visual identity of the breast. The most common options for reshaping the areola are tattooing, total skin grafting of the inner thigh and the total skin graft taken from the contralateral areola. Nipple reconstruction solutions include duplication of contralateral nipple, local flap, total skin graft and tattoo in three-dimension. Duplication of the nipple is the technique of choice because it immediately offers optimal color, texture and projection. The areolar tattoo is the most common procedure for its simplicity and reproducibility.

[Back loss cover in orthopedic surgery by helical lumbar perforator flaps: About 6 cases]

INTRODUCTION

The existence of voluminous paralumbar perforators allows a simplification of the coverage of the lumbar region.

MATERIALS AND METHODS

The authors present a series about lumbar loss substance following orthopedic surgery, from 2012 to 2017. Coverage was provided by a fascio-cutaneous lumbar perforator flap.

RESULTS

Six patients were operated with mean age of 62.3 years, with an average follow-up of 16 months (up 6 to 41 months). Substance losses were secondary to a carcinologic excision, to a radiodermitis excision and to four debridements after infection of the operative site. In five cases, the reconstruction was performed by one lumbar perforator flap, and in one case by two lumbar perforator flaps. The average size of the substance losses was 171.91 cm² (up 78 to 250 cm²). The average size of the flaps taken was 161 cm² (up 50 to 250 cm²). The donor site was self-closing without sequelae. The postoperative sequences were simple and marked by a single partial necrosis of a flap, with a favorable evolution after directed healing. The quality of the cover was good with excellent trophicity.

CONCLUSION

Lumbar perforator helical fascio-cutaneous flaps are a reliable means of covering the loss of substances in the lumbar region. The use of these flaps makes it possible to avoid the taking of complex myo-cutaneous flaps, causing sequelae of the donor site in a location difficult to cover.

[Trochanteric under gluteus lift or bodylift, technique for massive trochanteric lipodystrophy: About 11 cases]

INTRODUCTION

There is a growing demand for weight loss sequelae. Some women have a particular morphology with a major trochanteric excess that warrants specific treatment.

MATERIALS AND METHODS

On the basis of the technique published in 1964 by Pitanguy, the authors suggest a lift of the external face of the thigh with the scar redrawing the lower part of the buttock, from the gluteal fold to the inguinal region by crossing the trochanteric region. Eleven cases of major trochanteric excess after slimming are presented. In 4 cases, the trochanteric excess is solely treated by trochanteric under gluteus lift. In 7 cases, it is associated with abdominoplasty to perform a trochanteric under gluteus bodylifting.

RESULTS

Complications and results are presented. The trochanterian excess is reduced, the buttock is harmonious and the patients satisfied.

DISCUSSION

Modifications are made to the much criticized technique of Pitanguy. The lipectomy replaces the monobloc resection, the scar is verticalized on the trochanter to join the abdominoplasty scar. This technique is an alternative to the vertical trochanteric resection associated with classic bodylift.

CONCLUSION

The trochanteric under gluteus lift is an elegant solution for treating large trochanteric excess. It is adaptable. It can become bodylifting TSF in the cases of great slimming.

Design and evaluation of a new synthetic wrist procedural simulator (Wristsim®) for training of distal radius fracture fixation by volar plating

Legislation concerning workload of surgical trainees and pressure to reduce learning curves have forced us reconsider surgical training. Our goal was to evaluate a synthetic procedural simulator for teaching open reduction and internal fixation (ORIF) of distal radius fractures (DRF). Twenty surgeons used a synthetic procedural simulator (Wristsim^®) made by 3D printing for ORIF of DRF with a volar plate (Newclip Technics^®). The evaluation consisted of grading the simulator's realism compared to the surgeons' own experience with surgery on cadavers. The Wristsim^® was graded 5.10/10, compared to 8.18/10 for the cadaver specimen for introduction of the plate under pronator quadratus. For fracture reproduction, Wristsim^® scored 6.40/10, with the cadaver specimen scoring 7.15/10. For fracture reduction, Wristsim^® scored 5.62/10, with the cadaver specimen scoring 7.38/10. Plate application was scored 7.05/10 for Wristsim^® and 8.23/10 for the cadaver. Drilling was scored 6.60/10 for the Wristsim^® and 8.23/10 for the cadaver. Screw fixation was scored 7.40/10 for the Wristsim^® and 8.12/10 for the cadaver. Our results demonstrated that Wristsim^® is still inferior to a cadaver specimen for teaching ORIF by volar plating of DRF. A new model of Wristsim^® is being developed that will address shortcomings in pronator quadratus thickness, passive ROM in flexion/extension and bone size.