Suture Reinforcement Research Articles

Obturator bypass using a ringed polytetrafluoroethylene graft for inguinal graft infection.

Inguinal vascular graft infections are high-risk events that cannot be controlled medically but require surgical intervention. This study reviewed the long-term clinical outcomes of obturator bypass using a ringed polytetrafluoroethylene graft for inguinal graft infection. A total of eight consecutive patients who underwent obturator bypass using a ringed polytetrafluoroethylene graft for inguinal prosthetic graft infection at a single medical center between January 2006 and October 2017 were retrospectively analyzed. The demographics, clinical characteristics, surgical procedure, and clinical outcomes were evaluated. There was no perioperative death; however, there were three operative complications. On the 1st and 9th postoperative day, two patients underwent hematoma evacuation in the pelvic cavity, and the other patient underwent suture reinforcement for partial dehiscence of the distal anastomosis on the 49th postoperative day. The median length of hospital stay was 14.5 (range, 7-29) days. Only one graft occlusion was observed at postoperative month 40; however, there were no ischemic symptoms. There were no limb amputations and postoperative deaths during the long-term follow-up period. There were no infections of the previous residual and obturator bypass grafts and inguinal infection during the follow-up period of 49 (range, 7-154) months. Obturator bypass for inguinal graft infection is feasible and durable with excellent long-term outcomes. However, perioperative bleeding should be taken into consideration.

Intraoperative endoscopy with immediate suture reinforcement of the defect in colorectal anastomosis: a pilot study.

Colorectal anastomosis is the one at higher risk of complication in alimentary tract surgery. Several techniques have been used to intraoperatively check a colorectal anastomosis, without reaching a clear consensus. The aim of the present study is to evaluate the addition of intraoperative flexible endoscopy to indocyanine green fluorescence in detecting colorectal anastomotic defects in a consecutive series of patients. This was a pilot study conducted over a 15-month period. Patients were scheduled for an elective laparoscopic left colectomy or anterior resection with a planned stapled colorectal anastomosis. Pre-, intra- and postoperative data were collected. Intraoperative endoscopy was routinely performed and the anastomotic defects were classified. A suture reinforcement of the defect encountered was immediately performed either laparoscopically or transanally. The primary endpoint of the study was the rate of postoperative complications. Fitfty-two patients were enrolled. At intraoperative endoscopy, 12 anastomotic defects were detected and corrected with immediate suture reinforcement. Defects were classified as two leaks, two mucosal crash, one simultaneous leak and crash, one mucosal edema and six active bleedings. None of these patients developed any postoperative complication. Moreover, there was no postoperative bleeding complication in the entire cohort. The three patients developing a postoperative leak requiring anastomosis takedown were at high risk due to general status and cancer characteristics. Even though more data and a comparative group are needed, the results of this pilot study are very promising regarding the role of intraoperative endoscopy and suture reinforcement of a colorectal anastomotic defect.

Endoscopic Sleeve Gastroplasty Is Feasible, Safe, and Effective in a Non-academic Setting: Short-Term Outcomes from a Community Gastroenterology Practice.

Endoscopic sleeve gastroplasty (ESG) has demonstrated promising weight loss results with fewer adverse events and less new-onset gastroesophageal reflux disease (GERD) compared to laparoscopic sleeve gastrectomy. Publications on ESG have exclusively described the experience at large academic medical centers with little known about the implementation and outcomes of this procedure in community practice. We conducted a retrospective study of consecutive patients who underwent ESG at a private, community-based gastroenterology practice. Total body weight loss (TBWL), procedure duration, improvement in metabolic comorbidities, and adverse event (AE) rate and severity were assessed. One hundred patients underwent ESG (86 women, mean age 45 ± 9years) and were analyzed. Procedure duration was 59± 33min with an improvement in procedural efficiency from the first quartile (mean 105min) to the fourth quartile (mean 38min). Mean 12-month TBWL was 29.80± 11.46kg (23.1± 7.5%), with excess weight loss of 66.1 ±21.5%. Over this time period, mean change in BMI was 9.43± 0.22. A multiple linear regression model found that higher starting weight (P < 0.05) and absence of suture reinforcement (P = 0.037) were associated with increased TBWL at 3months. Fourteen of 20 cases of hypertension, and 5 of 10 cases of dyslipidemia, were in complete remission by post-procedure month 3. ESG performed in a community gastroenterology practice demonstrated comparable clinical outcomes to large tertiary referral centers. TBWL and excess body weight loss either met or exceeded previously reported data from these centers.

Safety and efficacy of endoscopic sleeve gastroplasty worldwide for treatment of obesity: a systematic review and meta-analysis.

Endoscopic sleeve gastroplasty (ESG) has gained momentum as a promising, minimally invasive bariatric therapy worldwide. We performed the first comprehensive systematic review and meta-analysis of studies to evaluate the efficacy, safety, and procedural technique of ESG. Bibliographic databases were systematically searched for studies assessing patients who underwent ESG for the treatment of obesity. Studies were included if they reported percent total weight loss or percent excess weight loss and the incidence of serious adverse events. Studies with <15 patients, follow-up period <6 months, and overlapping patients were excluded. Eight observational studies with 1859 patients were included. Pooled mean percent total weight loss at 6, 12, and 24 months was 14.86 (95% confidence interval [CI]: 13.83-15.90), 16.43 (95%CI: 15.23-17.63), and 20.01 (95%CI: 16.92-23.11), respectively. Pooled mean percent excess weight loss at 6, 12, and 24 months was 55.75 (95%CI: 50.61-60.89), 61.84 (95%CI: 54.75-68.93), and 60.40 (95%CI: 48.88-71.92), respectively. The pooled incidence of serious adverse events was 2.26% (95%CI 1.25-4.03) and no mortality was reported. Gastrointestinal bleeding and perigastric fluid collection were the most common reported serious adverse events; however, the pooled incidence of both was <1%. Variations in procedural technique were seen, but the full-thickness nature of suturing was reported in all studies. A layer of reinforcement sutures was performed in the majority of studies (n = 6). Limitations include the lack of controlled studies, long-term follow-up data, and standardization of technique. ESG, a minimally invasive bariatric therapy, is reproducible among centers worldwide with effective weight loss and favorable safety profile outcomes. Controlled studies would be valuable to further corroborate these findings.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias

BackgroundLaparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™).MethodsA retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO2Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks.ResultsTwenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63–79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred.ConclusionsTiO2Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

A407 Benefits of Suture Reinforcement in Laparoscopic Sleeve Gastrectomy

Obesity is an increasing problem worldwide. Laparoscopic sleeve gastrectomy is gaining popularity. Although it has unique complications such as leakage, bleeding and stenosis, it is a reliable procedure. A total of 1200 consecutive patients who underwent sleeve gastrectomy and omentopexy between March 2013 and December 2018 were enrolled in this retrospective study. Body mass index, age, sex, and postoperative complications were recorded in all patients. Of 1200 patients, 864 (72%) were female and 336 (28%) were male. The median age was 38 years (13 to 69 year). Preoperative median body mass index was found as 40.87 kg/m2(18 to 88 kg/m2). Operative complications included strictures which occurred in 16 (1.33%) patients, bleeding in 7 (0.58%), stapler line leaks in 3 (0.25%), wound infection in one (0.08%), fat necrosis in one (0.08%), splenic arterial injury in one (0.08%) and intraabdominal abscess in one (0.08%) patient. There was no mortality. Sleeve gastrectomy and omentopexy is a safe procedure with low complication rates.

1835 Closure of a Large Gastroesophageal Anastomosis Leak With Endoscopic Suturing After the Failure of Stent Therapy

INTRODUCTION: Gastroesophageal anastomotic leaks remains a potentially life-threatening post-esophagectomy complication. Surgical repair or conservative therapy have been used traditionally with suboptimal outcomes. Endoscopic methods are now an effective alternative to surgery for the management of anastomotic leak. We report a case of closure of a large Gastroesophageal anastomotic leak using a combination of endoscopic suturing with OverStitch (Apollo Endosurgery, Austin, Texas, USA) and esophageal stent after patient failed to respond to esophageal stent alone. CASE DESCRIPTION/METHODS: A 49-year-old male with a history of adenocarcinoma of distal esophagus underwent distal esophagectomy and placement of a percutaneous gastrostomy tube. The postoperative course was complicated by sepsis and empyema. Broad-spectrum antibiotics were started, and a percutaneous drain was placed in the mediastinum for drainage of empyema. EGD was then performed by the surgical team, which led to the identification of dehiscence of the gastroesophageal anastomosis and leak. A fully covered, 23 mm by 105 mm esophageal metal stent was placed. The patient was not able to tolerate liquids orally and continued to complain of nausea and vomiting. He continued to have a large amount of drainage from the mediastinal percutaneous drain. Repeat esophagram 8 weeks post op revealed persistent leak at the anastomosis (Figure 1). Gastroenterology was then consulted for endoscopic closure of the leak. Endoscopy was performed, and the fully covered metal stent was removed. Endoscopic examination after stent removal revealed a gastroesophageal anastomosis defect about 20 mm in diameter with necrotic appearing mucosa at the site of the leak (Figure 2). The anastomotic defect was then successfully closed with approximating the healthy gastric and esophageal mucosa. A figure-of-8 pattern of endoscopic sutures was placed using the Apollo OverStitch device. Another layer of reinforcement sutures was also placed. One fully covered 23 mm by 105 mm esophageal stent was placed over the anastomosis. The patient was started on a clear liquid diet. Esophagram performed on day 5 (Figure 1) showed no anastomotic leak. Diet was then further advanced, and the patient was discharged home. DISCUSSION: Large gastroesophageal anastomotic leak remains a potentially life-threatening complication post-esophagectomy. Patients failing stent therapy usually with large leaks can be successfully treated with a combination of endoscopic suturing and stent placement.

Benefits of Suture Reinforcement in Laparoscopic Sleeve Gastrectomy.

Obesity is an increasing problem worldwide. Laparoscopic sleeve gastrectomy is gaining popularity. Although it has unique complications such as leakage, bleeding, and stenosis, it is a reliable procedure. A total of 1200 consecutive patients who underwent sleeve gastrectomy and omentopexy between March 2013 and December 2018 were enrolled in this retrospective study. Body mass index, age, sex, and postoperative complications were recorded in all patients. Of 1200 patients, 864 (72%) were female and 336 (28%) were male. The median age was 38 years (13 to 69 y). Preoperative median body mass index was found as 40.87 kg/m (30 to 88 kg/m). Operative complications included strictures which occurred in 16 (1.33%) patients, bleeding in 7 (0.58%), stapler line leaks in 3 (0.25%), wound infection in 1 (0.08%), fat necrosis in 1 (0.08%), splenic arterial injury in 1 (0.08%), and intra-abdominal abscess in 1 (0.08%) patient. There was no mortality. Sleeve gastrectomy and omentopexy is a safe procedure with low complication rates.

Evaluation of suture reinforcement for stapled intestinal anastomoses: 77 dogs (2008-2018).

To determine the influence of oversewing a transverse staple line in functional end-to-end stapled intestinal anastomoses (FEESA) in dogs. Retrospective observational study. Seventy-seven client-owned dogs that underwent 78 FEESA reinforced (n = 30) or not reinforced (n = 48) with suture at the transverse staple line. The medical records database was searched and reviewed for dogs that had undergone a FEESA between January 2008 and September 2018. Data were collected regarding signalment, body weight, clinical presentation, indication for surgery, serum albumin, presence of septic peritonitis, previous surgeries, surgical techniques (ie, oversew, crotch suture, omental wrap, omental patch, serosal patch), histopathology results, and postoperative outcome. The only differences identified between groups consisted of higher preoperative albumin (2.89 ± 0.56 vs 2.34 ± 0.62 g/dL; P = .006) and lower postoperative dehiscence rate (0/30 vs 7/48; P = .028) in dogs with an oversewn FEESA. Oversewing the FEESA was identified as the significant factor in a model with oversewing and preoperative albumin fit to the outcome of dehiscence (oversew P = .010, albumin P = .761). The location of the dehiscence was specified in four of seven dogs, all along the transverse staple line. Patterns used for oversew were unspecified (n = 11), simple continuous (8), Cushing (4), simple interrupted (2), cruciate (1), interrupted horizontal mattress (1), and Lembert (1). Oversewing the transverse staple line in FEESA was associated with a reduced occurrence of postoperative dehiscence. Our results provide evidence to support additional investigation of suture reinforcement (oversewing) at the transverse staple line of FEESA to reduce postoperative dehiscence.

Patch Reinforcement of Rotator Cuff Repairs: Current Indications

Patch reinforcement of rotator cuff repairs is continuing to evolve. Patches in rotator cuff repair can be used for suture reinforcement, augmentation, or interposition. We will discuss current indications for patch reinforcement of rotator cuff repairs.

Anatomic Reinforced Medial Meniscal Root Reconstruction With Gracilis Autograft

Meniscal root tears, left untreated, result in accelerated progression of arthritis. Numerous techniques to repair medial meniscus posterior root tears have been presented in the literature. Direct repair of the meniscus to bone without reconstructive tissue may result in a nonanatomic and biologically weak construct with a significant number of structural repair failures. Re-creation of the ligament-like structures that fix the meniscal root to bone is critical to restoring normal knee biomechanics. We present an arthroscopic reconstructive technique using gracilis autograft with suture reinforcement for medial meniscus posterior root tears.

Perforations of Gastro-Duodenal Ulcers in the Surgery Department “A” at the University Hospital Point G Bamako

The purpose of this study was to investigate the clinical and therapeutic aspects of peritonitis by perforation of gastric and duodenal ulcer. This was a retrospective and descriptive study over 8 years (2010-2018) which allowed to collect 54 cases of peptic ulcer. Included in the study were all patients with confirmed gastroduodenal perforation on histology or laparotomy. We collected 54 cases of peptic ulcer perforated s. The age group of 30 - 49 years was the majority. The male sex was dominant with 90.7% of cases; the clinical picture was dominated by abdominal contracture associated with pain in 74.07% of cases. X-ray of the abdomen without preparation (AWP) revealed in 87.03% of cases of pneumoperitoneum. The perforation was in 68.52% of cases on the gastric antrum and in 31.48% on the duodenum. The surgical procedure used was the bank of excision, and a suture reinforcement epiploic in 68.52% of cases, a simple suture made in 31.48% of cases, the disease was marked by a fistula (1.90%) and mortality was 5.55% of cases. The gastroduodenal ulcer perforation is potentially serious and responsible peritonitis whose surgical treatment involves the peritoneal toilet and sutures the puncture.

Validation of the vulnerable crotch on a side-to-side anastomosis: Observation of the burst process

The vulnerability of the crotch on a side-to-side anastomosis to leak has been widely recognized. However, countermeasures to prevent leaks from the crotch have not proven to be sufficient. A side-to-side anastomosis was performed between two intestinal specimens using a linear stapler. We analyzed the burst pressures of anastomoses. Comparison was made in five groups, with different staple heights, presence of Neoveil® (Gunze, Japan), with or without crotch buttressed with nylon. Using an endoscope inserted into the intestinal lumen, we observed the burst process. We observed a significant difference in the resistance of the crotch to leak between the two types of reinforcement. In all experimental groups, the leak was observed not only on the serosal surface but also from within the lumen. Neoveil® significantly increased the burst pressure (41.4 ± 3.6 vs. 88.8 ± 14.6 mm Hg; p < 0.01). When reinforced with nylon suture, resistance to leak was recognized only in anastomoses with suture reinforcement from within the lumen. Observing from within the intestinal lumen, as the pressure increased, the intestine split along the length of the stapled anastomosis. A leak occurred when the split reached the center of the staple line. In the group using Neoveil® there was no obvious change in the Neoveil® itself with increases in pressure. In the group reinforced with nylon sutures, the crotch of the anastomosis expanded, and the intestine split, leading to a dehiscence and leak. The efficacy of various crotch reinforcement methods both experimentally and clinically has thus far been in doubt. With our experiment, the mechanism by which leaks occur at the crotch has become clear, giving evidence for the optimal reinforcement method for stapled intestinal anastomoses.

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia

BackgroundMagnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept. MethodsFive pigs weighing between 35 and 65 kg were used. In all pigs, a percutaneous endoscopic gastrostomy (PEG) tube was placed, and a right thoracotomy was performed. Esophageal atresia was simulated by transecting the esophagus with a cutting stapler, and magnets were placed endoscopically to approximate the two ends of the esophagus. In the first pig, the tissue within the magnetic ring was excised endoscopically to achieve immediate patency. In the second pig, approximation of the blind esophageal ends was reinforced with 3–4 externally-placed sutures but immediate patency was not performed. In the last three pigs, both external suture reinforcement and immediate patency were performed. The pigs survived for 10–14 days and received nutrition through PEG tube. At necropsy, an esophagram was performed, the specimen was explanted and a leak test was performed. ResultsThe first pig died in the early postoperative period from a leak owing to separation of the magnets. The second pig died from aspiration before the anastomosis formed. The last three pigs survived until the study endpoint. The third pig had a contained leak owing to the staple line being placed between the magnets; this was not clinically significant. The last two pigs had well-formed anastomoses. Burst tests showed no leak when injecting saline up to 30 mmHg. ConclusionMagnamosis is technically feasible for esophagoesophageal anastomoses. A survival model for pure esophageal atresia was developed and refined in pigs. Further work in this area may lead to clinical use in humans.

Fibrin patch influences the expression of hypoxia-inducible factor-1α and nuclear factor-κBp65 factors on ischemic intestinal anastomosis.

The intestinal anastomotic failure is one of the most severe complications in gastrointestinal surgery. Despite the great surgical improvements during the last decade, anastomotic leak rates remain practically the same, with a dramatically high grade of morbidity for patients. Leakages are usually the final consequence of ischemia in the anastomosis, leading to tissue hypoxia. In response to hypoxia, the cell orchestrates a variety of coordinated responses in order to restore oxygen homeostasis. The molecular mechanism of hypoxia sensitivity involves oxygen sensing hydroxylases, prolyl-hydroxylases, orchestrating two main transcription factors related to induction of inflammation and angiogenesis, namely nuclear factor-κB and hypoxia-inducible factors. The immunohistochemical expression of two transcription factors hypoxia-inducible factors-1α and nuclear factor-κB p65 has already been described in several disorders, including wound healing, asthma and chronic obstructive lung disease, rheumatoid arthritis, cancer, inflammatory bowel disease, and acute colitis. In the surgical field, fibrin sealants have been widely used to prevent leaks in lung surgery and they might also be useful as a reinforcement of sutures in intestinal anastomosis. The commercial fibrin sealant patches are hemostatic and adhesive surgical agents mainly derived from human plasma. We herein report the results of a prospective randomized experimental study on pigs. We performed a high-risk leakage model of bowel anastomosis, causing a significant devascularization of 10-15 cm of the bowel wall before performing a conventional colo-ileal anastomosis. We randomized the animals to receive a covering of the anastomosis with a fibrin patch (case group) or not (control group). We report the changes in the immunohistochemical expression of the proteins involved in tissue response to hypoxia in the experimental model. Our results indicate that the fibrin patch delays the healing response, promoting a longer lasting inflammation in the surgical bed. Nevertheless, the fibrin patches effectiveness to reduce dehiscence shown in clinical practice suggests that this delay does not negatively affect patients' outcome. Impact statement The consequences of the anastomotic failure are dramatic for patients. Understanding how the ever-increasing use of fibrin sealant, that seems to have a beneficial effect on the anastomoses, interacts with the tissue and the healing process can help to justify its use and encourage research on how to improve this effect even more. We feel that the present work shows that the patch can improve healing by complex mechanisms other than the mere contention and physical support of the intestine. Furthermore, research is needed to confirm our preliminary findings.

Surgical strategy for refractory aortitis.

In some instances, we encounter cases suffered from inflammatory aortic diseases (aortitis) in Japan, some of which are at the active stages with systemic inflammation. Most of them are refractory with some technical difficulties of surgical treatment. The aortic wall, particularly, at the active stage, is too fragile to hold the surgical sutures. Consequently, the suture reinforcement with Teflon felt is required. In the late stage after surgery, false aneurysms on the suture line, that is, suture detachment potentially occur. To prevent such sequelae in the early and late phases, continuous (life-long) as well as perioperative inflammation control using corticosteroid as an initial drug and/or other immunosuppression agents. This decade, instead of the conventional open surgical repairs, endovascular treatments have widely spread, predominantly for stenotic aortic/arterial lesions. In particular, for more difficult patients suffered from more troublesome Behçet disease, endovascular treatments would have greater advantages to avoid more occasionally occurred pseudo-aneurysm on the other parts as well as the surgical suture lines. The key issues on surgical treatment for refractory aortitis are perioperative inflammation control including the long term with corticosteroid and/or immunosuppressive agents, appropriate open surgical or endovascular treatment approaches, and sufficient reinforcement of surgical suture lines.

Evaluation of tensile strength of tissue adhesives made of fibrin and cyanoacrylate used as reinforcement of colon suture in “ex vivo” swine

AimTo evaluate rupture pressures of tissue adhesives of cyanoacrylate (Omnex®) and fibrin (Evicel®), used as reinforcement in colonic suture from “ex vivo” swine. MethodsSurgical procedures were performed in the Surgical Technique Laboratory. From a division in segments of 10cm of descending colon and sigmoid colon from three “ex vivo” female swine, Landrace breed, which were resected in less than six hours after the slaughter time, 30 segments were selected, 10 of each animal. They were stored in saline solution 0.9% at 36°C, being randomly allocated in three groups (Control, Evicel and Omnex), each one containing 10 segments. ResultsThe lower and higher pressure values found in the groups Control, Evicel and Omnex were 36mmHg and 41mmHg, 70mmHg and 90mmHg, 90mmHg and 120mmHg, respectively. Containing statistical significance (p-value <0.0001) concerning the 2 to 2 comparisons (Control, Evicel and Omnex) with 95% trusting rate based on the application of the Turkey Method. ConclusionOne concludes that the use of tissue adhesives in anastomoses colonic in an experimental animal model of “ex vivo” swine increased the anastomoses rupture pressures. Among the tested adhesives, cyanoacrylate presented higher rupture pressure in relation to fibrin adhesive.

Reinforcement of sutures to close surgical incisions in frail skin.

Reinforcement of sutures to close surgical incisions in frail skin.

Hallux Varus and Plantar Plate Repair

One of the most frequent problems encountered in foot and ankle are hallux valgus and lesser toes deformities. One of the complications after hallux valgus treatment is a iatrogenic hallux varus. This deformity can be solved at 2 levels, namely the skeletal level, through a metatarsal osteotomy to correct the varus component of the bone and at the soft tissue level, to compensate and rebalance soft tissue tension surrounding the metatarsophalangeal (MTP) joint. The soft tissue reconstruction may include capsular releases, capsulorraphies, tendon transfers, and augmentations such as nonreabsorbable suture reinforcement of some MTP capsular components. Lesser toe deformities have historically shown moderate to low levels of satisfaction after surgical treatment. Ten years ago the MTP component of lesser toes deformity was solved with some type of metatarsal shortening osteotomy and soft tissue release, specially including dorsal structures over the metatarsal head. Over the last few years’ knowledge from a series of articles have shown the importance in recognizing and repairing the MTP plate to regain stability and alignment at the joint. Different alternatives of repair exist at this level, and some of them are discussed in this article. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Breast Reduction: Decreasing Complications and Improving Long-Term Aesthetic Results with Parenchymal Sutures.

The inverted T/keyhole pattern is commonly used for large breast reductions. This technique relies on the breast skin to retain the shape. With the passage of time "fallout" (pseudoptosis) occurs impairing the cosmetic result. A technique is described that uses parenchymal sutures and inframammary fold (IMF) reinforcement sutures to maintain the intraoperative shape. A retrospective study of 25 consecutive patients (50 breasts) where the IMF was reinforced and parenchymal sutures were inserted. The patients were followed up and the nipple to notch and nipple to IMF distance was measured and compared with that marked preoperatively and set intraoperatively. Complications, especially T junction breakdown, were also recorded. The mean age was 38 years (range, 16-62 years) with a mean follow-up of 12 months. The mean body mass index was 31 (range, 22-41). The mean mass of tissue excised was 925 g (range, 340-1,800 g) per side. The distance from the suprasternal notch to the nipple remained unchanged. The distance from the nipple to the IMF remained the same as that marked preoperatively except in 3 patients who developed pseudoptosis. Only 3 patients had wound dehiscence. Parenchymal and superficial fascial system sutures combined with IMF reinforcement contributes to maintaining the aesthetic result and decreasing complications, in weight stable patients.