Nicolas Bertheuil

A Systematic Review and Meta-Analysis of Double Venous Anastomosis in Free Flaps.

Background: Venous problems are the most frequent causes of flap failure and surgical revision in free flap surgery. Double venous anastomosis can be used to improve flap drainage, but this procedure has not been adopted universally and remains controversial. The authors evaluated the benefits of double venous anastomosis in terms of venous thrombosis rate, surgical revision of flaps, and flap failure rate. Methods: A systematic literature review was conducted searching the MEDLINE, PubMed Central, Cochrane, and Embase databases for articles published between 1996 and July of 2014. Data analysis consisted of evaluating the pooled relative risks of single and double venous anastomoses in fixed and random-effects models. Results: The final analysis included 27 articles involving 6842 flaps. The overall success rate was 97.48 percent. Single venous anastomosis was performed in 4591 flaps versus two anastomoses in 2251 flaps. The failure rate was 3.1 percent for single anastomosis versus 1.3 percent for double anastomosis (OR, 0.511; 95 percent CI, 0.349 to 0.747; p = 0.001). The respective thrombosis rates were 3.1 percent versus 2.3 percent (OR, 0.586; 95 percent CI, 0.390 to 0.880; p = 0.010). In addition, more single venous anastomoses were revised: 7.7 percent versus 6 percent (OR, 0.601; 95 percent CI, 0.469 to 0.770; p < 0.0001). Stratified analysis by flap type did not show any significant differences. Conclusions: Although the physiologic mechanisms remain poorly understood, the data strongly support double venous anastomosis, considering the reduction in flap failure, microsurgical venous thrombosis, and surgical revision. The authors recommend double anastomosis whenever it is feasible in free flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Mechanically Isolated Stromal Vascular Fraction Provides a Valid and Useful Collagenase-Free Alternative Technique: A Comparative Study.

Background: The use of stromal vascular fraction and adipose-derived stromal cells in tissue regeneration is now being increasingly investigated, and studies have demonstrated that adipose-derived stromal cells present differentiation and immunomodulatory capacities. The development of a rapid, inexpensive, and enzyme-free technique to isolate adipose-derived stromal cell–enriched stromal vascular fraction is a major goal for stem cell therapy. Therefore, the authors compared innovative mechanical procedures to the gold standard technique, collagenase digestion. Methods: Stromal vascular fraction was prepared from 21 liposuctions using either enzymatic digestion or two different mechanical methods: high vortexing/centrifugation and dissociation by intersyringe processing. The effects of tissue processing on cell count, viability, proliferation, clonogenic enrichment, and the phenotypes of the different native cell were determined. Adipose-derived stromal cell phenotypes from the different protocols, and their differentiation and immunosuppressive potential, were compared. Results: Enzymatic digestion isolated more viable cells than dissociation by intersyringe processing and vortexing/centrifugation. The expansion rate and clonogenic enrichment were higher for stromal vascular fraction isolated with collagenase. The proportion of adipose-derived stromal cells was higher in stromal vascular fraction extracted with dissociation than with enzymatic digestion and vortexing/centrifugation (p < 0.01). Interestingly, all cultured adipose-derived stromal cells displayed similar differentiation and immunosuppressive capacities. Conclusions: Enzymatic digestion extracts more adipose-derived stromal cells, but intersyringe dissociation enables the rapid extraction of adipose-derived stromal cell–enriched stromal vascular fraction. Moreover, mechanical methods enable adipose-derived stromal cell isolation with stemness and immunosuppressive properties, similar to enzymatic digestion. Such mechanical procedures could allow easier and more rapid isolation of adipose-derived stromal cell–enriched stromal vascular fraction for practitioners. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The Lipo–body Lift: A New Circumferential Body-contouring Technique Useful after Bariatric Surgery

Background: After bariatric surgery, lifting of the lower body involves a contouring technique used to achieve optimal lower trunk reconstruction. The authors describe an innovative procedure applicable after massive weight loss: the lipo–body lift method. The authors describe their experience with this novel, safe procedure. Methods: Twenty-five abdominal body-contouring reconstructions following massive weight loss were treated by means of circumferential lipo–body lift. The authors describe the indications for the procedure and their perioperative and postoperative management. Results: The mean patient age was 39.4 years. The mean pre–body lift body mass index was 26.71 kg/m2; the average weight loss before surgery was 56.6 kg, with a mean delta body mass index loss of 20.82 kg/m2. The average hospital stay was 3.52 days and the drainage duration 3.56 days. No patient experienced any major complication (e.g., hematoma, thromboembolism, bleeding, skin necrosis, or a need for revision surgery to treat complications). Minor complications including wound dehiscence, wound infection, and fat necrosis were reported in 40 percent of patients. The occurrence of complications was associated with smoking status (p = 0.0280), the volume of liposuction (p = 0.0399), and the liposuction volume per unit of body mass index (p = 0.0071). Conclusions: The authors’ novel technique is less invasive than the traditional lower body-lifting method, as shown by the absence of major complications, and allows excellent conservation of connective tissue and vessels; undermining is minimal. As obesity becomes a major problem worldwide, lifting procedures that are safe and effective are important components of reconstructive strategies and should be widely offered to patients who experience massive weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.Background:After bariatric surgery, lifting of the lower body involves a contouring technique used to achieve optimal lower trunk reconstruction. The authors describe an innovative procedure applicable after massive weight loss: the lipo–body lift method. The authors describe their experience with t

Quality-of-Life assessment after medial thighplasty in patients following massive weight loss.

Background: The improvement of medial thighplasty techniques has greatly reduced the morbidity of these interventions and participated in their democratization among surgeons and patients. The aim of this study was to evaluate the beneficial effect of medial thighplasty on quality of life in patients following massive weight loss. Methods: The quality of life following massive weight loss after diet or bariatric surgery of 21 patients was measured using the Moorehead-Ardelt Quality of Life Questionnaire. Patients who underwent medial thighplasty following a percentage of weight loss greater than 20 percent of the body weight were included. Results: The mean age of the patients was 49.9 ± 8.7 years. The average pre–medial thighplasty body mass index was 28.4 ± 4.8 kg/m2 and the average weight loss before surgery was 46 ± 17.1 kg. In our study, medial thighplasty improved the quality of life of patients (mean quality-of-life scores, 1.49 ± 1.3; e.g., self-esteem, physical status, social life, and improved labor conditions of patients). However, the quality of the sex life of the patient was not improved by this operation. No difference was found in quality-of-life results between patients according to the number of months since they had undergone surgery (p = 0.7252). Conclusions: Medial thighplasty improves the aesthetic and functional outcome of the thigh. The authors report, for the first time, that medial thighplasty improves quality of life of patients with massive weight loss. With the worldwide development of obesity, this study demonstrated that the operation should be widely proposed to patients with massive weight loss to improve quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Professional Burnout Among Plastic Surgery Residents: Can it be Prevented? Outcomes of a National Survey.

BackgroundPlastic surgery residencies require significant investments of time and psychological resources. We herein determine the prevalence of burnout syndrome among plastic surgery residents and identify potentially protective factors. MethodsA national cross-sectional study was conducted among French plastic surgery residents in March 2013. We distributed a validated measure of burnout (Maslach Burnout Inventory) in addition to a general questionnaire collecting sociodemographic and professional information. ResultsFifty-two residents (61%) responded; their mean age was 29 years. A total of 25% and 13.5% of residents scored highly on the depersonalization and high-level emotional exhaustion burnout subscales, respectively, and 48.1% indicated perceived low-level personal accomplishment. The occurrence of a weekly ward round by a senior surgeon (reported by 67.3% of respondents) appears to protect against burnout (P = 0.007); regular staff meetings in the unit (75% of respondents) were also protective because they limited depersonalization (P = 0.048) and promoted personal accomplishment (P = 0.031). The number of hours worked/week was not significantly associated with burnout. Despite these data, 69.2% reported satisfaction with their careers. ConclusionsAlmost one third of plastic surgery residents exhibited a high degree of burnout; the risks were increased by being in the early years of training, feeling dissatisfied with career plans, and working in units in which senior surgeons did not make weekly ward rounds and in which regular staff meetings, which offer the opportunity to discuss cases or problems with other professionals, were not scheduled. Burnout increases the risk of medical errors and suicide among residents. Therefore, we suggest that screening for burnout is essential.

Autologous Fat Grafting for Cosmetic Breast Augmentation: A Systematic Review

BACKGROUND Breast augmentation is one of the most popular aesthetic surgical procedures. The only potential alternative is autologous fat grafting (AFG), which is not new in principle. This procedure has been used on native breasts since 2009, following the recommendations of some learned societies. OBJECTIVES We performed a systematic review to determine the current worldwide status of fat grafting for aesthetic breast augmentation. METHODS A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria was conducted using the PubMed, EmBASE, and Cochrane library databases. This protocol was registered at the National Institute for Health Research, Prospective Register of Systematic Reviews. RESULTS A total of 42 articles published between 1987 and July 2014 were included. Most of the studies had a low level of evidence, with only one level 2 study, published by Spear (2014), a prospective cohort study which included 10 patients. The publications were from North America, Europe, and Asia. The indications were aesthetic augmentation (92.4%) and congenital malformation (7.6%). Two cases of cancer were reported among the 2023 patients included (0.09%), with a mean follow-up of 22 months, although the follow-up was insufficient for medium- and long-term cancer diagnoses. CONCLUSIONS AFG seems to be a major tool in this field, but we must remain cautious about its systematization for this indication. Preoperative patient selection is essential but underreported. AFG appears particularly relevant in breast malformations. We believe that this method should be practiced within the scope of a national or international registry with proper follow-up of patients.

Another suspected case of breast cancer recurrence after lipofilling? Remain cautious …

We read with interest the article by Smit et al. entitled « Recurrence of invasive ductal breast carcinoma 10 months after autologous fat grafting ». We actually reported a similar case in 2012 then a second case in 2013 in PRS GO, equally disturbing, which has since made us step back from lipofilling. In this second case, the recurrence followed injection of fat to improve the cosmetic results of a latissimus dorsi flap. In these three cases, it is important to note the aggressive nature of the tumor after lipofilling. It would be interesting to know whether in the case of Smit et al. there has been a modification of hormone receptor status. Lipofilling is mainly controversial in the management of the conservative treatment sequelae and the publication of these cases suggests that even after mastectomy this procedure seems not so harmless. Given these cases, three points are particularly to discuss:

Liposuction Preserves the Morphological Integrity of the Microvascular Network: Flow Cytometry and Confocal Microscopy Evidence in a Controlled Study

BACKGROUND Liposuction is a very popular technique in plastic surgery that allows for the taking adipose tissue (AT) on large surfaces with little risk of morbidity. Although liposuction was previously shown to preserve large perforator vessels, little is known about the effects of liposuction on the microvasculature network. OBJECTIVES The aim of this study was to analyze the effect of liposuction on the preservation of microvessels at tissue and cellular levels by flow cytometry and confocal microscopy following abdominoplasty procedure. METHODS Percentage of endothelial cells in AT from liposuction and en bloc AT was determined by multicolor flow cytometry. Moreover, vessel density and adipocyte content were analyzed in situ in 3 different types of AT (en bloc, from liposuction, and residual AT after liposuction) by confocal microscopy. RESULTS Flow cytometric analysis showed that en bloc AT contained 30.6% ± 12.9% and AT from liposuction 21.6% ± 9.9% of endothelial cells (CD31(pos)/CD45(neg)/CD235a(neg)/CD11b(neg)) (P = .009). Moreover, analysis of paired AT from the same patients (n = 5) confirmed a lower percentage of endothelial cells in AT from liposuction compared to en bloc AT (17.7% ± 4.5% vs 21.9% ± 3.3%, P = .031). Likewise, confocal microscopy showed that en bloc AT contained 8.2% ± 6.3%, AT from liposuction only 1.6% ± 1.0% (P < .0001), and AT after liposuction 8.9% ± 4.1% (P = .111) of CD31(pos) vessels. Conversely, adipocyte content was 39.5% ± 14.5% in the en bloc AT, 45% ± 18.4% in AT from liposuction (P = .390), and 18.8 ± 14.8% in AT after liposuction (P = .011). CONCLUSIONS For the first time, we demonstrate that liposuction preserves the microvascular network. Indeed, a low percentage of endothelial cells was found in AT from liposuction and we confirm the persistence of microvessels in the tissue after liposuction.

Circumferential Contouring of the Lower Trunk: Indications, Operative Techniques, and Outcomes—A Systematic Review

BackgroundIncreasing obesity prevalence and development of bariatric surgery have led to the development of skin re-draping techniques. Several contouring techniques have been described for treating the circumferential excess of the lower trunk.Materials and MethodsWe performed a systematic review to summarize surgical indications, operative techniques, peri-operative management (nutritional supplementation, antibiotic prophylaxis, thrombo-prophylaxis), outcomes, complications, patient satisfaction, and impact on quality of life of circumferential contouring of the lower trunk procedures. A systematic review, based on the PRISMA criteria, was conducted using the Pubmed and Cochrane databases.ResultsThe review included 42 articles and 1748 operated patients. Two studies only were graded as level of evidence II; the others were graded as levels III to V. The most frequently reported indication was massive weight loss. All the described techniques derived either from belt lipectomy or lower bodylift. Belt lipectomy resulted in a posterior scar situated at the waistline and allowed a better correction of hip back rolls, whereas lower bodylift was more effective on buttock and lateral thigh ptosis. The most reported complication was wound dehiscence. Patient satisfaction and quality of life scores were high in all studies.ConclusionsThis review included a majority of low-level evidence studies that limit extrapolability of the results. Future randomized prospective studies may generate stronger evidence, with a standardization of surgical indications and operative techniques.Level of Evidence IIIThis 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.

Perforator detection with a hand-held Doppler device: Importance of the learning curve

We read with great interest the manuscript ‘‘The hand-held Doppler device for the detection of perforators in reconstructive surgery: What you hear is not always what you get’’ by Stekelenburg et al. [1]. We congratulate the authors for this work and would like to discuss two points that were not addressed by the authors. Indeed, the margin of error of acoustic Doppler is not negligible, but it is greatly decreased by the operator’s experience. We started to use the propeller perforator flap 2 years ago and have completed more than 60 on ‘‘small’’ perforators, called ‘‘freestyle’’ by some [2,3]. We prospectively compared the reliability of detection of acoustic Doppler (Bidop ES-100 8 MHz Hadeco) between our first and subsequent 30 flaps. For the first 30, we had a detection error rate of 23% (n = 7); in fact, no perforators were present during the dissection, and the acoustic Doppler detected the deep vessels. For the final 30, we had a 6.7% detection error (n = 2). The frequent use of acoustic hand-held Doppler allows one to distinguish more easily between perforating vessels and vessels located more deeply; the pulsatility and loudness of sound are indeed different. Second, we are surprised that the authors did not mention the ‘‘perforator compression test’’ of Mun and Jeon [4] (video). Described in 2006, this procedure can distinguish between a perforator and deep vessel. The course of perforators is usually perpendicular to the skin surface, making perforators easily compressible and collapsible by an external force applied perpendicular to the surface of the skin. The loudness of the pulsating sound decreases with increasing pressure if the pulse originates from a perforator. Mun and Jeon reported 100% specificity in detecting perforators for their test. Since we adopted it, we have reduced the rate of perforator detection errors. Ultimately, we believe that color Doppler sonography brings precision and provides information on the axis of the Transparency document