A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis.

BACKGROUND: Invasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. METHODS: Relevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. RESULTS: A total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. CONCLUSION: An early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes. PROSPERO registration: CRD42023415574.

Safety and feasibility of rotational atherectomy (RA) versus conventional stenting in patients with chronic total occlusion (CTO) lesions: a systematic review and meta-analysis.

BACKGROUND AND AIM: Interventional cardiologists face challenges in managing chronic total occlusion (CTO) lesions, with conflicting results when comparing rotational atherectomy (RA) to conventional PCI. This meta-analysis aims to provide a critical evaluation of the safety and feasibility of RA in CTO lesions. METHODS: PubMed, Scopus, Web of Science, Ovid, and Cochrane central library until April 2023 were searched for relevant studies. MACE was our primary outcomes, other outcomes were all cause of death, cardiac death, MI, and TVR. Also, we reported angiographic outcomes as technical success, procedural success, and procedural complications in a random effect model. The pooled data was analyzed using odds ratio (OR) with its 95% CI using STATA 17 MP. RESULTS: Seven studies comprising 5494 patients with a mean follow-up of 43.1 months were included in this meta-analysis. Our pooled analysis showed that RA was comparable to PCI to decrease the incidence of MACE (OR = 0.98, 95% CI [0.74 to 1.3], p = 0.9). Moreover, there was no significant difference between RA and conventional PCI in terms of other clinical or angiographic outcomes. CONCLUSION: Our study showed that RA had comparable clinical and angiographic outcomes as conventional PCI in CTO lesions, which offer interventional cardiologists an expanded perspective when addressing calcified lesions. PROSPERO REGISTRATION: CRD42023417362.

Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis.

Background Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm 2 . Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.

Cone-beam computed tomography-based radiographic considerations in impacted lower third molars: Think outside the box.

Purpose: This study aimed to evaluate the anatomic circle around the impacted lower third molar to show, document, and correlate essential findings that should be included in the routine radiographic assessment protocol as clinically meaningful factors in overall case evaluation and treatment planning. Materials and Methods: Cone-beam computed tomographic images of impacted lower third molars were selected according to specific inclusion criteria. Impacted teeth were classified according to their position before assessment. The adjacent second molars were assessed for distal caries, distal bone loss, and root resorption. The fourth finding was the presence of a retromolar canal distal to the impaction. Communication with the dentist responsible for each case was done to determine whether these findings were detected or undetected by them before communication. Results: Statistically significant correlations were found between impaction position, distal bone loss, and detected distal caries associated with the adjacent second molar. The greatest percentage of undetected findings was found in the evaluation of distal bone status, followed by missed detection of the retromolar canal. Conclusion: The radiographic assessment protocol for impacted third molars should consider a step-by-step evaluation for second molars, and clinicians should be aware of the high prevalence of second molar affection in horizontal and mesioangular impactions. They also should search for the retromolar canal due to its associated clinical considerations.

Unipolar Latissimus Dorsi Transfer for Restoration of Elbow Flexion in Residual Post-traumatic Brachial Plexus Palsy Associated with Distal Humeral Fractures.

Introduction Elbow flexion is indispensable for both functioning and nonfunctioning hands. It is well perceived that restoration of elbow function is the first reconstructive priority in cases of brachial plexus injuries. The authors assessed the impact of associated distal humeral fractures on the functional outcome after unipolar latissimus dorsi transfer (ULDT) for restoration of elbow flexion in patients with residual brachial plexus palsy (BPP). Patients and Methods Twenty-three patients operated for restoring elbow flexion after residual post-traumatic BPP (with or without distal humeral fracture) by unipolar latissimus dorsi transfer (ULDT) were reviewed for a retrospective study. Patients were divided into two groups; associated distal humeral fracture group (HF-group; 10 patients) and non-associated distal humeral fracture group (NHF-group; 13 patients). Elbow flexion active range of motion (AROM), flexion deformity in addition to Mayo Elbow Performance Score (MEPS) were assessed. Results In both groups there were statistically better postoperative MEPS grading ( p = 0.007, p = 0.001 , respectively) and scoring with a mean of 81 ± 16.1 and 90 ± 4.6, respectively ( p < 0.001). The mean postoperative elbow flexion AROM was statistically better in both groups. The mean supination AROM was better in NHF group ( p = 0.057). Conclusion The use of ULDT in residual post-traumatic BPP is an efficient procedure in regaining functional flexion and supination. An associated distal humeral fracture does not significantly affect the final functional outcome. Level of Evidence Level IV.

Experimental study of the effects of nitroglycerin, botulinum toxin A, and clopidogrel on bipedicled superficial inferior epigastric artery flap survival.

Beneficial effects could be achieved by various agents such as nitroglycerin, botulinum toxin A (BoTA), and clopidogrel to improve skin flap ischaemia and venous congestion injuries. Eighty rats were subjected to either arterial ischaemia or venous congestion and applied to a bipedicled U-shaped superficial inferior epigastric artery (SIEA) flap with the administration of nitroglycerin, BoTA, or clopidogrel treatments. After 7 days, all rats were sacrificed for flap evaluation. Necrotic area percentage was significantly minimized in flaps treated with clopidogrel (24.49%) versus the ischemic flaps (34.78%); while nitroglycerin (19.22%) versus flaps with venous congestion (43.26%). With ischemia, light and electron microscopic assessments revealed that nitroglycerin produced degeneration of keratinocytes and disorganization of collagen fibers. At the same time, with clopidogrel administration, there was an improvement in the integrity of these structures. With venous congestion, nitroglycerin and BoTA treatments mitigated the epidermal and dermal injury; and clopidogrel caused coagulative necrosis. There was a significant increase in tissue gene expression and serum levels of vascular endothelial growth factor (VEGF) in ischemic flaps with BoTA and clopidogrel, nitroglycerin, and BoTA clopidogrel in flaps with venous congestion. With the 3 treatment agents, gene expression levels of tumor necrosis factor-α (TNF-α) were up-regulated in the flaps with ischemia and venous congestion. With all treatment modalities, its serum levels were significantly increased in flaps with venous congestion and significantly decreased in ischemic flaps. Our analyses suggest that the best treatment option for ischemic flaps is clopidogrel, while for flaps with venous congestion are nitroglycerin and BoTA.

Virtual planning of the anterolateral thigh free flap for heel reconstruction.

PURPOSE: three dimensional (3-D) virtual planning is an example of computer assisted surgery that improved management of composite tissue defects. However, converting the 3-D construct into two dimensional format is challenging. The purpose of this study was to assess 3-D virtual planning of complex heel defects for better optimized reconstruction. PATIENTS AND METHODS: a prospective analysis of 10 patients [9 male and 1 female; mean age = 27.9 years] with post-traumatic heel defects was performed. Heel defects comprised types II (three patients) or III (seven patients) according to Hidalgo and Shaw and were managed using anterolateral thigh (ALT) free flap adopting 3-D virtual planning of the actual defect which was converted into a silicone two dimensional mold. The mean definitive size of the defects was 63.4 cm3 . Functional, aesthetic, and sensory evaluations of both donor and recipient sites were performed 1 year after surgery. RESULTS: Six patients received thinned ALT (mean size = 139 cm3 ) while four patients received musculofasciocutaneous ALT flap (mean size = 199 cm3 ). One flap exhibited partial skin flap necrosis. Another flap was salvaged after re-exploration secondary to venous congestion. The mean follow-up was 20.2 months. The Maryland foot score showed 4 excellent, 5 good, and 1 fair cases. The mean American Orthopedic Foot and Ankle hind foot scoring was 76.3 (range: 69-86). All patients regained their walking capability. CONCLUSIONS: 3-D virtual planning of complex heel defects facilitates covering non-elliptical defects while harvesting a conventional elliptical flap with providing satisfactory functional outcomes and near-normal contour, volume, and sensibility.

Management of Vasopressor-Induced Acute Limb Ischemia (VIALI) in Septic Shock.

Vasopressors used in critically ill patients with refractory shock poses a serious risk of non-occlusive peripheral limb ischemia leading to tissue necrosis and amputation. Acute limb ischemia is associated with high morbidity and mortality. Evidence-based medical literature is scarce on the prevention and management of vasopressor-induced acute limb ischemia (VIALI). Despite being a well-known and frequent complication of vasopressors, there is no standardized guideline for the prevention and management of vasopressor-induced limb ischemia. Vasopressors are required for the management of refractory shock which is defined as hypotension not responsive to intravenous fluid resuscitation alone. Distributive shock, which includes septic shock, causes inadequate tissue perfusion in adjunct with vasopressor use and is the most common cause of non-occlusive peripheral limb ischemia. This case study will focus on how early recognition and prompt treatment of VIALI are crucial in minimizing tissue necrosis and preventing amputations. We present a case of a middle-aged woman who developed distributive shock from sepsis of a urinary source secondary to obstructive uropathy (ureteral calculi). She presented with refractory shock and continued to remain in shock while undergoing emergent rigid cystoscopy with the placement of a ureteral stent. Despite adequate volume resuscitation, she required high doses of vasopressors resulting in peripheral extremity ischemia and necrosis of all her fingers and toes. By promptly initiating mitigation and preventive management strategies, we succeeded in minimizing tissue ischemia and reducing morbidity resulting from iatrogenic vasopressor-induced peripheral non-occlusive ischemia. These strategies include but are not limited to external warming of bilateral lower extremities, nitroglycerin paste application over the entire extremity, arterial assist pump, and low-dose therapeutic anticoagulation. The novel use of the arterial pump in acutely ischemic lower extremities likely helped salvage the toes which appeared to be at high risk of amputation.

A Huge Carotid Space Schwannoma Arising from The Cervical Sympathetic Chain - A Case Report.

THE RATIONALE: Although 25%-45% of schwannomas are originating from the neck, carotid space schwannomas are extremely rare. PATIENT CONCERNS: We report a rare case of huge-sized schwannoma in a 20-year-old student who presented with a symptomless large carotid space mass. DIAGNOSIS: Cervical magnetic resonance imaging (MRI) with contrast revealed a huge, well-defined mass measuring 13.7 cm × 6.4 cm × 4.1 cm. Cervical MRI along with brain MRI were consistent with neurofibromatosis type II. TREATMENT AND OUTCOMES: Preoperative tracheostomy and wide local excision of schwannoma via a transcervical approach were performed with nerve preservation. TAKEAWAY LESSONS: The scarceness of cervical sympathetic chain schwannoma made this case of our patient very interesting to report. Moreover, our patient's huge tumour size is extremely rare, and we could not find any similar cases in the literature.

Assessment of Freestyle Local Facial Perforator Flaps for Coverage of Facial Defects.

OBJECTIVE: To assess local freestyle facial perforator flaps in the reconstruction of small to medium-sized facial defects. MATERIALS AND METHODS: In a case series, local freestyle perforator flaps were used in Suez Canal University Hospital to reconstruct 28 facial defects in 26 patients between 2017 and 2019. Adequate perforators were identified near those defects and flaps were designed as propeller or VY advancement. Four scales from the FACE-Q (satisfaction with facial appearance, satisfaction with the outcome, psychological function, and appearance-related psychosocial distress) and 2 scales from the SCAR-Q (Appearance scale and Symptom scale) were used as well as the observer part of the Patient and Observer Scar Assessment Scale. The mean follow up period was 10 months. RESULTS: Complete reconstruction was achieved in all cases with a high rate of patient satisfaction which was assessed by FACE-Q and SCAR-Q. Moreover, observer assessment by Patient and Observer Scar Assessment Scale score showed high patient satisfaction with the scars with a mean (SD) 15.5 (3.4) and there was a positive correlation between subjective and objective: results (r2 from 0.27 to 0.41, P < 0.01). Regarding complications, bulkiness occurred in 2 flaps, congestion in 2 flaps, dehiscence in 1 flap, and tip necrosis in 5 flaps. Accordingly, secondary intervention in the form of medicinal leech therapy was used in 3 flaps, delayed closure for the dehisced flap and debulking for 1 flap. CONCLUSIONS: Local freestyle perforator flap reconstruction is one of the recommended techniques for small to medium-sized facial defects which gives a high aesthetic outcome and patient satisfaction.

Aesthetic and functional outcomes of thinned anterolateral thigh flap in reconstruction of complex wounds of the upper limb.

We studied outcomes of reconstruction of complex upper limb wounds using thinned anterolateral thigh flaps. There were 18 patients with a mean age of 27.5 years. The mean thickness of the flap before and after thinning was 23 mm and 5 mm, respectively. Two patients had partial tip necrosis that was treated conservatively. Aesthetic and functional evaluations were performed using a 5-point Likert scale, QuickDASH score, passive range of motion and power grip at 12 months after surgery. The study showed good results in the aesthetic evaluation by a panel of plastic surgeons (mean score: 19.7) and patient self-assessment (mean score: 18.1). There was a significant correlation between the total scores of the panel and the patients. The mean QuickDASH score was 21, with a high percentage in the middle category 'had a problem but working'. The thinned anterolateral thigh flap is versatile and safe in upper limb reconstruction with good aesthetic and functional results.Level of evidence: IV.

Dual Reconstruction of Lumbar and Gluteal Defects with Freestyle Propeller Flap and Muscle Flap.

The reconstruction of complex tissue defects in the lumbar and gluteal areas is a surgical challenge. The use of freestyle perforator-based flaps has gained popularity in the reconstruction of these defects due to several advantages: versatility, minimal donor-site morbidity, and tension-free closure. The present study reports the outcome of using a dual coverage of lumbar and gluteal defects with a gluteus maximus rotation flap as a deep layer and a freestyle propeller perforator-based flap as a superficial layer. METHODS: A retrospective analysis of 18 patients who had a dual coverage of complex wounds of the lumbar and the gluteal areas was conducted. Different propeller flaps were used as superior gluteal artery perforator flap (SGAP), inferior gluteal artery perforator flap (IGAP), and posterior thigh perforator flap (PTP). RESULTS: The study included 15 men and 3 women. The mean age was 26.3 years. The causes of the defects were: pressure ulcers in 14 patients and post-traumatic in 4 patients. A total of 28 freestyle flaps was used: 11 patients had 1 flap, 4 had 2 flaps, and 3 had 3 flaps. The mean postoperative follow-up was 12.2 months. The complications registered in the medical records were venous congestion in 2 patients, partial flap necrosis in 2 patients, and wound dehiscence in 1 patient. CONCLUSIONS: A freestyle propeller perforator-based flap combined with a gluteus maximus muscle flap is a solution that provides well-padding over bony prominence with a low complication rate. However, a long-term follow-up is needed to verify these results.

Comparison between long and lower medial head triceps branches in dual neurotization for shoulder function restoration in upper brachial plexus palsy.

PURPOSE: In upper brachial plexus injury (UBPI), restoring shoulder function is crucial. This study compares the transfer of long and lower medial heads of triceps branches to the axillary nerve to achieve proper restoration of function. PATIENTS AND METHODS: A retrospective comparative study was conducted between two groups of patients with (UBPI). Group I patients (10) [mean age: 19 ± 10.6 years] were managed by transferring triceps long head branch to axillary nerve while group II patients (8) [mean age: 26 ± 9.6 years] were managed by triceps lower medial head branch transfer. The mean time from injury to surgery was 6 ± 1.3 and 5 ± 1.7 months respectively. All patients were followed up for a minimum of 12 months with the assessment of VAS, DASH score, active range of motion (AROM) and strength of shoulder abduction and external rotation; in addition to shoulder endurance and strengths of donors. Postoperative, three-monthly, electrodiagnostic assessments were performed. RESULTS: Postoperatively, the mean VAS and DASH scores; in addition to endurance time, showed significant enhancement in both groups. Patients in both groups have accomplished a mean abduction (AROM) of 98° ± 27.9 and 97° ± 11.9 respectively. The mean external rotation (AROM) was 48° ± 18.4 and 47° ± 9.2 respectively. Furthermore, group II patients had less triceps morbidity in addition to earlier and enhanced electrophysiological recovery. CONCLUSIONS: Dual neurotization for shoulder function restoration in (UBPI) is capable of providing proper functional results with minimal donor morbidity. The triceps lower medial branch provides an excelling donor due to less triceps morbidity, extra length; yet, earlier and enhanced electrophysiological recovery.

Diabetic Mastopathy: Reporting an Unusual Scenario of a Rare Disease.

Diabetic mastopathy is a rare, benign breast disease that presents with fibrous breast lumps usually induced by the hyperglycemic state in diabetic patients and often associated with type 1 or 2 diabetes mellitus. Clinical and radiographic appearances are usually confusing and pathologic confirmation is essential for diagnosis mainly to rule out malignancy. However, a specialized breast pathologist often utilizes patient's history of diabetes as a guide to solve this diagnostic dilemma. We report a challenging scenario in which a case of diabetic fibrous mastopathy was pathologically identified with no previous given history of diabetes. This benign breast entity should be included in the differential diagnosis of breast lumps even without history of diabetes that may be overlooked before surgery.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction.

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Propeller Flaps of the Lower Extremity.

Wounds of the lower extremity involving the distal third of the leg remain a significant challenge due to anatomic location and often poor host physiology. Perforator-based propeller flaps may provide rapid coverage of these wounds with a relatively low rate of major complications and often readily managed minor complications. A thorough vascular evaluation must be performed prior to the procedure to ensure adequate flap design and selection of the correct perforator is performed. They have the added advantage over their soft tissue free flap counterparts in that they have significantly less host morbidity with similar rates of total necrosis.

Medial Plantar Artery Flap for Wound Coverage of the Weight-Bearing Surface of the Heel.

Covering soft tissue defects of the heel is particularly challenging because of the highly specialized functional units unique to the plantar fat pad and the shear and compressive forces experienced in this area. The medial plantar artery fasciocutaneous flap provides the unique ability to restore both sensation and the functional units to the plantar heel by taking tissue similar to that which was lost and relocating it from a non-weight-bearing portion of the foot, while maintaining minimal host morbidity. This provides a lasting solution and may prevent future ulcerations from occurring.

The Effects of Sildenafil and/or Nitroglycerin on Random-pattern Skin Flaps After Nicotine Application in Rats.

Smoking aggravates skin necrosis as a complication of random-pattern flap ischaemia. Sildenafil and nitroglycerin (NTG) are vasodilator agents that may affect skin flap survival. Fifty rats were subjected to a dorsal random-pattern flap operation and randomly divided into 5 groups. The control group received no treatment. The ischaemic group were administered local nicotine injections. The sildenafil group were administered oral sildenafil treatment in addition to the same intervention as the ischaemic group. The NTG group received topical NTG ointment application instead of sildenafil. The combined group were given both sildenafil and NTG treatments. After 7 days, all rats were sacrificed for flap assessment. Flap survival percentages at the 3rd and 7th days were significantly higher in the combined group than in the other study groups. Histologically, the ischaemic group exhibited dermal disorganization and inflammatory cell infiltration, which were improved in the 3 treated groups; however, the combined group presented the most relevant effect. The epidermal thickness showed a decrease in the ischaemic group (23.1 µm) that was significantly increased in the sildenafil (28.4 µm), NTG (28.8 µm) and combined (35.8 µm) groups. Immunohistochemically, the combined group exhibited a significant decrease in the apoptotic index and an increase in the proliferative index (2.3 and 56.9%, respectively) compared to those in the ischaemic (63.2 and 3%), sildenafil (41.7 and 28.1%) and NTG (39.3 and 30.4%) groups. Transmission electron microscopy (TEM) showed that the combined group displayed improvement in most of the ischaemic changes. Our analyses suggest that the combined use of sildenafil and NTG is more efficacious than using only one of these treatments for skin flap survival.

Single-Stage Immediate Breast Reconstruction Using Anatomical Silicone-Based Implant and The Hammock Technique of Dermal-Muscle Flap in Large and Ptotic breasts: A Multicenter Study.

BACKGROUND: This study revisits the previously described technique of inverted-T skin-reducing mastectomy and dermal-muscle pocket as a single-stage breast reconstruction using anatomical implants in large and ptotic breasts. Refinements have been added to enhance the quality of implant coverage, improve aesthetic outcome, and augment the implant volume than previously described in the literature. SUBJECTS AND METHODS: The study was performed in three centers in the UK, Egypt, and Libya. It included patients with large ptotic breasts with a breast cup size of D or larger. The areola-to-inframammary fold distance is of 8 cm or more, and a nipple-sternal notch distance is 25 cm or more. Modification of the dermal-muscle flap was made through dividing the medial and lateral ends of the de-epithelialized flap at a distance of one inch to create wings that could be sutured to the free edge of pectoralis major muscle to act as a hammock. RESULTS: It included 42 patients, and the mean age of the patients was 44.4 years (range 28-62). The mean body mass index was 34.2 (range 24-42). The reconstruction was unilateral in 32 (76.2%) patients and bilateral in ten (23.8%) patients. The average implant volume was 498.5 CC (range 375-650). Seventeen (40.5%) patients had a symmetrizing breast reduction. The average follow-up time was 52 weeks. Major complications were noticed in four (7.7%) breasts: Three breasts had major skin necrosis and one breast had hematoma that necessitated surgical evacuation. There were no reported cases of implant extrusion. Minor complications were recorded in six (11.5%) breasts; two had wound infection, and three had minor skin necrosis. CONCLUSION: The hammock technique of dermal-muscle flap is safe and versatile in large and ptotic breasts. It also creates a natural-looking breast with bigger implants.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.