Raphael Carloni

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

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.

Eyelid fat grafting: Indications, operative technique and complications; a systematic review

INTRODUCTION Many recent studies concerning autologous fat grafting in the eyelids have been published, mostly consisting of case reports and retrospective case series. However, no study on the overall complication or satisfaction rate associated with the various grafting techniques exists. We performed a comprehensive literature review to determine the outcomes and complications of eyelid fat grafting, as well as patient satisfaction. METHODS A systematic review of the literature using the PRISMA criteria was conducted. This protocol was registered at the Prospective Register of Systematic Reviews at the National Institute for Health Research. RESULTS Sixteen studies, representing 1,159 patients and published between June 2004 and December 2014, were included. Satisfactory results, judged by clinical examination, were observed in all studies. Few postoperative complications were reported. CONCLUSIONS We demonstrated that the procedures were easy to perform, and achieved satisfactory and sustainable results with few complications in both reconstructive and cosmetic surgery. However, a wide disparity exists in the various fat harvesting, fat purification, and reinjection techniques. Further studies are required to assess the long-term outcomes. Our conclusions should be accepted cautiously due to the small number of articles and the lack of evidence in published studies.

Comparison of propeller perforator flap and venous supercharged propeller perforator flap in reconstruction of lower limb soft tissue defect: A prospective study

In lower limbs, reliability of propeller perforator flaps (PPF) remains uncertain. The main complication is venous congestion, which can lead to distal necrosis. We aim to highlight if venous supercharging of PPF could substantially limit complications in lower limb coverage.

Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps

Background The use of distally based neurocutaneous sural flaps (DBNCSF) is one of the most common methods of reconstructing the distal lower leg. However, they have developed a bad reputation because of their propensity for venous engorgement. Venous congestion that can lead to distal necrosis can be prevented by venous supercharging. Using a prospective comparative study, we thus explored the effect of venous supercharging on the reliability of these useful workhorse flaps. Methods We prospectively included 38 patients who received a conventional DBNCSF and 38 patients who received a supercharged version of this flap (sDBNCSF) between January 2012 and July 2016. Results No significant difference was identified between the groups in terms of age, sex, comorbidity, or defect origin. The main reconstruction etiology was traumatic (open fracture, scar disunion, and chronic osteitis). The flap size was noticeably larger in the sDBNCSF group, albeit without significance. The length‐width ratio was significantly greater in the sDBNCSF group (6.08 vs. 5.53, p = 0.022). Venous congestion was significantly more common in the non‐supercharged group (28.6 vs. 2.6%, p = 0.01), as was coverage failure (23.7 vs. 2.6%, p = 0.035). Conclusion There are significant benefits to using venous supercharging of DBNCSF, when technically feasible. In our experience, venous supercharging increases reliability, allows the raise of larger skin paddles with much narrower pedicles limiting the morbidity of the procedure, and improves the functional and esthetic results.

Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures

Background In hypertrophic and/or very ptotic breasts, skin-reducing mastectomy (SRM) is challenging and the risk of complications is high. Few publications have reported the use of an autologous latissimus dorsi flap (ALDF) in this indication. Most studies opt for implant reconstructions, with a high failure rate. Objectives We aimed to identify and present the technical refinements that reduce the risk of reconstruction failure in patients with hypertrophic and/or ptotic breasts with breast cancer or at risk of breast cancer after SRM with immediate breast reconstruction (IBR) utilizing an ALDF. Methods Our retrospective study, covering a period of 18 years, included a series of 60 patients with hypertrophic and/or ptotic breasts who underwent 67 SRM and IBR procedures utilizing an ALDF. The complications were recorded and the risk factors analyzed. Results Sixty-seven SRMs were reviewed. Forty-nine procedures were performed with an inverted-T scar technique and 18 with a vertical scar technique. The nipple-areola complex (NAC) was preserved in 10 cases. There were eight (11.9%) cases of minor mastectomy flap necrosis after skin-reducing reconstructions, 16 (23.8%) wound dehiscences, no infections, no breast seromas, and no reconstruction failures. Smoking increased the risk of minor mastectomy flap necrosis (P = 0.048) and wound dehiscence (P = 0.002). Previous radiotherapy was associated with minor mastectomy flap necrosis (P = 0.001). Conclusions The use of an ALDF together with technical refinements that preserve the vascular supply of the skin envelope leads to successful IBR with consistently good aesthetic results. Above all, it avoids failure of the reconstruction in very large or ptotic breasts. Level of Evidence 4

Reply to: A systematic review of complications associated with direct implants vs. tissue expanders following wise pattern skin-sparing mastectomy

We read with great interest the recent paper in JPRAS entitled “A Systematic Review of Complications Associated with Direct Implants vs. Tissue Expanders Following Wise Pattern Skin-Sparing Mastectomy”, by Corban et al. Although this is the first systematic review of the topic, some methodological issues require discussion. In our opinion, the conclusion of the authors, to the effect that two-step reconstruction seems to be associated with fewer complications than one-step reconstruction, is debatable. First, we would like to discuss the methodology of the systematic review. The authors state that they followed the PRISMA criteria. Although they did follow most of the criteria, numbers 20 and 21, which require data to be accompanied by confidence intervals and measures of consistency such as I2 index values, were not respected. Indeed, the authors do not explain their statistical methodology in the Materials and Methods, rather seeming to perform simplistic calculations of means after extraction of all data from eligible studies. This is statistically inappropriate; such an approach does not consider among-study heterogeneity (which is generally high in retrospective works), and does not allow more weight to be placed on larger studies. The complication rates reported are thus not representative of those after oneor two-stage breast reconstructions, being associated with high levels of error. A meta-analysis would have been more appropriate; complication rates should have been presented with both confidence intervals and I2 index values to allow heterogeneity to be assessed; this is mandatory in such analyses.

Abdominoplasty: Risk Factors, Complication Rates, and Safety of Combined Procedures.

1051e Abdominoplasty: Risk Factors, Complication Rates, and Safety of Combined Procedures Sir: We read with great interest the article entitled “Abdominoplasty: Risk Factors, Complication Rates, and Safety of Combined Procedures” by Winocour et al.1 We would like to congratulate the authors on their work and their conclusion that provides for the first time a finding of a high level of evidence-based medicine (Level II). Based on a prospectively filled database, the authors demonstrate using a multivariate analysis that male sex (relative risk, 1.8), age 60 years or older (relative risk, 1.4), body mass index greater than or equal to 30 (relative risk, 1.3), and combined procedures (relative risk, 1.5) are independent risk factors for major postoperative complications. We would like to discuss some points related to this article based on our recent results2 and to provide insight to develop future studies. First, this study is very informative on major complications but does not analyze risk factors for minor complications, such as wound dehiscence and seroma, which are the most frequent ones. Further prospective studies including all complications are necessary to fully inform our patients before surgery and to be able to provide an unbiased message. Second, the study confirmed that male sex and preoperative body mass index impact the complication rate. Neaman et al.3 had already found a correlation between male sex and increased complications during abdominoplasties in a retrospective analysis of 1008 patients. Arthurs et al.,4 Parvizi et al.,5 and Neaman et al.3 found preoperative body mass index greater than 25 or greater than 30 as also being an independent risk factor. Nonetheless, this study led to a highly relevant finding because it identified age as a new risk factor. Because of a larger number of included patients compared with previously cited studies, it showed for the first time that advanced age is associated with an increased operative risk. This correlation was difficult to highlight in smaller samples, as old people represent a small proportion of indications of abdominoplasty. Among these risk factors, we believe that age has to be the only operative exclusion criterion, as neither male sex nor body mass index has to be considered a contraindication. Third, this study confirmed the data of our recent review comparing abdominoplasty versus abdominoplasty and breast surgery, and showing an increased complication rate when combining procedures.2 However, Winocour et al. analyzed various associated procedures with a higher level of evidence design, providing a stronger relevance to the results. In our 3. Swanson E. Limitations of the BREAST-Q as an outcomes measure for evaluation of breast augmentation patients. Plast Reconstr Surg. 2014;134:986e–988e. Reply: Face-Lift Satisfaction Using the FACE-Q Sir: Dr. Swanson’s detailed letter should be addressed in two parts. First is his criticism regarding limitations of the present study.1 We completely agree with Dr. Swanson that ideally preoperative and postoperative evaluations are performed. Our study served to demonstrate that the FACE-Q can be used in face lift patients to successfully acquire information regarding patient satisfaction and our own results. We have found these data to be extremely useful, but we recognize that an ideal study, as mentioned in our Discussion, would include preoperative sampling, a standardized postoperative interval, and larger patient samples. We hope that future studies will aim to achieve these goals. Second is his criticism of the FACE-Q, as well as the BREAST-Q. Dr. Swanson has previously expressed his views on both of these instruments2,3; his current sentiments are not new. While we may never change Dr. Swanson’s opinion, it is our belief that the BREAST-Q and FACE-Q are not only well-designed, tested, and validated outcome measures but also, most importantly, extremely useful clinically. We have experience using both, and as attested by the hundreds of studies that have used the BREAST-Q and will use the FACE-Q, there is so much valuable information to learn from our patients using these priceless tools. DOI: 10.1097/PRS.0000000000002001

Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review

IntroductionThe elbow joint is particularly exposed to soft tissue injuries associated with fractures and dislocations. Different coverage options within the past decades for recovering loss of soft tissue defects around the elbow region have been proposed based on anatomical research. Our aim was to make an updated focus on the anatomical basis of different techniques of coverage of loss of tissues around the elbow.Materials and methodsThe main procedures of flaps were defined: local random, axial fasciocutaneous, local muscle pedicle, propeller and free microvascular flaps. A systematic literature review on anatomical basis on these different flaps options was conducted searching on PubMed databases and the selection process was undergone according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. Inclusion criteria were: review and original articles, including anatomical basis of the procedures, in English and French languages.ResultsThe final analysis included 37 relevant articles out of 1499 published references. 640 flaps were referenced, for covering 302 elbows. Local random flaps provide a good quality skin for small tissue defects in posterior elbow and periolecranon area, and depend on dermal and subdermal blood supply. Axial fasciocutaneous flaps have well-defined blood supplies and are designed as peninsular, island, or microvascular free flaps, as the radial forearm, lateral arm, ulnar artery, antecubital fasciocutaneous, and posterior interosseous flaps. Muscular flaps have advantages as strength, capacity to contrast local infection and to avoid empty spaces, and can be used as pedicle or as free transfers. Propeller flaps can be rotated up to 180° around an axis corresponding to the perforator vessel and do not require the sacrifice of a major artery or functional muscle. The concept of perforasome is evoked. Free microsurgical transfers can be proposed to cover any defect around the elbow.Discussion and conclusionThe anatomical basis of the flap’s harvesting and the possibilities of elbow coverage are discussed through the selected articles. The different indications according to the areas of soft tissues defects are considered.

Reply: The Lipo–Body Lift

1. Bertheuil N, Chaput B, De Runz A, Girard P, Carloni R, Watier E. The lipo-body lift: A new circumferential body-contouring technique useful after bariatric surgery. Plast Reconstr Surg. 2017;139:38e–49e. 2. Le Louarn C, Pascal JF. High superior tension abdominoplasty. Aesthetic Plast Surg. 2000;24:375–381. 3. Dixit VV, Wagh MS. Unfavourable outcomes of liposuction and their management. Indian J Plast Surg. 2013;46:377–392. 4. Shiffman MA. Prevention and treatment of liposuction complications. In: Shiffman MA, Di Giuseppe A, eds. Liposuction: Principles and Practice. 1st ed. New York: Springer; 2006:333–341.