Pressure sore incidence and treatment in left ventricular assist device (LVAD)-equipped patients: Insights from a prospective series.

INTRODUCTION: A left ventricular assistance device (LVAD) is indicated in patients with end-stage heart failure. Due to the non-physiologic blood flow, a LVAD may favor pressure sores with a devastating risk of infection. This work shows the prevalence and treatment of pressure sores in LVAD patients, to optimize their management. MATERIAL AND METHODS: We retrospectively investigated all LVAD implantations at the Lausanne University Hospital (CHUV) from 2015 to 2019. We detected patients who developed a pressure sore and evaluated the timeline, management, and outcomes. RESULTS: Forty-two patients benefited from LVAD, among whom 5 (12%) developed a stage III/IV pressure sore, within a mean time of 25 days. Due to their poor overall condition, 4/5 patients were treated surgically and 1/5 conservatively. Half of the patients treated with surgery had major complications requiring reoperation. After flap coverage, the mean time to healing for patients was 6 weeks. DISCUSSION: The rapid development of deep pressure sores seen in 12% of patients may be a manifestation of the maladaptive blood flow induced by LVADs, combined with their bedridden condition. Initial signs of pressure sores should be considered seriously, as they are rapidly evolving and needing an aggressive surgical treatment whenever possible (80%). Complication rate was similar compared to standard pressure sore flap treatment. All patients benefiting from flap surgery achieved effective coverage after a mean follow-up of 24 months. No patient developed a LVAD infection. CONCLUSION: Surgery must be considered early in this population to prevent potential device infection.

Drain Versus No Drain in Open Mesh Repair for Incisional Hernia, Results of a Prospective Randomized Controlled Trial.

BACKGROUND: Open mesh repair of incisional hernia is associated with different local complications, particularly bleeding and seroma formation. Traditionally, drains have been placed perioperatively to prevent these complications, despite the lack of scientific evidence or expert consensus. We formulated the hypothesis that the absence of drainage would reduce number of patients presenting collections or complications. The present study aimed to compare postoperative complication rates after open mesh repair for incisional hernia with or without prophylactic wound drainage. METHODS: Prospective randomized study using standardized surgical technique and drain placement. The primary endpoint was the evaluation of residual fluid collection with ultrasound on postoperative day 30. Other complications, subdivided into medical and surgical, were analyzed as secondary endpoints. RESULTS: There were 144 patients randomized (70 with drain, 74 without drain). No difference was identified between both groups for fluid collection at 30 days (60.3% vs. 62%, p = 0.844). However, less surgical complications were identified in the drain group (21.7% vs. 42.7%, p = 0.007), with a lower wound dehiscence rate (1.5% vs. 9.3%, p = 0.041). CONCLUSIONS: Prophylactic drainage in open incisional hernia repair does not objectively reduce the rate of postoperative fluid collections. Therefore, our results do not support the use of routine drainage in incisional hernia repair. TRIAL REGISTRATION: Trial registration on clinicaltrials.gov (NCT00478348).

Abdominal-based adipocutaneous advancement flap for reconstructing inguinal defects with contraindications to standard reconstructive approaches: a simple and safe salvage reconstructive option.

BACKGROUND: Groin wounds occurring after vascular surgical site infection, oncologic resection, or occasionally orthopedic surgery and trauma may represent a surgical challenge. Reconstruction of these defects by the usual workhorse flaps may be contraindicated following previous surgery and in patients with lower limb lymphedema or extreme morbidity. METHODS: This study included 15 consecutive patients presenting with inguinal wounds after vascular or general surgery that required debridement and soft tissue coverage. All cases had absolute or relative contraindications to conventional reconstructive techniques, including a compromised deep femoral artery network, limb lymphedema, scarring of potential flap harvesting sites, or poor overall condition. Abdominal adipocutaneous excess enabled the performance of adipocutaneous advancement flaps in an abdominoplasty-like fashion. Immediate and long-term outcomes were analyzed. RESULTS: Soft tissue coverage was effective in all cases. Two patients required re-intervention due to flap-related complications (venous congestion and partial flap necrosis). All patients fully recovered over a mean±standard deviation follow-up of 2.4±1.5 years. CONCLUSIONS: Abdominal flaps can be an effective and simple alternative technique for inguinal coverage with reproducible outcomes. In our experience, the main indications are a compromised deep femoral artery network and poor thigh tissue quality. Relative contraindications, such as previous open abdominal surgery, should be considered.

Lumbar Perforator Flaps for Coverage of Extensive Defects With Osteomyelitis.

INTRODUCTION: Lumbar osteomyelitis is a rare, although serious condition if not appropriately treated, potentially leading to neurologic complications, such as radiculopathy. Traditionally, studies have suggested the preferred use of muscle or myocutaneous flaps to prevent recurrent infections. However, late evidence suggests that radical debridement and dead space obliteration are more important than the type of flap. The lumbar perforator flap is a reliable local option with low donor site morbidity. It is a powerful tool for local trunk reconstruction, but its use in case of osteomyelitis is scarcely described. We aimed to report long-term outcomes of lumbar perforator flaps to cover lumbar soft tissue defects with chronic osteomyelitis. MATERIAL AND METHODS: This retrospective investigation was performed on a prospectively maintained database including 7 consecutive patients (10 flaps), all presenting extensive defects of the posterior midline at L2-S1 level (defect size 287 ± 136 cm [average ± SD]). Four patients presented defects after recurrent tumor resection, whereas in 2 patients, the defect was due to vascular jeopardy of internal iliac arteries with consequent necrosis. Last defect derived from debridement of a neglected wound in a paraplegic patient. All patients had concomitant bone infection. Infectious details and postoperative complications were recorded. RESULTS: Patients were in general poor medical condition (including peripheral arterial disease, hypertension, diabetes, or a combination of these). Eight flaps were raised as propeller perforator, whereas 2 as V-Y perforator. One propelled flap had venous congestion on postoperative day 1 and required a revision surgery to be converted to V-Y. Subsequent partial flap necrosis was treated conservatively. One patient presented a wound dehiscence that required surgical revision. All flaps were closed primarily except for 1 patient whose flap presented a mild intraoperative congestion, which was treated by delayed closure on postoperative day 6, with uneventful outcome. Time to complete healing was 29 ± 17 days (mean ± SD). No flap loss occurred, and all patients benefited from effective coverage at a mean follow-up of 20 months. CONCLUSIONS: Lumbar perforator flap is a reliable option to cover large soft tissue defects in the lumbar area despite chronic osteomyelitis, with low morbidity and acceptable cosmetic outcome.

Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients.

INTRODUCTION: The "traditional" method to perform vaginoplasty in male-to-female transgender surgery consists in inverting the penoscrotal skin into a surgically created cavity in the perineum between the rectum and the bladder creating a neovagina. To overcome the noteworthy disadvantage of lack of depth, the use of a rectosigmoid graft can be preferred over the penile skin inversion. AIM: The aim of this study was to compare 2 methods for vaginoplasty in male-to-female transgender surgery in regard of the functional and cosmetic long-term result. Additionally this study aims to understand key factors leading to secondary sigmoid vaginoplasty in patients with previous penile skin inversion. METHODS: This is a retrospective survey of outcomes and complications of 43 patients who underwent neovaginoplasty by the same senior surgeon, between 2007 and 2017. 13 patients underwent a secondary rectosigmoid neovagina later (30.2%). Moreover, we performed an aesthetic and functional evaluation on 28 patients (65%) at long-term follow-up. Mean follow-up was 32.6 ± 3.5 months (average ± SEM). Patients were also evaluated by a questionnaire to assess both aesthetic and functional (penetration, orgasm, and pain) outcomes. Statistical analysis was used to compare results between groups. MAIN OUTCOME MEASURE: Patient satisfaction was assessed by a questionnaire sent to all 43 patients and was made of 5 questions (Q1 to Q5) designed in a way to evaluate patient outcomes in terms of both functionality and cosmesis of the neovagina. RESULTS: Our findings showed that the use of a rectosigmoid graft in secondary cases significantly decreased sexual pain during intercourse. Both techniques had similar aesthetic and functional outcomes with mostly satisfied patients (no statistical significance). CLINICAL IMPLICATIONS: The use of sigmoid vaginoplasty could improve functional outcomes when compared to penile skin inversion vaginoplasty. STRENGTH & LIMITATIONS: This study strength is its retrospective nature conducted on a prospectively-maintained database limiting biases with 43 consecutive vaginoplasties, performed by the same surgeon. Relative limitation was that not all patients returned our questionnaire and, thus, only 65% of our patients were evaluated for satisfaction. CONCLUSION: This study reports long-term outcomes in transgender surgery using 2 different techniques for neovagina creation. The use of sigmoid vaginoplasty showed better functional outcomes than penile skin inversion, whereas cosmetic results were similar. di Summa PG, Watfa W, Krähenbühl S, et al. Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients. J Sex Med 2019;16:2030-2037.

Chest resurfacing with a reverse abdominoplasty flap for invasive breast cancer recurrence.

We present a patient with recurrent breast cancer requiring massive resection of the upper chest. Management included a reverse abdominoplasty flap to resurface the anterior chest wall, with acceptable aesthetic outcomes, and adjuvant chemotherapy. RA is a simple and versatile coverage option in patients with high risk of disease recurrence.

Late avulsion of a free flap in a patient with severe psychiatric illness: Establishing a successful salvage strategy.

Post-traumatic defects of the distal third of the leg often require skipping a few steps of the well-established reconstructive ladder, due to the limited local reliable reconstructive options. In rare cases, the reconstructive plan and flap choice may encounter challenges when the patient has psychiatric illness affecting compliance with postoperative care. We describe a case of a patient with severe intellectual disability and an open fracture of the distal lower limb. After fracture management and debridement of devitalized tissues, the resultant soft tissue defect was covered with a free gracilis flap. On postoperative day 7, the patient ripped out the newly transplanted flap. The flap was too traumatized for salvage, so a contralateral free gracilis muscle flap was used. The patient showed good aesthetic and functional outcomes at a 1-year follow-up. When planning the postoperative management of patients with psychiatric illness, less complex and more robust procedures may be preferred over a long and complex surgical reconstruction requiring good compliance with postoperative care. The medical team should be aware of the risk of postoperative collapse, focus on the prevention of pain, and be wary of drug interactions. Whenever necessary, free tissue transfer should be performed despite potential compliance issues.

Preclinical Optimization of a Shelf-Ready, Injectable, Human-Derived, Decellularized Allograft Adipose Matrix.

IMPACT STATEMENT: Trauma, disease, surgery, or congentital defects can cause soft tissue losses in patients, leading to disfigurement, functional impairment, and a low quality of life. In the lack of available effective methods to reconstruct these defects, acellular adipose matrices could provide a novel therapeutic solution to such challenge.

Lumbar artery perforator (LAP) flap: a salvage tool for extended lumbo-sacral necrosis after bilateral internal iliac arteries embolization.

We report the case of a 52-year-old man presenting an extensive lumbosacral necrosis after bilateral internal iliac arteries embolization following unstable pelvic fracture. Coverage of the defect was performed using two extended lumbar artery perforator flaps in a propeller fashion. Good functional and esthetic result was achieved at one-year follow-up.