Free Functional Platysma Transfer for Restoration of Spontaneous Eye Closure in Facial Paralysis.

BACKGROUND: Facial palsy patients experience an array of problems ranging from functional to psychological issues. With regard to the eye, lacrimation, lagophthalmos, and the inability to spontaneously blink are the main symptoms and, if left untreated, can compromise the cornea and vision. This article reports the outcomes of 23 free functional vascularized platysma transfers used for reanimation of the eye in unilateral facial paralysis. METHODS: Data were collected prospectively for all patients undergoing reanimation of the paralyzed eye using free functional platysma transfer. The only exclusion criterion was that a minimum of a 2-year follow-up was required. Patients were assessed preoperatively and postoperatively and scored using the eFACE tool focusing on eye-symmetry with documentation of blink reflex. RESULTS: A total of 26 free functional platysma transfers were completed between 2011 and 2018; three patients were excluded because of inadequate follow-up. The mean age was 9.1 ± 7.1 years and there were 12 boys and 11 girls. Preoperatively, no patients had evidence of a blink reflex in comparison to 22 patients at 2-year follow-up. There was a statistically significant improvement in palpebral fissure ( P < 0.001) and full eye closure ( P < 0.001) scores at 2-year follow-up; however, there was no statistically significant difference in gentle eye closure ( P = 0.15). CONCLUSIONS: This is the first report of free functional platysma long-term outcomes in eye reanimation. The results demonstrate that successful restoration of the blink reflex can be achieved and full eye closure is obtainable following surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Management of periprosthetic breast infection: a systematic review and meta-analysis.

BACKGROUND: The current management of an infected breast implant is varied. This systematic review and meta-analysis aim to synthesise the current evidence and establish the efficacy of the various managements of infected breast implants. METHODS: A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted for primary clinical studies that report on the management of infected breast implants from 1946 to September 2019. The primary outcome measure was the proportion of patients with successful treatment. RESULTS: Nineteen articles that involve 1044 patients were included. Overall, 29.00% (95% CI = from 11.51% to 50.58%) of the patients with mild infection were treated exclusively with antibiotics, of which, 81.41% (95% CI = from 57.82% to 96.63%) were successfully treated without the need for surgical intervention. Another 39.01% (95% CI = from 21.41% to 58.23%) of the patients underwent surgical salvage of the infected breast implants, of which 84.56% (95% CI = from 74.92% to 92.20%) successfully retained the salvaged implants without infection recurrence. Meanwhile, 35.01% (95% CI = from 27.01% to 43.57%) of the patients underwent explantation of the infected breast implant, of which, only 39.02% (95% CI = from 23.93% to 55.28%) had re-insertion of a new implant on a later date and 4.99% (95% CI = from 1.66% to 9.99%) of these patients had recurrence of infection requiring removal of the infected implant. The commonest complication was capsular contracture, which was reported in 10.78% (95% CI = from 4.41% to 19.49%) of the patients. Changes in the quality of life and cost implications were not reported. CONCLUSION: This study consolidates current available evidence on the management of infected breast implants, which could assist decision-making and improve patient education; however, current data are limited because of the lack of level-1 evidence.

Patient-reported outcome and cost implication of acute salvage of infected implant-based breast reconstruction with negative pressure wound therapy with Instillation (NPWTi) compared to standard care.

INTRODUCTION: Implant loss due to infection is the most devastating complication of implant-based breast reconstruction. The use of negative pressure wound therapy with instillation(NPWTi) for salvage of infected implant-based breast reconstructions has shown promising results allowing early reinsertion of a new implant as an alternative to the current management with delayed reinsertion. This study compares the patient-reported outcome and cost implication of NPWTi to the current management. METHODS: Twenty cases of infected breast implants treated with NPWTi(V.A.C. VERAFLO™ Therapy), followed by early reinsertion of new implants were compared to 20 cases that had delayed reinsertion(non-NPWTi). Patient satisfaction was evaluated using the BREAST-Q questionnaire. The average cost per patient was calculated using total operative expense, cost of inpatient stay, investigations, antibiotics, and outpatient visits. RESULTS: Treatment with NPWTi allowed earlier reinsertion of a new implant (NPWTi: 10.3 ± 2.77days vs. non-NPWTi: 247.45±111.28days, p<0.001). Patients in the NPWTi group reported higher satisfaction. The average cost per patient for NPWTi and non-NPWTi was £14,343.13±£2,786.70 and £8,920.31±£3,005.73, respectively(p<0.001). All patients treated with NPWTi had one admission and spent 11.9 ± 4.1days as inpatients, while non-NPWTi patients had 2.1 ± 0.3 admissions(p<0.001) and spent 7.1 ± 5.8days(p<0.004) as inpatients. Patients treated with NPWTi had more procedures (NPWTi:3.35±0.81 Vs. non-NPWTi:2.2 ± 0.41, p = 0.006); however, three non-NPWTi cases required flap reconstruction. CONCLUSION: Patients treated with NPWTi reported higher satisfaction, received a new and earlier implant, and had fewer admissions and outpatient visits; however, they incurred higher average costs, longer inpatient stays, and underwent more procedures. Early implant reinsertion preserves skin envelope; hence avoiding additional cost and stress related to further major autologous reconstruction.

Pedicled ipsilateral anterolateral thigh (ALT) with flow-through to a secondary contralateral-free ALT flap for coverage of large thigh, trochanteric, and gluteal area defects: A case report.

Reconstruction of the trochanteric area can be difficult in extensive defects postsarcoma resection. It requires a robust flap. In reconstructing the upper thigh, trochanteric, and gluteal area, a pedicled anterolateral thigh (ALT) flap is a good option. If the defect extends further than the pivot point of a single pedicled ALT, this can be used a flow-through for a secondary free flap. Here we describe a case of a 66-year-old gentleman with a 25 cm × 15 cm defect in the trochanteric and gluteal area where a single pedicled ALT was insufficient for coverage and hence a second ALT from the contralateral leg is anastomosed to the distal runoff of the descending branch of the lateral circumflex femoral vessel of the pedicled ALT, using it as the flow-through donor vessel. This method requires less time if a second free flap is required and a smaller range of dissection, and it also facilitates anastomosis, as the vessel can be brought to the surface for anastomosis while supine before inset. The patient healed with no complications and received radiotherapy to the area. On 1-year follow-up, the area has healed well despite some contraction secondary to the radiotherapy. Using the pedicled ALT as a flow-through for a second free flap is a useful adjunct to large defects in the gluteal and trochanteric area, which is a difficult area to reconstruct with limited donor vessels.

Necrotizing fasciitis of the periorbital region: from presentation to reconstructive journey.

Periorbital necrotizing fasciitis is a very rare condition with a UK incidence of 0.24 cases per million per annum. Outcomes can range from disfigurement to sight loss and even death. Debridement is crucial when sight or life is threatened and the subsequent reconstructive stages can be challenging. We describe two cases of periocular necrotizing fasciitis demonstrating the progression of the disease as well as the surgical debridement for both pre-septal and post-septal disease and the reconstructive steps leading to outcome. Level of evidence: Level V, therapeutic study.