Is Salvage of Recently Infected Breast Implant After Breast Augmentation or Reconstruction Possible? An Experimental Study.

INTRODUCTION: The reinsertion of an infected implant when peri-prosthetic infection occurs early after breast augmentation or breast reconstruction remains controversial. In this experimental study, the authors tried to remove bacteria, and their biofilm, from the colonized surface of breast prostheses, without damaging their integrity. MATERIALS AND METHODS: A total of 112 shell samples of silicone breast prostheses, smooth (SPSS) and textured (TPSS), were colonized by S. epidermidis (SE) or S. aureus (SA) strains, all able to produce biofilms. After 15 days, all the samples were removed from the contaminated culture broth and constituted 4 groups of 20 contaminated samples: SPSS/SE (group I), SPSS/SA (group II), TPSS/SE (group III), TPSS/SE (group IV). In another group-group SEM-, 16 colonized samples were used for documentation with scanning electron microscopy (SEM). The remaining 16 samples were used to test the limits of detection of the sterility test. All samples of groups I-IV and 8 samples of group SEM were « washed ¼ with a smooth brush in a povidone-iodine bath and rinsed with saline solution. A subset of the washed samples was sent for SEM and the others were immersed in sterile broth and were incubated at 35 °C for 3 weeks (groups I-IV). RESULTS: Fifteen days after contamination, all the samples in groups I-IV were colonized. In the SEM group, SEM images attested to the presence of bacteria in biofilm attached to the shells. After cleaning, SEM did not reveal any bacteria and there was no visible alteration in the outer structure of the shell. Sterility tests performed after decontamination in groups I-IV remained negative for all the samples. CONCLUSION: Breast prostheses recently contaminated with Staphylococci, frequently involved in peri-prosthetic breast implant infection and capable of producing biofilms, can be efficiently decontaminated by the procedure used in this study. Our decontamination procedure did not alter the surface structure of the prostheses. This decontamination procedure could allow reinsertion of an infected implant when peri-prosthetic infection occurs early after breast augmentation or breast reconstruction and when a salvage procedure is indicated. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Shoulder function after latissimus dorsi transfer in breast reconstruction.

BACKGROUND/AIMS: Latissimus dorsi (LD) transfer in the case of breast reconstruction remains frequently used because this muscle provides a good size source of tissue in reconstructive surgery. Given that, the consequences of the LD removal on shoulder function and the actual loss of maximal strength developed must be investigated. METHODS: Twenty women (50 ± 7.5 years old) were evaluated before surgery, 3 and 6 months after an unilateral transfer of a pedicle flap of LD muscle used for breast reconstruction. Women performed a bilateral shoulder isokinetic assessment [for the internal rotators (IRs) and external rotators and for the abductor and adductor (ADD) muscles] allowing the establishment of bilateral muscular deficit status and the study of agonist/antagonist muscle ratios. The algofunctional and clinical status of the shoulders was analysed by the means of Constant score and specific shoulder clinical tests. The women did not perform any specific strengthening of muscle shoulder after surgery. RESULTS: The isokinetic assessment showed a muscle weakness 3 and 6 months after LD transfer, mainly on the ADDs (33 ± 9% at 6 months) and on the IRs (16 ± 11% at 6 months). The Constant score significantly decreased after surgery on the operated shoulder. Women with a Constant score impairment showed pain during specific shoulder clinical tests. We also found a correlation between Constant score impairment and internal rotators weakness or rotator muscle imbalance. CONCLUSION: Given those results, we could advocate a specific shoulder strengthening after LD transfer, focused mainly on the IRs and ADDs.

[Sensibility of the abdomen after high superior tension abdominoplasty]. / Sensibilité de la paroi abdominale après abdominoplastie haute tension.

INTRODUCTION: Patients who undergo an abdominoplasty frequently complain about the loss of sensibility of the abdominal wall. In this study, we analyze this sensibility after the high tension abdominoplasty. PATIENTS AND METHODS: This is a prospective study of 23 females operated between July 2003 and January 2005. The abdominoplasty technique used in our study combines extensive liposuccion, limited undermining centered on the linea alba and traction sutures. The sensibilty tests are carried out preoperatively, as well as at 3 and 6 months postoperatively. The three components of the skin sensibility -tactile, algesic and thermic- are evaluated in four differents areas of the abdomen. RESULTS: In the lateral areas of the abdomen (liposucted only), the thermoalgesic sensibility is diminished at 3 months and completely recovers at 6 months. At 3 months postoperatively, the tactile sensibility is even better than the preoperative one and continues to improve by 6 months. The postoperative hypogastric area is widely undermined during surgery. In this area, the three types of sensibility are heavily altered at 3 months and only partially recover at 6 months. The undermining of the postoperative epigastric area is limited. In this zone, the postoperative thermoalgesic sensibility is diminished at 3 months, but completely recovers at 6 months. At 3 months, the tactile sensibility is less than the preoperative one, but it improves with time to even exceed the preoperative values at 6 months. CONCLUSION: The high tension abdominoplasty only needs a limited undermining and largely preserves the innervation of the abdominal flap. Only the hypogastric area, largely undermined, presents a sensitivity loss. These results are better than those previously reported in the literature.

Necrotizing fasciitis: case report and review of literature.

We report a case of necrotizing fasciitis of the lower limb. This medico-surgical emergency is a life-threatening invasive soft-tissue infection which primarily involves the fascia superficialis and rapidly extends along subcutaneous tissue with relative sparing of skin and underlying muscles. Clinical presentation includes fever, signs of systemic toxicity and pain out of proportion to clinical findings. Paucity of cutaneous findings early in the course of the disease makes diagnosis challenging. The confirmation of the diagnosis is often made after surgical debridement. Delay in diagnosis and/or treatment correlates with poor outcome, leading to sepsis and/or multiple organ failure. Radiologic studies including plain radiographs, CT-scan or MRI may help to diagnose necrotizing fasciitis. Prompt surgical debridement, intravenous antibiotics, fluids and electrolytes management and analgesia are mainstays of the therapy. Adjuvant treatments like clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed.

[Tissular expansion and tuberous breasts: 10 cases report]. / Expansion tissulaire et seins tubéreux: à propos de dix cas.

INTRODUCTION: Tuberous breast is a deficiency of mammary development, principally in the lower lateral and medial quadrants. In types II and III of the Grolleau classification, we perform a two-stage correction by tissue expansion associated with an implant in order to avoid the double bubble deformity and the difficulty of medial infra-mammary fold reconstruction. MATERIALS AND METHODS: Between February 2003 and February 2006, ten patients have been treated by implantation of an anatomical expander associated with a vertical and horizontal Puckett plasty. The second operation consisted in the replacement of the expander by an anatomical prosthesis associated, if necessary, with a second Puckett plasty and lipofilling. RESULTS: There was no double bubble deformity. Three patients required a complementary lipofilling to improve the result of the lower medial fold. One prosthesis had to be repositioned and one expander infection was responsible of a three-month delay in the reconstruction procedure. CONCLUSION: Tuberous breast correction is a therapeutic challenge in quite psychologically distressed patients. In types II and III, tissue expansion associated with a Puckett plasty increase the volume of the lower pole and reduces the risk of the double bubble deformity. The implantation of an anatomical prosthesis gives more natural effect to the contour of the glandular lower pole. This therapeutic attitude gives the chance of achieving a completely satisfactory result.

[Surgical treatment of chest wall tumors]. / Chirurgie des tumeurs de la paroi thoracique.

The observation of a primary chest wall desmoid tumor discovered incidentally in a young patient is an opportunity to review the nosology, diagnosis and treatment of this uncommon pathology. Surgical intervention should aim at resecting completely the lesion with sufficient margins. Subsequent reconstruction of the bony thorax uses synthetic materials and muscle or myocutaneous flaps.

Thromboprophylaxis in microsurgery.

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture.

[Necrotizing fasciitis: diagnosis and treatments]. / Fasciites nécrosantes : stratégie diagnostique et thérapeutique.

The necrotizing fasciitis is a medico-surgical emergency, characterized by the rapid speard of the infection in the subcutaneous tissue, involving fascia superficialis. Peaucity of cutaneous findings early in the course of the disease makes diagnosis a challenge for physician. Pain out of proportion to clinical findings, fever and signs of systemic toxicity are the keys in identification of necrotizing fasciitis. Delayed diagnosis lead to sepsis syndrom and/or multiple organ failure and correlate with poor oucome. Radiolographs, CT-scan or MRI are main radiologic studies, but such procedures should never delay surgical intervention. Intravenous antibiotics, fluid and electrolyte management and analgesia are needed in addition to radical debridment. Clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed treatments. Only prompt recognition and immediat care warrant a lower mortality and morbidity for this life-threatening infection.

[How I treat...fibroproliferative scars]. / Comment je traite...les cicatrices fibroprolifératives.

Following a skin injury like burn, surgery or a trauma, fibroproliferatives scars are responsible of cosmetic, psychologic and symptomatic disorders. Keloids are benign and occur secondary to an imbalance between the synthesis of extracellular matrix and its degradation. There is a lot of therapeutic modalities available. Despite this, recurrence and sometimes increasing lesions are the major complications. Surgery with adjuvant therapy like steroids injections, radiotherapy, silicone materials seems today the best therapeutic choice. A best physiopatholgy's comprehension is at the base of new treatments, but their efficacity still need to be demonstrate in larger studies.

Liposuction: review of the techniques, innovations and applications.

Liposuction is currently the most frequently performed aesthetic operation in the world. Despite its wide-spread popularity, it should nevertheless be stated that it is not trivial surgery, not always benign and not as safe as intimated in the glossy office brochures. Since the initial description of liposuction, numerous changes have taken place. Today, surgical indications are well defined and the liposuction procedure is well codified. However, several surgeons and manufacturers have developed new equipment and techniques. We propose to survey all the techniques showing the real place of each of them. Their advantages and disadvantages will be discussed. The various techniques dealt with are: the wetting solution techniques, standard liposuction or Suction-Assisted Lipoplasty (SAL), internal Ultrasound-Assisted Liposuction (iUAL), VASSER assisted liposuction, external Ultrasound-Assisted Liposuction (eUAL), Laser-Assisted Liposuction (LAL), Power-Assisted Liposuction (PAL) and Vibroliposuction (VL). On the basis of this review of the literature and of our clinical experience, we conclude that VL is the safest, most effective and precise surgery that can be used in any of the modern indications for liposuction. We concluded that VL seems to have all the advantages and none of the disadvantages associated with iUAL.

[Smooth or textured implants: what to select?]. / Prothèses lisses ou texturées: que choisir?

Envelope structure has evolved since the seventies. Indeed, low-bleed implants allow an important reduction of capsular contracture for silicone filled implants. Later, textured implants permit an additional reduction of capsular contracture, especially when positioned in a retroglandular pocket. Whereas many studies confirm these findings, the interest of textured implants in the retromuscular plane is not really clear, even if some authors recommend it. Due to the need of a tissular anchorage, anatomical implants are not manufactured with smooth envelopes.

[Mondor's disease: a complication after breast surgery]. / La maladie de Mondor: une complication de la chirurgie mammaire.

Mondor's disease is a rare but not uncommon complication of breast surgery. This problem is commonly described as the thrombophlebitis of the superficial thoracoabdominal veins. Symptoms combine painful contracture occurring in the sub-mammary region and/or in the axillary region, rising during arm abduction. The contracture located in the axillary region usually join the epitrochlea. Based on a serie of 8 patients, the fascial hypothesis is developed. All the patients were treated by LPG and myo-fascial techiques with a complete relief of pain in 10 days.

Covering small defects on the weight bearing surfaces of the foot: the free temporal fasciocutaneous flap.

Although defects in the weight bearing area of the heel can be covered by local flaps, radiodermatitis is a contraindication to these flaps. Thin free flaps, as grafted fascial or muscles flaps and thin fasciocutaneous flaps, are usually the option of choice in these particular defects. These reconstructions are prone to shearing strains resulting in ulceration, hypertrophic scars and hyperkeratosis. The authors present a retrospective study of the reconstruction of six small heel defects with the fasciocutaneous temporal free flap performed between 1996 and 2001. The mean size of the defect was 20 cm(2). All arterial anastomoses were performed end to side on the posterior tibial artery. Despite the flap thinness, swelling was present during 12-25 months and one debulking had to be performed. With a mean follow-up of 32 months, all flaps regained protective sensibility after 7 months. No sliding of the flaps could be noted but there was one transient hyperkeratosis. Although the amount of hair on the transferred flaps decreased spontaneously with time, laser hair removal was performed in two patients for psychological reasons. In conclusion, it seems that in selected cases where local flaps are contraindicated, the fasciocutaneous temporal free flap can offer an excellent alternative for heel reconstruction. Due to its particular architecture, it resembles the complex tissue of the sole of the foot resulting in fewer complications and maintenance of flap durability.

Tip of the greater horn of the hyoid bone: a landmark for cervical surgery.

The purpose of this study was to assess the relevance of the tip of the greater horn of the hyoid bone (THB) in the localization of the carotid bifurcation, the superior thyroid and lingual arteries, and the hypoglossal and superior laryngeal nerves. Measurements of these structures with respect to the THB were also made. Thirty perfusion-fixed human cadavers (60 specimens) were studied. Sharp measurements were made along two orthogonal axes crossing exactly on the THB. The vertical axis was parallel to the craniocaudal axis of the body. Taking the THB as a landmark, the five structures were identified in all the specimens. The mean value, standard deviation, and range of measurements for each structure studied are given in the text. This study shows the THB to be a useful landmark which is an aid to locating the aforementioned structures with confidence, and concludes that knowledge of this landmark would be beneficial for the surgeon dealing with the mid neck area.

Combined reconstruction of the diabetic foot including revascularization and free-tissue transfer.

Diabetic patients, presenting with both peripheral vascular disease and large soft-tissue defects, are too often treated by primary amputation. A combined revascularization and free-tissue transfer procedure can extend limb salvage in these patients. The authors report their experience over 4 years with 19 diabetic patients with peripheral vascular disease and large soft-tissue defects of the foot requiring free-tissue transfer. Although there was a 100 percent flap survival, early local wound problems occurred in three patients (16.6 percent). The recurrence rate was about 18.7 percent, but no complementary flap procedures were mandatory. With a mean follow-up of 38 months (range: 23 to 55 months), the limb salvage rate was 94.4 percent. Although there was one limb loss and one patient with ambulation difficulties, 16 patients (84.2 percent) were fully rehabilitated and were able to function independently. Despite a rather small series, this study confirms that in selected diabetic patients, a combined approach of vascular and reconstructive surgeons can reduce the limb amputation rate with acceptable complication rates. This combined approach offers major benefits to these patients, especially stable coverage and preservation of ambulation, and should always be considered before amputation.

[Severe paroxysmal drug eruptions]. / Les toxidermies paroxystiques graves.

Some drug reactions showing cutaneous expression exhibit a paroxysmal course. These diseases encompass the toxic epidermal necrolysis, the drug hypersensitivity syndrome, and the acute generalized exanthematic pustulosis. These syndromes are associated with dismal outcome. They represent medical emergencies needing hospitalization in specialized care units.

Breast implants. A review.

Breast implants have been used for about four decades for both reconstructive and aesthetic purposes. In 1963, the quality of the artificial implants was revolutionized by the introduction of the silicone gel-filled implant. Since, this modern prosthesis has gone through an evolution of change and improvement with several types of devices with many variations and styles within each class. Actually, for the last three decades, approximately one million women have received silicone breast implants in the USA. But, in 1992, the American FDA banned silicone from the market, leaving saline implants as the only product generally available as an alternative until now. Other filler materials were introduced, but have never progressed beyond the experimental stage in the USA (in contrast with Europe). The evolution of the different implants through time, with their advantages and disadvantages will be discussed, but also the controversy on silicone implants in the USA and their suspected association with systemic diseases.

Abdominal aplasia cutis congenita: case report and review of the literature.

A case of bilateral abdominal aplasia cutis congenita without skull defect is reported and was treated successfully by a combination of allografts and growth factors delivered by allogenic cultured keratinocytes.

[Free flap pedicle loss: clinical study on 8 cases]. / Perte du pédicule nourricier d'un lambeau libre : étude clinique sur 8 cas.

The authors report on 8 cases of free flaps with vascular pedicle disruption that were encountered between postoperative days 8 to 18. In one case, the inflow disappeared 18 months after the transfer without any trouble. This resulted in 2 partial and one complete flap losses. The 4 other flaps survived completely. This complete survival is related to the angiogenesis process coming from the surrounding tissues. The most obvious causal factor responsible for the 2 partial losses was the coverage of large, non viable areas, such as a prosthetic material and bone deprived of periosteum. The only causal factor that could be assessed in the case of total necrosis was the presence of an immunosuppressive treatment. Variables participating in the installation of an adequate angiogenic response are then discussed in accordance to this experience and to the literature. Limited contact with viable tissue, ischemia-reperfusion or drugs limiting the angiogenesis seems to promote failure when the pedicle is quickly disrupted. Hypoxia seems to be the most important cellular mechanism promoting the angiogenesis in this context.

[Coverage of defects: principles]. / La couverture des pertes de substance: les principes.

The coverage of defects is a broad field with which the plastic surgeon is confronted daily within traumatic, tumoral or other context. The various techniques used are skin graft and flaps, forming both heterogeneous groups. Indeed, there are various types of skin graft although a common denominator is the need for a good recipient site in order to allows an adequate "take". On the other hand, flaps carry their own vascularization. Thus, they are not dependent of the recipient site for their survival. Those are divided into three groups: local flaps, pedicled flaps and free flaps. The choice of the adequate technique with respect to the defect to be covered depends on the characteristics of the defect, its localization, the functional requirements of the area, the exposed structures, the medical status of the patient. The possible morbidity left on the donor site the aesthetic and functional goals are taken into consideration. For each case, there are often several good options as well as others less optimal solutions. The existing solutions are often so numerous that the plastic surgeon is frequently able to solve all the types of defects.