Plastic Surgery Techniques Research Articles

Erratum to: Oncoplastic Breast-Conserving Surgery for Tumors Larger than 2 Centimeters: Is it Oncologically Safe? A Matched-Cohort Analysis.

Background Oncoplastic surgery is a well-established approach that combines conserving treatment for breast cancer and plastic surgery techniques. Although this approach has been described for T2 tumors, no long-term oncologic follow-up and no comparison with patients undergoing mastectomy has been published. The purpose of the study was to demonstrate that oncoplastic surgery is a safe and reliable treatment for managing invasive primary T2 breast cancer.

Oncoplastic Breast-Conserving Surgery for Tumors Larger than 2 Centimeters: Is it Oncologically Safe? A Matched-Cohort Analysis

Oncoplastic surgery is a well-established approach that combines conserving treatment for breast cancer and plastic surgery techniques. Although this approach has been described for T2 tumors, no long-term oncologic follow-up and no comparison with patients undergoing mastectomy has been published. The purpose of the study was to demonstrate that oncoplastic surgery is a safe and reliable treatment for managing invasive primary T2 breast cancer. We compared a consecutive series of 193 T2 patients who have undergone oncoplastic surgery (study group) with 386 T2 patients who have undergone mastectomy (control group). The endpoints evaluated were disease-free survival (DFS), overall survival (OS), cumulative incidence of local recurrence (CI-L), regional recurrence (CI-R), and distant recurrence (CI-D), all measured from the date of surgery. Median follow-up is 7.4years. The OS is similar within the two groups: 87.3 and 87.1% at 10years in the ONC group and control group, respectively (p value, adjusted for multifocality and tumor size, 0.74). Also, the DFS is similar in both groups: 60.9 and 56.3% at 10years in the ONC group and control group, respectively. The incidence of local events is slightly higher in the oncoplastic group, whereas the incidence of regional events is slightly higher in the mastectomy group. These differences are not statistically significant. The cumulative incidence of distant events is similar within the two groups. To our knowledge, the present study provides the best available evidence to suggest that oncoplastic approach is a safe and reliable treatment for managing invasive pT2 breast cancers.

Autologous tracheal replacement for cancer.

Surgical research has failed during fifty years to find an ideal substitute for the trachea after extended resection. All the prostheses could erode the adjacent structures or lead to infection or obstructive issues. Innovation in surgery development has been improved using novel techniques of plastic surgery. During the last ten years, we have developed a technique using free fasciocutaneous flaps. This allows us to construct tubes for tracheal replacement. The most accurate flap used for this technique is the forearm free flap (FFF). Reinforcement of the flap with autologous strips of cartilage harvested from the last ribs offers sufficient resistance to respiratory pressure. This technique is also completely autologous without any stent in the tracheal lumen. From 2004 to 2015 we have already reconstructed the trachea of 16 patients for 12 primary tracheal neoplasms [including 9 adenoid cystic carcinoma (ACC) and 3 squamous cell carcinoma (SCC)], 3 secondary tracheal Neoplasms and one for benign lesion. This article describes the indications, determination of resectability, patient selection, subheading for surgery, postoperative management and results of this technique.

Plastic Surgery in the Multimodal Treatment Concept of Soft Tissue Sarcoma: Influence of Radiation, Chemotherapy, and Isolated Limb Perfusion on Plastic Surgery Techniques.

Surgical intervention is the mainstay treatment for soft tissue sarcomas (STSs). The significance of adjuvant and neoadjuvant therapies, such as chemotherapy, radiation, and isolated limb perfusion, remains under controversial discussion. The goal of this review is to discuss the effects of the aforementioned treatment modalities and their timing of application in plastic surgery techniques. Furthermore, options of reconstruction in cases of complications caused by adjuvant and neoadjuvant therapies are discussed. When compared with adjuvant radiation, neoadjuvant treatment can reduce negative side effects such as fibrosis and edema because radioderma can be removed during the subsequent surgical procedure. Furthermore, there have not been any reports of negative effects of neoadjuvant radiation on microsurgical procedures. However, the dose of neoadjuvant radiation correlates with increased risks of impaired wound healing postoperatively. Thus, a patient-specific approach to decide whether radiation should be performed adjuvant or neoadjuvant is necessary. Preoperative irradiation should be considered in cases where functional structures are exposed after tumor resection, in order to ensure the best possible functionality. Adjuvant radiation should be considered in all other cases because of its known superior wound healing. As for chemotherapy, no negative influence of its use adjuvant or neoadjuvant to reconstructive procedures, such as local or free flaps, has been reported. Lastly, small sample size studies have not shown increased risks of microsurgical failure or wound complications after isolated limb perfusion. The findings of this review suggest that the chronological order of the discussed therapeutic approaches is not a decisive factor in the surgical outcome of reconstructive procedures for STS.

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

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. 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. 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. 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). 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.

Emergency repair of the facial soft tissue injuries with plastic surgery

Objective To investigate the effect of cosmetic surgery on the facial soft tissue injuries. Methods The clinical data of 52 patients with facial soft tissue injuries from June 2013 to June 2014 were analyzed retrospectively. And plastic surgical techniques were applied to the early treatment of facial soft tissue injuries in patients, according to the size of defect and the degree of deformity of the patients, different plastic surgery treatment was chosen, such as skin flap or skin graft to repair wound surfaces. In this process, one must follow sterile noninvasive principle strictly with emphasis on the technique of plastic surgery such as entire debridement, wound healing application of skin flap and so on. Results Total 49 cases of facial soft tissue injuries were healed by first intention without significant complications, while 4 cases of them had mild scars. Absorbable suture exposition appeared in 3 patients after primary healing. Those sutures were romoved after disinfected and no sequelaes were happened. All patients were recovered with good appearances and functions to the most exent. Conclusions The treatment of facial soft tissue injuries, by applying plastic and aesthetic surgery, could reduce scar and postoperative deformity, and secondary corrective procedures can be avoided in most patients. Key words: Soft tissue injury; Facial; Emergency; Repair; Plastic surgery

Building Orthopaedic Trauma Capacity: IGOT International SMART Course.

Orthopaedic injuries from trauma are increasingly common in Low to Middle Income Countries secondary to the increase in road traffic. These injuries commonly contain a soft tissue component, which complicates treatment of bony injuries and increases amputation rate. Specialized care using plastic surgery techniques is required to effectively treat these injuries. Historically medical mission models have been used to provide specialists to help provide soft tissue coverage where plastic surgeons are not available. This type of care is inherently unsustainable. We present an approach where a course was designed to teach soft tissue coverage techniques to orthopaedic surgeons. The course was given annually over 5 years, serving approximately 300 participants. Data collected from participants demonstrated that they found the course useful, learned techniques that allowed them to care for patients, and disseminate the knowledge further. Participants endorsed that they had performed 594 flaps with a 93% success rate at 1 year of follow-up from the course. We find that this type of intervention has the potential to address the need for soft tissue coverage in countries where this need is present, and resources are unavailable.

Minimally Invasive Approach to Achilles Tendon Pathology

Many surgical procedures have been described for Achilles tendon pathology; however, no overwhelming consensus has been reached for surgical treatment. Open repair using a central or paramedian incision allows excellent visualization for end-to-end anastomosis in the case of a complete rupture and detachment and reattachment for insertional pathologies. Postoperative wound dehiscence and infection in the Achilles tendon have considerable deleterious effects on overall functional recovery and outcome and sometimes require plastic surgery techniques to achieve coverage. With the aim of avoiding such complications, foot and ankle surgeons have studied less invasive techniques for repair. We describe a percutaneous approach to Achilles tendinopathy using a modification of the Bunnell suture weave technique combined with the use of interference screws. No direct end-to-end repair of the tendon is performed, rather, the proximal stump is brought in direct proximity of the distal stump, preventing overlengthening and proximal stump retraction. This technique also reduces the suture creep often seen with end-to-end tendon repair by providing a direct, rigid suture to bone interface. We have used the new technique to minimize dissection and exposure while restoring function and accelerating recovery postoperatively.

Place de l’oncoplastie dans la prise en charge des carcinomes canalaires in situ

DCIS (Ductal carcinoma in situ) constitutes 15,2% of breast cancers. Conservative surgery coupled with adjuvant radiotherapy is often recommended. The rate of revision surgery is high, from 30 to 60%. The concern is a high quality resection within clear margins with a satisfactory aesthetic result. The objective of this review is to precise the place of oncoplastic surgery in DCIS care. Among risk factors of recurrence, tumoral invasion of surgical margins is capital. In histology, clear margins usually adopted for DCIS are 2mm, even though there is no international consensus. Recent studies show that a 10mm limit would be better. Aesthetic damage caused by surgery, often increased by radiotherapy, has a negative impact on women quality of life : oncoplastic surgery may minimize it. Techniques of plastic surgery, arranged into level 1 and 2, allow pushing back conservative treatment limits by removing a larger tumor with clear margins. Often used in invasive cancers, few data exist regarding oncoplastic surgery and DCIS. It allows to increase the dimensions of surgical resection by 20% and to decrease positive margins significantly therefore the rate of revision surgeries. Patients are satisfied with it. Specific indications need to be clarified according to age, size and “comedonecrosis” presence. Oncoplastic surgery should be developed in DCIS specific care.

Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas

Urogenital fistulas are devastating complications occurring after tumors or trauma. Surgical treatment is challenging. Thus, further surgical repair options are needed for treatment of complex fistulas within the pelvic region. Twelve patients with urogenital fistulas were surgically treated in our department from 2004 to 2012. These selected cases fulfilled eligibility criteria for continence-preserving surgery - a history of fistula recurrences with ongoing incontinence after receiving at least two surgical attempts. Five VRAM and eight gracilis flaps were used to cover up given tissue defects and to perform functional continence-preserving reconstruction with mean follow-up of 6.3 years. Data were retrospectively reviewed, and standardized survey was performed to evaluate quality of life of all living patients (n = 10). In all cases, final surgical treatment of the given fistulae by VRAM or gracilis flaps could be achieved, with mean operating time of 5:31 h (range: 4:50-6:48 h) for VRAM flap and 3:11 h (range: 2:04-4:42 h) for gracilis flap. Outcome measures were primarily to avoid fistula recurrence after plastic surgical treatment, and secondary quality of life and survival. All patients had their continence preserved, but two patients died during follow-up period. Postoperative assessment revealed the following: VRAM flap patients (n = 3) showed slight incontinence during the follow-up period, whereas continence was restored in all patients with gracilis flap reconstruction (n = 7). Quality-of-life assessment indicated restoration of quality of life in comparison to general population (women > men). Furthermore, key points of the two presented surgical techniques are demonstrated in detail. With preformed VRAM or gracilis flaps, complex urogenital fistulas can be successfully eradicated and continence is restored. The main focus should be the recovery of quality of life, which could be successfully regained. Nevertheless, the continence success rate has to be defined on an individual, case-by-case basis. Original work, cohort study level III.

How You Become Who You Are: A New Concept of Beauty for Plastic Surgery.

The search for beauty and its value has been a discussion topic since the ancient Greeks composed their myths. The advent of safer and more advanced modern plastic surgery techniques and the spread of aesthetic medicine have renewed the search for beauty. Today, beauty seems possible, accessible, and more democratic than ever before [1]. To be beautiful is going to become an imperative, and from this standard, new and more subtle discriminations will arise: natural beauty will become more precious than artificial beauty, so that naturally beautiful bodies are privileged [2]. With regard to clinical practice, one of the most fundamental and interesting questions in aesthetic surgery is whether an objective indication exists for such procedures.

The intraoral anastomosing technique in reconstructive surgery of the face – A consecutive case series of 70 patients

New techniques in microvascular flap transfer result in new indications for reconstructive treatment of facial defects. In this study, the indications and success rate of an intraoral anastomosing technique in facial reconstruction were examined. Seventy patients with intraoral defects or central midface defects were reconstructed with the use of microvascular flaps. Anastomoses were performed by an intraoral anastomosing technique. Indications for the use of this technique, types of flaps, complications and problems were evaluated. Except for 5 reconstructions, all were performed to correct bone defect coverage of the jaws. All anatomising procedures worked without severe intraoperative problems. There was one total flap loss caused by venous congestion, and two partial losses not associated with the anastomosing technique. There were no other complications or problems. The main indications for the use of intraoral anastomosing techniques are alveolar ridge reconstruction in patients with defects not caused by a malignant tumour and central midface reconstruction in the case of short flap pedicle. The success rate of the intraoral anastomosing technique is similar to that of extraoral techniques reported in the literature.

Functional and Therapeutic Indications of Liposuction: Personal Experience and Review of the Literature.

Liposuction is the most common cosmetic surgical procedure worldwide. It has evolved from being designed primarily for body contouring to becoming essential adjunct to various other aesthetic procedures, greatly enhancing their outcome. Despite its hard clear differentiation between an aesthetic and therapeutic indication for some pathologic conditions, liposuction has been increasingly applied to a gamut of disorders as a therapeutic tool or to improve function. In fact, liposuction has ceased to define a specific procedure and became synonymous to a surgical technique or tool same as the surgical knife, laser, electrocautery, suture material, or even wound-dressing products. At present, there seems to be an enormous potential for the application of the basic liposuction technique in ablative and reconstructive surgery outside the realm of purely aesthetic procedures. The present review contemplates the various nonaesthetic applications of liposuction, displaying the enormous potentials of what should be considered a basic surgical technique rather than a specific aesthetic procedure. Implications of this new definition of liposuction should induce third-party public payers and insurance companies to reconsider their remuneration and reimbursement policies.

Ptosis: An Underestimated Complication after Autologous Fat Injection into the Upper Eyelid.

Autologous fat injection into the upper eyelid is a commonly used technique in plastic surgery for volume restoration. However, ptosis, as one of the potential complications of the procedure, has been less well-discussed than other complications. To present five cases of ptosis after autologous fat injection for the correction of sunken eyelid deformity and explore its causes. In this retrospective, non-comparative, and interventional case series, we identified five patients with ptosis. All patients had a history of previous autologous fat injection into the upper eyelid, performed by different plastic surgeons. Preoperative, intraoperative, and postoperative photographs were taken to analyze the causes of ptosis. Five patients developed ptosis after autologous fat injection for upper eyelid augmentation and were referred to our group for treatment. Three of the patients had received two injections of autologous fat each. Grafted fat removal with or without levator aponeurosis advancement was required in all five cases. Ptosis can develop following autologous fat injection into the upper eyelid. Surgeons should be aware of this complication, which rarely manifests during the procedure itself. Techniques for performing autologous fat injection and knowledge of upper eyelid anatomy should be refined to avoid postprocedural ptosis. 5 Risk.

Design and preliminary testing of a novel skin expander for total ear reconstruction in a rabbit model

BackgroundEar reconstruction is one of the most complicated and challenging techniques in plastic surgery because of the histologic and anatomic properties of the ear. Success depends on fitting the auriform cartilage scaffold into the overlying skin, but current approaches can just give results that are not lifelike and can lead to complications. Materials and methodsA novel double-capsule, double-valve plastic ear expander was designed and implanted subcutaneously on either side of the dorsum of six New Zealand white rabbits (two expanders per rabbit). The outer capsule was expanded by injecting approximately 120 mL of physiological saline, then withdrawing the liquid on two occasions. Next, the ear-shaped inner capsule was filled with high-hardness plaster, and the external capsule was emptied such that the expanded skin flap and external capsule responded to the negative pressure and closed over the ear-shaped inner capsule. As a result, the skin flap adopted an ear shape. The ear expander was left in place for 4 wk, removed with the help of a mini-incision, and stripped of its fibrous capsule. To simulate human ear reconstruction, the expander was replaced with an auriform silicone prosthesis, and the effects of auricular reconstruction were observed dynamically. ResultsAll 12 skin flaps maintained abundant blood supply, created a clear outline of the ear framework, and produced a lifelike result. No complications were observed during the 4-wk observation period. ConclusionsThe expanded skin flaps described here can mold to the desired contours and appear lifelike, as well as maintain abundant blood supply. This may provide a simpler approach to total ear reconstruction that reduces risk of complications.

Introduction to conservative mastectomies.

Conservative mastectomy (CM) has become an established alternative in the treatment of breast cancer, offering by different techniques a good cosmetic outcome, as well as oncologic control. The different options to achieve these goals are presented. Oncoplastic treatment of breast cancer needs planning and knowledge of well-established plastic surgery techniques.

Local Skin Warming Enhances Color Duplex Imaging of Cutaneous Perforators

The perforator flap is one of the most useful techniques in reconstructive surgery. The operative procedure for these flaps will be greatly simplified if accurate localization of the course of the perforator can be preoperatively confirmed. However, small vessels with diameters less than 0.5 mm cannot be readily traced with conventional imaging techniques. Local skin warming temporarily increases cutaneous blood flow and vasodilation. In this study, we established a local skin warming procedure, and performed this before color duplex imaging to improve preoperative perforator mapping and enable precise flap design.

La gingivopériostoplastie avec substitut osseux : technique et premiers résultats

Ortho dontico-surgical coverage of alveolar crack is essential in reason of its repercussions on facial growth and implementation of children's teeth set. We proposed to realize a premature gingivo periosto plastic surgery from 4 years old by osseous substitute to lower age of alveolar cracks closure and decrease the morbidity of patients. We conducted a retrospective study over one year (January, 2012 to December, 2012), with six months postoperatively outcomes, on 23 cases of gingivo periosto plastic sugary with osseous substitute type glass by bone transplant at infantile plastic surgery service of Timone-Children teaching hospital of Marseille, France. We held 23 patients. Seventeen children, 12 boys and 5 girls presented unilateral cracks. Twenty patients required a quantity of glass bone under 1cc for the narrow cracks. Prevalence of the mucous cracks was low (4 cases on 23). Technique of gingivo periosto plastic surgery with osseous substitute is simple and our results are globally satisfactory. We observed less morbidity of the operating site. The first results of this study showed that gingivo periosto plastic surgery with osseous substitute glass bone is a simple, reliable and reproducible technique, with promising results. Reduction of site's morbidity by osseous transplant, accessibility of glass bone cost and simplicity of surgical gesture justified adoption of this technique.

Minimally invasive management of urological fistulas.

Urological fistulas are an underestimated problem worldwide and have devastating consequences for patients. Many urological fistulas result from surgical complications and/or inadequate perinatal obstetric healthcare. Surgical correction is the standard treatment. This article reviews minimally invasive surgical approaches to manage urological fistulas with a particular emphasis on the robotic techniques of fistula correction. In recent years, many surgeons have explored a minimally invasive approach for the management of urological fistulas. Several studies have demonstrated the feasibility of laparoscopic surgery and the reproducibility of reconstructive surgery techniques. Introduction of the robotic platform has provided significant advantages given the improved dexterity and exceptional vision that it confers. Fistulas are a concern worldwide. Laparoscopic surgery correction has been developed through the efforts of several authors, and difficulties such as the increased learning curve have been overcome with innovations, including the robotic platform. Although minimally invasive surgery offers numerous advantages, the most successful approach remains the one with the surgeon is most familiar.

Valve reconstructions.

The history of venous valve reconstruction extends back to 1968 when Robert L Kistner performed the first internal valve plasty to treat deep venous axial reflux. Throughout the past 50 years other techniques of reconstructive deep venous surgery (RDVS) were developed, not only to repair but also to replace venous valves. And the fact that several surgeons and centers have undertaken RDVS in the treatment of chronic venous insufficiency (CVI) reporting outcomes, has added knowledge to define more clearly the role of this kind of specialized surgery. Patients who may benefit from RDVS are among those where conventional treatment with compression stockings combined with superficial surgery has failed. Ulcer-healing rates of up to 70% have been reported after RDVS and ulcer-free periods of up to 36 months have been generated. But during five-year follow-up, freedom from ulceration period and clinical improvement rates were reduced significantly. This raises then the issue and challenge of durability of RDVS since the average age of patients who can benefit from it is about 50 years.