Short Incision Research Articles

Systematic review and meta-analysis of cutting diathermyversusscalpel for skin incision

Skin incisions have traditionally been made using a scalpel. Cutting diathermy, a more recent alternative, is thought to increase the risk of infection, impair healing and decrease cosmesis. Recent studies suggest otherwise, claiming that diathermy may offer potential advantages with respect to blood loss, incision time and postoperative pain. The aim of this meta-analysis was to compare skin incisions made by either scalpel or cutting diathermy. A systematic literature search and review was performed for studies published from January 1980 until June 2011. Randomized clinical trials comparing scalpel and cutting diathermy for skin incisions of any operation were included. Primary outcomes included wound complication rate, blood loss, incision times and pain scores. Fourteen randomized trials met the criteria for inclusion in the meta-analysis, providing outcome data for a total of 2541 patients (1267 undergoing skin incision by cutting diathermy and 1274 by scalpel). The median length of follow-up across all studies was 6 weeks (range 4 days to 19 months). Compared with a scalpel incision, cutting diathermy resulted in significantly less blood loss (mean difference 0.72 ml/cm(2); P < 0.001) and shorter incision times (mean difference 36 s; P < 0.001), with no differences in the wound complication rate (odds ratio 0.87; P = 0.29) or pain score at 24 h (mean difference 0.89; P = 0.05). Skin incisions made by cutting diathermy are quicker and associated with less blood loss than those made by scalpel, and there are no differences in the rate of wound complications or postoperative pain.

Managing the Neck in the Era of the Short Scar Face-Lift

A recent trend in rhytidectomy has included the introduction of various short incision techniques, particularly the S-lift, the minimal access cranial suspension lift, and other short scar methods. However, this trend has not been without a criticism that these minimally invasive techniques might be limited in what might be achievable by such surgery. As with more traditional face-lift surgery, the management of the neck often presents as the most challenging aspect of the procedure when using short scar techniques. This article will present a brief history of cervical rhytidectomy and relevant surgical anatomy, as well as the authors' algorithmic approach to surgical assessment and management of the neck, the short incision operative techniques, and potential complications. In the authors' experience, attention to both the selection criteria and operative modifications in the execution of short scar techniques are critical to optimizing outcomes in cervical rejuvenation.

Minimally Invasive Hip Surgery

Describe the most common techniques used for minimally invasive hip surgery. Certainly the most commonly described approaches in the literature are the posterior and direct anterior. The posterior approach is essentially the same as what surgeons have done traditionally but with a shorter incision and less dissection of the deep musculature. The 2-incision approach, which I prefer, has fallen out of favor because it is technically diffi cult; several proponents of the 2-incision approach have switched to using an anterior approach only and then placing the femur into hyperextension and external rotation. The basic issue with hip replacement is that you have 2 different axes—that of the acetabulum and that of the femur. To access these axes, you have 3 options: (1) make an incision long enough to incorporate both axes in 1 incision (a traditional approach); (2) make a short incision and move the axis into the incision, which is what we do with an anterior approach—the femur is drawn into the wound; or (3) make a dissection in line with the acetabulum and a second dissection in line with the femur (the 2-incision approach). Overall, the concept is of hip replacement as a soft tissue procedure with the parenthetical inclusion of implant placement.

Delayed Consultation and Treatment of Penile Fracture: A Case Report

Introduction: A case of penile fracture referred three days after the injury is reported, highlighting the potential advantages of delayed rather than acute treatment, once the hematoma and swelling caused by trauma had decreased. Case presentation: A 31 year-old-man was diagnosed with fracture of the left corpus cavernosum that had occurred three days before. Due to the patient desire, surgical treatment was delayed and performed at day nine of penile fracture, with an incision limited to the penoscrotal angle. There was a rupture of the left corpus cavernosum and laceration of the corpus spongiosum of the urethra, which were repaired with an absorbable suture. The patient recovered erections without curvature of the penis, and with an almost invisible skin scar. Conclusion: There is an overwhelming consensus on the need for surgical treatment of penile fracture. Recently, it has been proposed that the repair could be made on a delayed rather than an emergency basis, once the hematoma and inflammation caused by trauma had reduced, and using a short incision, as close as possible to the point of penile fracture. The case here presented highlights the advantages of these options, coincidental with the delayed consultation by the patient.

Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique

Purpose: Doughnut mastopexy lumpectomy (DML) is a breast resection technique in which a tissue segment is removed and the breast reshaped through a doughnut-shaped de-epithelialized periareolar area. In this study, we attempted to determine whether the DML technique could be useful for other types of breast surgery, in addition to breast cancer lumpectomy. Methods: This study examined a total of 4 patients who underwent the DML technique and were followed up for at least 1 year postoperatively. One patient underwent phyllodes tumor resection, 1 patient underwent removal of a siliconoma, and 2 patients underwent breast reduction mammaplasty. Results: This method enabled en-bloc removal of a large tissue mass or large foreign body that could not be removed through a short periareolar incision. The surgical method of this study enabled the extent of de-epithelialization to be changed according to the size and location of the mass to be excised; good cosmetic results were also obtained. In addition, the surgical method enabled the facile excision of tumors and foreign materials. Conclusions: The DML technique is a useful surgical method that is applicable to other breast surgeries, in addition to breast cancer surgery.

Comparison between Lateral Supraorbital Approach and Pterional Approach in the Surgical Treatment of Unruptured Intracranial Aneurysms

ObjectiveThe lateral supraorbital (LSO) approach is a modified method of the classic pterional approach and it has advantages of short skin incision and small craniotomy compared with the pterional approach. This study was designed to compare the two approaches in the surgical treatment of unruptured intracranial aneurysms.MethodsWe retrospectively reviewed 122 patients with 137 unruptured intracranial aneurysms treated by clipping, from July 2009 to April 2011. Between August 2010 and April 2011, 61 patients were treated by clipping via the lateral supraorbital approach and the same number of patients treated by clipping via the pterional approach were retrospectively enrolled. We analyzed the two groups and compared demographic, radiologic and clinical variables.ResultsThe mean age of patients in the two groups was 54.6 years (LSO group) and 55.7 years (Pterion group). The mean duration of hospitalization was shorter in the LSO group than in the Pterion group (7.9 days vs. 9.0 days, p=0.125) and the mean operation time was also significantly shorter in the LSO group (117.1 minutes vs. 164.3 minutes, p<0.001). Furthermore, the mean craniotomy area was much smaller in the LSO group (1275.4 mm2 vs. 2858.9 mm2, p<0.001). The two groups showed similar distributions of aneurysm location and postoperative complications.ConclusionThe lateral supraorbital approach for the clipping of unruptured intracranial aneurysm could be a good alternative to the classic pterional approach.

Treating protrusion of lumbar Intervertebral disc with small Incision open-window discectomy

Objective To explore the effect of small incision open-window discectamy in treating protrusion of lumbar intervertebral disc.Methods 71 cases with protrusion of lumbar intervertebral disc,who were treated with small incision open-window discectomy were selected.Results Average operation time was (55.34 ± 15.29) min,average blood loss was(67.30 ±29.36) ml,average length of stay( 14.3 ± 1.2) days.Self-rated improvement pains were significantly reduced.JOA score was significantly better than preoperative patients( P ＜0.01 ).Conclusion Compared with the traditional methods,small incision open-window discectomy had less traumas,shorter incision length,faster recovery,and little damage. Key words: Intervertebral disk displacement; Small incision; Discectomy

Evaluation of laparoscopic versus open colorectal surgery in elderly patients more than 70 years old: an evaluation of 727 patients

With longer life expectancy, surgeons can expect to operate on older patients. Laparoscopic colorectal (LC) surgery has been demonstrated to be superior to open surgery. Controversy persists, however, regarding benefits of LC in the elderly due to increase in operative time. The aim of our study was to compare short-term outcomes of LC versus open colorectal (OC) surgery in elderly patients. Patients ≥70years old that underwent elective LC between 2005 and 2008 were compared with controls who underwent OC. Data was extracted from a prospectively collected database. Seven hundred and twenty-seven patients underwent colorectal resection in this study period (LC n = 225, OC n = 502). The laparoscopic arm was characterised by shorter incisions (LC 6.0cm vs. OC 12.0cm, p < 0.001) but longer operating times (LC 125min vs. OC 85min, p < 0.001). Median use of narcotics and length of stay were significantly shorter in the laparoscopic group (LC 2days vs. OC 3days, p < 0.001 and LC 6days vs. OC 7days, p < 0.001, respectively). There was no significant difference in median recovery of bowel function (LC 4days vs. OC 4days, p = 0.14) and post-operative morbidity (p = 0.725). Thirty-day mortality was significantly lower in the laparoscopic arm (LC 1.3% vs. OC 4.6%, p = 0.03) This is the largest series from a single institution comparing LC and OC in elderly patients. In our series, LC in elderly patients was safe and not associated with a higher morbidity. LC was also associated with less narcotic use and shorter length of stay.

Alteration in skin sensation following knee arthroplasty and its impact on kneeling ability: a comparison of three common surgical incisions

Disturbance in skin sensation is a recognised, often unpleasant consequence of knee replacement for many patients and may affect function especially kneeling. The aim of this study was to compare post-operative changes in skin sensation following total (TKA) and unicompartmental knee (UKA) arthroplasties using three different incision types and its effect on kneeling ability. Skin sensation was recorded using a purpose-designed grid over the front of the knee in 72 patients (78 knees) following knee arthroplasty. Surface area of sensory change, length of incision, and kneeling ability were recorded and compared between three different types of incision; long antero-medial and midline for TKA, and short medial for UKA. The average length of the long antero-medial incision was 19 ± 5 cm with an average area of sensory alteration of 88 ± 56 cm(2). The average length of the midline incision was 18 ± 3 cm with an average area of sensory alteration of 57 ± 52 cm(2). The short medial incision used for UKA averaged 11 ± 3 cm in length with an average area of sensory alteration of 54 ± 45 cm(2). Long antero-medial produced a significantly greater area of sensory alteration than standard short medial (P = 0.017), but not the midline incision. There was a significant positive correlation of incision length with reduced sensation. Patients unable to kneel demonstrated a significantly larger area of hypersensitivity than patients who could kneel (P = 0.002). Increased length of incision results in a greater surface area of sensory change in the front of the knee. This finding was greatest in the long antero-medial incisions used in TKA. The inability to kneel following knee arthroplasty is associated with increased area of hypersensitivity of the anterior knee. Prospective comparative study, Level II.

Elective living donor liver transplantation by hybrid hand-assisted laparoscopic surgery and short upper midline laparotomy

Although the technique of liver transplantation is well developed, the invasiveness of the operation can be decreased with laparoscopic procedures. We performed elective living donor liver transplantation (LDLT) through a short midline incision combined with hand-assisted laparoscopic surgery (HALS). Nine selected patients with end stage liver disease underwent the procedure between July, 2010 and February, 2011 (median age 60, median Child-Pugh 9, median MELD score 14). Splenectomy was performed simultaneously in 7 cases. The liver (and spleen) were mobilized by a sealing device under a HALS procedure with an 8-cm upper midline incision, followed by explantation of the diseased liver (and spleen) through the upper midline incision which was extended to 12 to 15 cm. Partial liver grafts were implanted through the upper midline incision. The median duration of the operation was 741 minutes, the median time needed for anastomosis was 48 minutes, the median blood loss was 3,940 g, and the median liver weight was 866 g. Eight recipients are alive and have good graft function. A difficult implantation for one patient required an additional right transverse incision. When compared with 13 recent liver recipients who underwent LDLT with a regular Mercedes-Benz-type incision, no clinically relevant drawbacks of the HALS hybrid procedure were observed. We have shown the feasibility and safety of LDLT performed through a short midline incision without abdominal muscle disruption with the aid of HALS.

Pectus Excavatum Repair According to Nuss: Is It Safe to Place a Retrosternal Bar by a Transpleural Approach, Under Thoracoscopic Vision?

We present a new case of cardiac perforation during retrosternal dissection beginning a Nuss procedure for pectus excavatum repair in an 18-year-old boy. The true incidence of life-threatening complications, such as heart injuries during Nuss bar placement for pectus excavatum repair, as well as cardiac lacerations during removal of the bar, remains unknown. Many papers suggest measures to prevent these complications: approaching the retrosternal space through an additional subxiphoid short incision, lifting the sternum during bar placement, or placing the bar extrapleuraly. Nuss procedure is gaining more and more popularity due to its apparent simplicity; however, its operational complications should be well known and discussed to be avoided later on.

Revealing sediment sources, mixing, and transport during erosional crater evolution in the hyperarid Negev Desert, Israel

To better understand the sedimentary history of the erosional crater of Makhtesh Hazera in the hyper-arid Negev Desert of southern Israel we have measured concentrations of in situ 10Be in alluvial sediments from the active drainage system and from abandoned alluvial terraces and dated them using optically stimulated luminescence (OSL). These sedimentary sequences suggest changes in the drainage system behavior over time and show a periodic pattern in which periods of sediment aggradation alternate with periods of degradation through incision and erosion. In alluvial terrace sediments, 10Be concentrations were combined with OSL ages to gain insight of the temporal framework of sediment deposition and shed light on the process of sediment storage. OSL and simple 10Be exposure ages of terrace sediments give deposition ages between ~ 340 ka to ~ 50 ka, at which time the youngest alluvial terrace was incised. Deposition was interrupted twice, at ~ 300 ka and ~ 160 ka, when periods of rapid incision caused the abandonment of the active fluvial surface and the stabilization of a younger and lower fluvial surface. In the active drainage system, 10Be concentrations suggest several possible quartz sources, of which the Lower Cretaceous sandstone bedrock exposed at the base of the cliff enclosing the Makhtesh is the most dominant. The results suggest that sediment eroding form these cliffs are conveyed through the active alluvial channels without significant sediment contribution from alluvial terraces or from eroded bedrock exposed within the Makhtesh. In contrast to our measurements in the active drainage system, 10Be concentrations in alluvial terrace sediments record significant storage within the Makhtesh. We suggest that the geometry of the Makhtesh, mainly the disproportion between the size of the Makhtesh and its narrow outlet, leads to significant accumulation of sediment within the Makhtesh. Episodic breaching of the barrier is followed by rapid and short-lived incision into the stored sediment. The long residence time of sediment within the Makhtesh results in high measured 10Be concentrations. At the end of each of these short incision episodes, when channels are already carved into the alluvial sediment and terraces are formed, the channels only convey sediment directly eroded from the bounding cliff of the Makhtesh; a situation presently observed.

Differences in technique between different disciplines: a lesson in sharing evidence

The technical note by Mownah et al on ultrasound mapping of the long saphenous vein for coronary artery bypass1 prompts reflection on how different disciplines might profit from observing and reading about the practices of others. It is just one illustration of surgeons in two related specialties approaching the same task in different ways, despite evidence and practice that might guide them otherwise. The note describes how to map and mark the long saphenous vein using ultrasound prior to harvesting, with the aim of making incisions accurately over it, so reducing the amount of dissection and subsequent wound complications. The tone of the article and the fact that our reviewer judged it to have merit suggest that this is a practice that is unfamiliar to many cardiac surgeons (or at least not in common use by them). For peripheral vascular surgeons, saphenous vein mapping and marking by ultrasound has been normal practice for many years and is well described in their specialist literature.2,3 It seems strange that cross-fertilisation has not occurred between vascular and cardiac surgery in this area. A further, closely related, illustration of different practice relates to the way the long saphenous vein is harvested. Since the 1980s it has been common practice among vascular surgeons to expose the vein through a number of short incisions, based on evidence that wound problems occur less frequently and discharge from hospital is less often delayed,4,5 By contrast, most cardiac surgeons continued to harvest the vein using a continuous long incision. The complications from these long incisions stimulated their interest in endoscopic harvesting, which may have inferior long-term outcomes for the grafts.6 None of this is intended as a vascular surgical snipe at cardiac surgeons: the technical note on vein mapping by ultrasound was simply a prompt to raise this general issue. Other illustrations of different approaches are not difficult to find: variation in perioperative management for bowel resection provides a good example. Within the last decade, there have been numerous meta-analyses (including Cochrane reviews) demonstrating that routine placement of nasogastric tubes and routine use of mechanical bowel preparation are unnecessary in elective colorectal surgery.7–10 Studies have demonstrated that pre-operative mechanical bowel preparation and delayed feeding after operation are not only unnecessary but can be counterproductive.8–10 On the basis of this evidence, colorectal surgeons largely abandoned these practices, but similar changes have been rather slow to disseminate through other disciplines involved in abdominal surgery. Many urologists continue to advocate pre-operative ‘elemental diets’, mechanical bowel preparation and routine nasogastric tube placement in procedures such as radical cystectomy. It is only recently that studies have appeared in the urological literature showing that omission of these measures prior to radical cystectomy is safe and associated with an accelerated recovery.11,12 Working within specialty-based ‘silos’ has impeded the rapid adoption of advances in surgical care. This culture has also bred a perceived but in some cases unnecessary need to repeat clinical trials by specialty-specific groups to confirm findings that should logically apply across similar patient groups. The examples above should perhaps make surgeons of all specialties think about the techniques used and published by related disciplines, from whom they often remain strangely separate. A certain tribalism persists in surgery and medicine, which fuels the belief that the practices of one's own specialty are just a little better than all the others. There may be useful lessons to learn from the technical literature of other disciplines.

Lymphoscintigraphic findings: delayed oedema after great saphenous vein harvesting

The aim of this study was to identify lymphoscintigraphic changes associated with lower-extremity oedema after the harvesting of the saphenous vein using a series of short Q2 incisions for coronary bypass. Forty-four patients (32 males and 12 females) with a mean age of 62.7 ± 7.8 (47-75 years old) were evaluated in a retrospective, quantitative, cross-sectional study from June 2007 to January 2008, three to 188 months (mean: 46 months) after the surgical procedure. Assessment was by water displacement volumetry and lymphoscintigraphy of the lower limbs. Results expressed as means with standard deviations were compared employing the Student's t-test and the chi-square or Fisher's exact tests were used to compare data expressed as frequencies. An alpha error of 5% was considered acceptable (P ≤ 0.05). The presence of dermal backflow, as identified by lymphoscintigraphy with an accumulation of radiotracer in the thoracic duct and popliteal lymph nodes was significantly greater on the operated side. There was a significant association between dermal backflow and delayed oedema.

Rates and Risk Factors for Unfavorable Outcomes 6 Weeks after Trichiasis Surgery

Several studies of trichiasis recurrence suggest an association between surgical factors and long-term recurrence, yet data on short-term risk factors are limited. This study was conducted to evaluate risk factors for early trichiasis recurrence and other unfavorable short-term outcomes. Trichiasis patients presenting for surgery were evaluated for presence of active trachoma and signs of cicatricial outcomes of trachoma, including number of trichiatic lashes, epilation, and entropion. Surgical factors recorded included incision length, surgery duration, and the surgeon performing the operation. Participants were followed up for 6 weeks after surgery and evaluated for eyelid closure defect and trichiasis recurrence; in addition, in two thirds of the patients, eyelid contour abnormality and granuloma formation were evaluated. First-time trichiasis surgery was performed on 2615 eyelids. Of these, 2601 eyelids without surgical failure were followed up 6 weeks after surgery. Of the eyelids treated, 2.3% had recurrent trichiasis and 1.3% had an eyelid closure defect. Data on eyelid contour abnormalities and granuloma formation were recorded for 1881 eyes, with rates of 1.2% and 10.5%, respectively. Associated risk factors differed by outcome. Surgeon was predictive of eyelid closure defect and granuloma formation. Eyelids with short incisions were nearly four times more likely to have recurrent trichiasis (95% confidence interval, 1.7-9.3). Baseline trichiasis severity was predictive of eyelid contour abnormalities and recurrent trichiasis. Epilation was associated with granuloma formation, but was protective against eyelid closure defect. Surgical factors are important predictors of unfavorable outcomes in the weeks immediately after surgery. Although the overall rate of serious uncorrectable unfavorable outcomes was very low, the high rate of granuloma formation, which can be treated by removal, highlights the need for follow-up of patients after trichiasis surgery. (ClinicalTrials.gov number, NCT00347776.).

An Algorithm for Recipient Vessel Selection in Microsurgical Head and Neck Reconstruction

This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.

Les cous difficiles. Diagnostic et traitement. Étude rétrospective de 145 cas utilisant la méthode de Feldman

To identify a neck as difficult seems an easy thing. Nevertheless, we must admit that various clinical situations are represented under this single designation. A clinical and anatomical classification is proposed regarding the surgical strategy presented in this paper. Predominant tissue laxity and predominant fat accumulation are presented as progressive forms. Short platysma muscles and low hyoid bones are presented as constitutional. According to this classification, 145 patients among 438 facial rejuvenations were designated as difficult necks. The surgical strategy was intended, in each case, to address the underlying anatomical features, using a short incision system. A combination of wide skin undermining, fat removal under direct vision and corset platysmaplasty was performed in the 145 patients between November 2003 and May 2008. The average age was 59 years old and medium follow-up at 22 months. There was only 2% of secondary touch up for aesthetic reasons. Difficult necks, as described in this article, responded adequately to the present protocol. The postoperative results on the neck were consistent with the rest of the rejuvenated face and stood the test of time.

Minimally invasive peripheral nerve surgery: A short scar technique

As peripheral nerve specialists can have a wide variety of training backgrounds, few standards of care exist with respect to necessary incision length, amount of dissection, and operative technique for common nerve decompressions. Approaches for the following 12 common peripheral nerve surgeries were minimized using shorter incisions and a simple lighted retractor: zygomatico-temporal and auriculotemporal, greater occipital, brachial plexus, ulnar, radial, median, lateral femoral cutaneous nerve of the thigh, peroneal at the groin, fibular neck and lateral calf, and tibial and inner ankle. The new "minimal" incision length was recorded as was that of the "classical" approach as taught to the senior author and frequently represented in atlases. A Mann-Whiney analysis was independently performed to evaluate for significance between the lengths of incisions for each procedure. The average length of the "minimal" incisions was 3.9 ± 0.6 cm (range, 3.1-6.1 cm), with an average reduction in length of 51% as compared with the "classical" incisions (range, 30-75%; P < 0.001). There were no perioperative morbidities. Minimally invasive peripheral nerve surgery applied to the above procedures yields successful surgical outcomes while shortening incision lengths and maximizing patient satisfaction without sacrificing patient safety.

A New Technique of Expanding the Underdeveloped Scrotum

Sir: Absence of testis often leads to underdevelopment of the scrotum. Tissue expanders1 stretch the underdeveloped scrotum to accommodate a testicular prosthesis. Disadvantages are the need for a second operation, the use of an implant with the risk of infection, the inflation time, repeated visits, and punctures to inflate the expander. A self-inflatable device overcomes these disadvantages. In 1982,2 a self-inflating model was introduced based on a silicone balloon filled with a hyperosmotic fluid, later replaced by hydrogel in 2000,3 commercialized as the OSMED expander (OSMED GmbH, Hartheim, Germany). The expander absorbs body fluids, leading to gradual swelling, providing a predetermined volume and size. The use of an osmotic expander for this indication has never been described before. A 17-year-old boy with bilateral cryptorchidism was treated earlier with bilateral orchidopexy and later with orchidectomy on the right side and scrotal fixation on the left side. The left testis atrophied. Placement of a testicular prosthesis failed. At examination, the testicular implant was fixed in the right inguinal region, with an underdeveloped scrotum without palpable testis (Fig. 1).Fig. 1.: Preoperative situation: migrated testicular prosthesis on the right side and shriveled underdeveloped empty scrotum.A large pocket was created under general anesthesia by an incision high on the scrotal sac. The OSMED rectangular expander with a final volume of 200 ml was inserted. The pocket was closed using a purse-string suture to prevent migration. Drains were not used. The migrated testicular prosthesis was removed. The patient was discharged to home on the first postoperative day. No infection or wound dehiscence, discomfort, or pain was observed at follow-up. Maximum expansion was achieved after 4 weeks, with explantation after 40 days. Two 5-cm testicular implants were fixed at the bottom of the pouch. A 4-month follow-up showed no adverse effects, with a satisfactory result (Fig. 2).Fig. 2.: Satisfactory result after 4 months.By expanding the scrotal tissue, additional scarring from multiple procedures in the past was overcome, providing adequate scrotal soft-tissue coverage. Tissue expansion does not alter the contractility or expansion of the scrotal wall in response to ejaculation, cold, or warmth. Disadvantages of traditional expanders are implant leakage, because of the great mobility of the scrotum, and the need for fillings, risking iatrogenic infections.4 The position of the valve can be troublesome because of the great mobility and limited space. Osmotic expanders overcome many of these disadvantages. The small size of the device reduces operative time, requiring a short incision.5 The final volume of the osmotic expander is defined accurately, facilitating surgical planning. The inflation process is uncontrollable, which can be troublesome in causing, for example, skin ischemia or pain. In our patient, the inflation progress was gradual, without pain or discomfort even at full expansion. At 4-month follow-up, no adverse effects were observed. The testicular prosthesis did not migrate or override and had an aesthetically pleasing result. Scrotal tissues responded well with contraction to cold and relaxation after warm stimuli. In conclusion, we can say that the use of an osmotic expander for expanding the underdeveloped scrotum is a safe, reliable, and easy technique that brings important advantages over the use of traditional expanders. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Gregory P. A. Van Eeckhout, M.D. Bert Vanmierlo, M.D. Marc Kioe A. Sen, M.D. Paul Wylock, M.D. Department of Plastic, Reconstructive, and Aesthetic Surgery Johan Braeckman, M.D. Department of Urology Universitair Ziekenhuis Brussel Brussels, Belgium

A Transthoracic, Left Ventricular Vent Facilitates Challenging Sternal Reentry

In this brief report, we describe a technique to facilitate hypothermic arrest before a redo sternotomy that is likely to require extensive dissection. This approach may be well-suited for patients with significant aortic insufficiency, as it allows control of left ventricular distention once hypothermic ventricular fibrillation ensues. The procedure entails inserting a second venous cannula through the left ventricular apex through a 7-cm left mini-thoracotomy. We used the technique successfully in a patient with a ruptured, infected ascending aortic pseudoaneurysm and severe aortic insufficiency who had undergone a previous sternotomy.