Joseph Bou-Merhi

The double capsules in macro-textured breast implants.

Breast implants are amongst the most widely used types of permanent implants in modern medicine and have both aesthetic and reconstructive applications with excellent biocompatibility. The double capsule is a complication associated with textured prostheses that leads to implant displacement; however, its etiology has yet to be elucidated. In this study, 10 double capsules were sampled from breast expander implants for in-depth analysis; histologically, the inner capsular layer demonstrated highly organized collagen in sheets with delamination of fibers. At the prosthesis interface (PI) where the implant shell contacts the inner capsular layer, scanning electron microscopy (SEM) revealed a thin layer which mirrored the three-dimensional characteristics of the implant texture; the external surface of the inner capsular layer facing the intercapsular space (ICS) was flat. SEM examination of the inner capsule layer revealed both a large bacterial presence as well as biofilm deposition at the PI; a significantly lower quantity of bacteria and biofilm were found at the ICS interface. These findings suggest that the double capsule phenomenons etiopathogenesis is of mechanical origin. Delamination of the periprosthetic capsule leads to the creation of the ICS; the maintained separation of the 2 layers subsequently alters the biostability of the macro-textured breast implant.

Replantation vs revision amputation in single digit zone II amputations

The objective of this study was to compare the functional outcomes of zone II amputations treated with either replantation or revision amputation at our institution to better aid patients in their decision making process regarding these treatment options. We conducted a comparative retrospective study. All cases of single digit amputations received at our replantation center between 2007 and 2011 were screened for single digit zone II injuries. These patients were stratified based on the treatment received: replantation vs revision amputation. Patients were called and invited to participate in the research project. Those who accepted to enter the study were asked to complete the Quick-DASH, the Beck Depression Inventory-short form, and a custom made questionnaire. There were seventeen patients with single digit zone II replantation and fourteen patients with similar injuries who underwent revision amputation and agreed to take part in the study. Our data revealed that the duration of sick leave, occupation after injury, professional and social reintegration, discontinued activities, and self-confidence were not statistically different between the two groups. The average hospital stay and the follow-up period of replanted individuals were longer. The replantation group did not have higher levels of pain or cold intolerance, and the global functional and esthetic satisfaction levels were similar between the two groups. Also, Beck Depression Inventory and Quick-DASH scores were not statistically different. Yet, significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation. From a functional viewpoint, our study suggests that revision amputation is not superior to replantation in zone II single digit amputations. This is valuable information that should be given to patients when deciding on the treatment process and to insure a proper informed consent.

A new microsurgical research model using Thiel-embalmed arteries and comparison of two suture techniques *

PURPOSE To assess the utility of the Thiel arterial model in microsurgical research, we compared interrupted horizontal mattress (HM) sutures to simple interrupted (SI) sutures in human vessels. METHODS A microsurgical set-up using an operating microscope and Thiel-embalmed arteries was used to practice ten SI and HM anastomoses. Vessel patency, leak and stricture were evaluated using angiography, and vessel wall architecture was evaluated using light microscopy and scanning electron microscopy (SEM). The technique speed was also assessed. RESULTS We have successfully evaluated all outcomes. All anastomoses were patent. The stricture rate was higher with HM than with SI (60% vs. 35% surface area reduction). Three minor leaks occurred with HM sutures versus one with SI sutures. Edges were evenly everted without any intimal flaps with HM compared to SI. The anastomoses were performed faster using HM than SI sutures (7:58 min vs. 12:41 min, respectively). CONCLUSION This is the first study to evaluate the feasibility of a Thiel-embalmed artery model for research purposes. The HM microvascular suture is a promising technique that requires further in vivo validation.

Microvascular replantation of head and neck amputated parts: A systematic review

As opposed to upper and lower extremity amputations representing a considerable volume of admissions, the prowess of microsurgeons is seldom solicited in complex cases of head and neck replantation. Our aim was to determine the rate of successful replantation of craniofacial parts in a systematic review of the literature.

Duration and cessation characteristics of heparinization after finger replantation: A retrospective analysis of outcomes

To prevent postoperative thrombosis, indications for anticoagulation in finger replantation have been described, but no consensus has yet been found for cessation protocols. The aim of this study is to investigate cessation methods of intravenous anticoagulation after finger replantation.

The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy

INTRODUCTION In the management of breast cancer radiation therapy plays a substantive role in decreasing local recurrence and increasing overall survival. Still, there exists controversy concerning compromised radiation delivery plans and suboptimal delivery after immediate autologous breast reconstruction. Our study aims to assess the oncologic safety of immediate breast reconstruction (IBR) with a Deep inferior epigastric perforator flap (DIEP), in the setting of adjuvant radiation therapy. METHODS We conducted a retrospective analysis using a prospectively maintained database of all consecutive women undergoing breast reconstruction with a DIEP flap in the setting of radiation therapy. Independent variables included patient age, cancer stage, tumor grade type and subtype, adjuvant and neoadjuvant chemotherapy, hormonal therapy, diabetes mellitus, and tobacco use. Main outcome variables were: local recurrence, distant metastasis, patient demise and total flap failure. RESULTS From July 2008 to January 2014, and out of 450 patients who underwent reconstruction with a DIEP flap, 62 were considered eligible. Thirty patients (48%) had IBR followed by radiation therapy and 32 (52%) had delayed reconstruction preceded by radiation therapy. The two groups were comparable with respect to the independent variables. Local recurrence occurred in 3.2% of patients; 3.3% in the immediate group and 3.1% in the delayed (P=0.963). Distant metastasis occurred in 6.4% of patients: 10% in the immediate group and 3.1% in the delayed (P=0.27). Breast cancer related mortality occurred in 4.8%: 6.7% in the immediate group and 3.1% in the delayed (P=0.52). CONCLUSION Immediate reconstruction with a DIEP flap in the setting of adjuvant radiation therapy is an acceptable approach and appears not to influence the oncologic efficacy of radiation treatment. Further prospective studies are advocated.

Free Transfer of a Paralyzed Contralateral Little Finger for Total Thumb Reconstruction in an Electrical Burn Patient: A Case Report and Literature Review.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Epidemiology of Upper Extremity Amputations in the Province of Québec.

RESULTS: A total of 377 patients were referred during the period of 2010-2013. The referral rate was 1.17/100 000 person/year. 131 patients completed the questionnaire. The majority were male (85.41%), mostly in the 40-60 years-old age category (43.5%). 66.4% of the injuries occurred in the non-dominant hand. 66.31% involved one finger, with the thumb and index comprising 48.42% of the cases. They mostly worked an average of 30hours/week (64.12%), though most injuries (61.83%) occurred at home. Power hand tools or fixed powered machines accounted for 69.12% of the injuries with the table saw being responsible for 35.2% of them. Most patients reported that guards were absent at the time of injury (80.1%). 70.59% had more than 10 years experience with the machine. When respondents were asked what was according to them the reason of the injury, a clear pattern was noticed. For the table saw it was the absence of guard that was most cited (66.5%). They mentioned the lack of dexterity with small pieces as the main reason for guard retrieval (88.6%). For the miter, radial and mechanical saw it was an improper position adopted while performing the cut that was mentioned the most, as it led to the unexpected kickback of the tool in 95.5% of the cases. For the wood splitter, the lack of coordination was responsible for 65.4% of the injuries, as they were two persons performing the task at the moment of the accident.