The management of velopharyngeal insufficiency with Furlow double-opposing Z-plasty procedure

The aim of the study was an evaluation of Furlow’s method in correction of velopharyngeal insufficiency. A prospective study was conducted by a speech pathologist and a plastic surgeon. Rating of hypernasality and speech intelligibility were completed prior to and after surgical intervention. Nasometric measurements were also performed before and after surgical intervention. From May 2003 through September 2006, the first author performed 44 Furlow surgeries for the treatment of velopharyngeal insufficiency in patients with cleft palate. Patients with short, repaired cleft palates but with preserved normal function of pharyngeal sphincter qualified for the operation. The surgery was performed using double-opposing Z-plasty. The method was used in 24 males and 20 females aged from 6 to 25 years (mean age, 12 years). One patient (2%) developed wound dehiscence, and two further patients (4.5%) developed maceration of the wound margins, which delayed the healing process by only several days. Very good, good, or moderate results were obtained in 41 patients (91%). Poor outcome of treatment—excessive hypernasality or poor speech quality after the operation—was still present in four patients (9%). In our opinion, Furlow’s method is a very useful treatment method in patients with velopharyngeal insufficiency especially with sagittal orientation of levator veli palatini muscles.     

Retrofascial mesh repair of ventral incisional hernias

BACKGROUND: Recurrence rates after ventral incisional hernia repair are reported to be as high as 33% and are associated with considerable morbidity and lost time. The purpose of this study was to determine if retrofascial mesh placement reduces the incidence of recurrence as well as the severity of wound infections. METHODS: A prospective database covering the period from January 1995 to June 2003 was maintained. All patients underwent a standardized technique by a single surgeon. Polypropylene mesh was placed between the fascia and the peritoneum with the fascia closed over the mesh. RESULTS: There were 150 patients (126 women, 24 men) with a mean age of 55 years. Their average weight was 88 kg, with an average body mass index of 32. Sixty-three (42%) of the hernias were recurrences of a previous repair. The average size of the hernia was 8 x 14 cm. There was 1 postoperative mortality. There was a 9% postoperative infection rate with 2 patients (1%) requiring mesh removal. Long-term follow-up evaluation has revealed 3 recurrences (2%) and 3 readmissions for bowel obstruction with 1 patient requiring surgical release. There were no fistulas noted. CONCLUSIONS: Incisional hernia repair with mesh placed in the retrofascial position decreases both the risk for recurrence and the severity of wound infection without significant problems from bowel obstruction or enteric fistula.     

Clinical value of the laparoscopic transabdominal preperitoneal technique in recurrent inguinal hernia repair

ObjectiveTo assess the clinical value of the laparoscopic transabdominal preperitoneal (TAPP) technique in recurrent inguinal hernia repair.MethodsThe clinical data of 354 patients with recurrent inguinal hernia who underwent TAPP surgery from June 2010 to June 2016 at the Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, were retrospectively analyzed.ResultsLaparoscopic surgery was successfully completed in all 360 patients. Among them TAPP were finished in 354 patients, while TAPP repair were attempted but finally converted to open or TAPE repair in 6 patients. The mean operation time was 54.7 ± 19.4 min (range 30–90 min), mean duration of hospitalization was 4.7 ± 2.1 days (range 2–14 days), and mean duration of follow-up was 37.7 ± 12.4 months (range 12–60 months). The rate of intraoperative injury was 4.5% (16/354), and the rate of postoperative complications was 13.6% (48/354). No patient developed a foreign body sensation, wound infection, intestinal obstruction, mesh infection, or chronic pain. Two patients (0.6%) developed re-recurrence requiring reoperation, with no further recurrence.ConclusionWhen performed by an experienced surgeon with excellent technique, the TAPP technique is safe and effective for recurrent hernia after surgical treatment via the anterior repair, and maybe a good alternative for recurrent hernia after surgical treatment via the posterior repair.     

Traumatic hemipelvectomy: Improvements in the last decennia illustrated by 2 case reports

INTRODUCTIONIn this article we present two cases of young men who sustained a traumatic hemipelvectomy.PRESENTATION OF CASEThe first case occurred more than 10 years ago and the second case happened less than 1 year ago. Changes in the management for resuscitation, surgical intervention, and in postoperative treatment are detailed. Goal of this article is to evaluate the changes over time in the treatment of trauma in general and this specific injury in particular.DISCUSSIONMaximum survival chance could be achieved by an aggressive resuscitation (following a massive transfusion protocol-ratio of 1:1:1 unit of blood-products), starting pre-hospitally and continued in the emergency department, immediate control of the haemorrhage and direct surgical intervention. Early and frequent re-explorations are necessary to prevent complications as sepsis and to minimize the chance for complications such as disturbed wound healing and fistula formation. The use of the Vacuum-Assisted Closure therapy nowadays gives the patient an earlier recover and lesser chance at developing complications. Early consultation with plastic surgeons needs to be done in order to achieve an adequate definitive wound-closure (reconstructive surgery).CONCLUSIONA traumatic hemipelvectomy is a catastrophic and mutilating injury, seldom survivable. Maximum survival chance could be achieved by an aggressive resuscitation, frequent re-explorations, the use of VAC therapy and early consultation with a plastic surgeon for reconstructive surgery.     

规范疝修补术后手术部位事件标准和范围

腹部疝修补术（VHR）术后伤口事件是评估手术质量的一项重要的预后指标，目前缺乏识别和处理伤口事件定义的标准，文献报道伤口事件的发生率差异很大，难以进行比较性研究和质量控制。临床上使用标准化定义的伤口事件术语，即手术部位感染（SSI）、手术部位事件（SSO）和需介入处理的手术部位事件（SSOPI） ，有利于减小伤口事件发生率的差异，便于疝外科医生用一种准确的共同语言进行学术交流，提高对腹部疝治疗循证决策的能力。建议讨论VHR术后伤口事件发生率时采用上述3个术语的标准定义。     

Early and long-term results of surgery for severe necrotising pancreatitis

BACKGROUND: Necrotising pancreatitis is a challenging problem for the surgeon, as it is associated with considerable morbidity and mortality. The indications, timing of surgical intervention and type of procedure continue to be debated in an effort to improve the outcome of this devastating disease process. METHODS: A retrospective analysis of early and long-term results in a series of 44 consecutive patients (34 men, 10 women, median age 46.5, range 13-74 years) who underwent necrosectomy for severe necrotising pancreatitis. In 16 patients necrosectomy and primary abdominal closure with drains was performed, 14 patients had planned staged necrosectomy and delayed abdominal closure with drains, and in 14 patients necrosectomy with open laparostomy was undertaken. RESULTS: There were 8 deaths (18%) and 14 cases (32%) of significant hospital morbidity (fistula 10, pseudocyst 2, renal failure 2). Variables which correlated with mortality were: high APACHE II score, acute renal failure requiring dialysis, and requirement for surgical intervention at an early stage (within the first two weeks). A total of 28 late complications occurred in 21 of the surviving patients (endocrine pancreatic insufficiency 10, exocrine pancreatic insufficiency 2, pseudocyst 2, chronic renal failure 2, incisional hernia 10, recurrent pancreatitis 1, and chronic pain 1). CONCLUSIONS: Low mortality can be achieved in patients with severe necrotizing pancreatitis with aggressive surgical intervention and careful perioperative management. Long-term morbidity remains high, and emphasises the need for prolonged follow-up.     

A basal cell carcinoma mimicking a sign of rosacea

A 55-year-old Caucasian man presented to a plastic surgeon for the treatment of two lesions on his nose, first a chronic indented area with some telangiectasia on the proximal nasal bridge (Figure 1) and second a hyperkeratotic nodule with central crusting on the ala nasi that developed rapidly over several weeks (Figure 2). The surgeon appropriately diagnosed the ala nasi nodule as a squamous cell carcinoma, keratoacanthoma type, but requested an opinion from dermatology for the proximal nasal bridge indentation that he suspected to be a morpheaform or erosive basal cell carcinoma possibly requiring Mohs micrographic surgery. Upon further questioning, the patient revealed that he has had persistent erythema and problems with facial flushing for many years, particularly with alcohol, coffee, and moderate exercise. He infrequently develops papulopustular lesions. Closer clinical inspection revealed a mild erythema, telangiectases, and a hypertrophied nose. He noted that he wore an old heavy pair of glasses every day. He was notified of a coexisting diagnosis of rosacea, and various treatment options were discussed. He was pleased that he would not need any further surgery to his nose.     

A call for standardization of wound events reporting following ventral hernia repair

Introduction

Postoperative wound events following ventral hernia repair are an important outcome measure. While efforts have been made by hernia surgeons to identify and address risk factors for postoperative wound events following VHR, the definition of these events lacks standardization. Therefore, the purpose of our study was to detail the variability of wound event definitions in recent ventral hernia literature and to propose standardized definitions for postoperative wound events following VHR.

Methods

The top 50 cited ventral hernia, peer-reviewed publications from 1995 through 2015 were identified using the search engine Google Scholar. The definition of wound event used and the incidence of postoperative wound events was recorded for each article. The number of articles that used a standardized definition for surgical site infection (SSI), surgical site occurrence (SSO), or surgical site occurrence requiring procedural intervention (SSOPI) was also identified.

Results

Of the 50 papers evaluated, only nine (18%) used a standardized definition for SSI, SSO, or SSOPI. The papers that used standardized definitions had a smaller variability in the incidence of wound events when compared to one another and their reported rates were more consistent with recently published ventral hernia repair literature.

Conclusion

Postoperative wound events following VHR are intimately associated with patient quality of life and long-term hernia repair durability. Standardization of the definition of postoperative wound events to include SSI, SSO, and SSOPI following VHR will improve the ability of hernia surgeons to make evidence-based decisions regarding the management of ventral hernias.

     

Plastische Versorgung sternaler Wundheilungsstörungen nach Sternotomie

Sternotomies for cardiac and thoracic surgery interventions frequently lead to presternal defects and manifestation of sternal osteitis, especially in multimorbid patients. Whereas defects of almost any size can be closed by plastic surgery according to the reconstructive tree, a sufficiently radical debridement must always precede any wound closure. If an experienced plastic surgeon is integrated early in the surgical team approach and guides the debridement, in many cases local flaps are sufficient and technically still possible for a stable closure. By this, extensive microsurgically demanding rescue procedures may be prevented, as they can have a considerable intrinsic morbidity. In severe cases, however, they represent the only optimal option for the patient. The following article illustrates the principles and the range of modern plastic surgical treatment options for presternal defects and sternal osteitis cases to demonstrate the risk of inadequate, hesitant debridements for a stable wound closure with the lowest morbidity for our patients.     

A chronic nocardial infection following conservative treatment of a high pressure injection injury of air.

We present a case of recurrent cutaneous nocardiosis following a high pressure air injection injury which was treated conservatively. The patient subsequently developed multiple chronic granulomatous nodules in the palm and dorsum of the hand requiring repeated surgical debridements and long term antibiotics for complete resolution. Some reports suggest that high pressure injection injuries of air or water run a benign course and may be treated conservatively. However, inoculation by high pressure injection injury of air or water may result in chronic infections, which cause significant morbidity and are a therapeutic challenge. Although uncommon, they may be avoided by adherence to established treatment principles which include prompt recognition, realisation of its severity and aggressive treatment by open wound management, even for seemingly innocuous trauma or inoculum.     

Strategies of management of necrotizing soft tissue infections

Necrotizing soft tissue infections represent a group of rapidly progressive diseases requiring early and repeated debridement, associated with broad spectrum antibiotics. Delay in surgery or inadequate therapy are the main risk factors for death. Most patients need aggressive critical care management and intensive nutritional support. The management of these patients by experimented senior surgeons is mandatory. A plastic surgeon can help debridement in order to preserve possibilities of later myocutaneous or rotational skin flaps. Intravenous immunoglobulins are an efficacious adjunctive therapy for severe group A streptococcal infection.     

Randomized clinical trial of a new cyanoacrylate flexible tissue adhesive (Adhflex) for repairing surgical wounds

The use of synthetic adhesives such as cyanoacrylates for closing surgical wounds remains controversial. In a multicenter, prospective and randomized clinical trial, we compared a new cyanoacrylate elastic tissue adhesive, Adhflex, with standard suturing methods for repairing surgical wounds. Sixty patients who underwent surgery for inguinal hernia were randomly chosen for Adhflex or standard silk suture. We evaluated wound closure time and parameters related to wound healing and complications using the Hollander Scale; overall surgeon, patient, and independent evaluator satisfaction with scar appearance using a visual analog scale; and scar cosmesis and cosmetic outcome using the Patient and Observer Scar Assessment Scale. The major finding of this study was that surgical wound closure time (minutes) was significantly lower (p < 0.05) when using Adhflex (1.50 ± 0.63) than when using sutures (2.23 ± 0.66), reducing surgery costs. Patient, surgeon and independent evaluator satisfaction was greater with Adhflex (p < 0.05). No differences were found in the final cosmetic outcome of surgical wounds (p > 0.05). The results of this clinical trial showed that Adhflex could be considered a promising and suitable wound closure method. Undoubtedly, lower operating room times will reduce overall surgical costs. Cosmetic outcomes in the medium term are comparable to those seen with sutures, yet there is no need for dressing changes, postoperative wound checks, or removal of stitches or clips. The comfort of the patient is an important factor when considering wound closure methods. Registration number: Eudra CT2012‐002701‐22.     

Primary lumbar hernia: A rarely encountered hernia

IntroductionLumbar hernia is an uncommon abdominal wall hernia, making its diagnosis and management a challenge to the treating surgeon. Presentation may be misleading and diagnosis often missed. An imaging study forms an indispensable aid in the diagnosis and surgery is the only treatment option.Presentation of caseA 42 year old male presented with history of pain in lower back of 4 years duration and was being treated symptomatically over 4 years with analgesics and physiotherapy. He had noticed a swelling over the left side of his mid-back and consequently on examination was found to have a primary acquired lumbar hernia arising from the deep superior lumbar triangle of Grynfelt. Diagnosis was confirmed by Computed Tomographic imaging.DiscussionA lumbar hernia may be primary or secondary with only about 300 cases of primary lumbar hernia reported in literature. Lumbar hernias manifest through two possible defects in the posterior abdominal wall, the superior being more common. Management remains surgical with various techniques emerging over the years. The patient at our center underwent an open sublay mesh repair with excellent outcome.ConclusionA surgeon may encounter a primary lumbar hernia perhaps once in his lifetime making it an interesting surgical challenge. Sound anatomical knowledge and adequate imaging are indispensable. Inspite of advances in minimally invasive surgery, it cannot be universally applied to patients with lumbar hernia and management requires a more tailored approach.     

Body Contouring Following Massive Weight Loss

Background: Obesity and its associated medical morbidities carry substantial health risk. While massive weight loss allows improvement in health status and lifestyle, physical sequelae due to symptomatic skin redundancy still require treatment. Areas affected include the arms, breasts, abdomen, back, and thighs. After open gastric bypass, patients often have poor abdominal support and incisional hernias. To completely address the treatment of patients following massive weight loss, body contouring procedures are performed, often in one stage and tailored to each patient, to rid the functional and esthetic impairment from skin redundancy. Methods: This retrospective study includes 30 patients treated from March 1998 to August 2002 by a single surgeon at an academic hospital. Average weight loss had been 71 kg, and average weight and BMI at the time of contouring surgery were 98.6 kg and 33 kg/m² respectively. Procedures included abdominal panniculectomy, thighlift, backlift, brachioplasty, mastopexy and incisional hernia repair, performed either alone or in combination. Results: Average weight of resected tissue was 5.9 kg. Average length of stay was 3 days. Complications included seroma, wound breakdown, hematoma requiring surgical drainage, and lymphocele after brachioplasty. One patient died of a pulmonary embolus within weeks after surgery. Conclusion: Patients requiring surgical skin excision after massive weight loss for functional and/or esthetic reasons are challenging, and require individualized approaches with intensive follow-up.     

A review of alternative approaches in the management of iatrogenic femoral pseudoaneurysms

The management of iatrogenic pseudoaneurysms (IPAs) demands close co-operation between radiologist, vascular surgeon and plastic surgeon. Ideally, each patient should be reviewed employing a team approach. Many IPAs require only observation; those with a volume greater than 6 cm3 will require treatment as spontaneous thrombosis is uncommon. Radiological treatment options include ultrasound guided compression repair (UGCR), embolisation, and covered stenting. Occasionally, these are unsuccessful or contra-indicated, and the vascular surgical approach is discussed in detail. Finally, the role of the plastic surgeon in dealing with skin ischaemia is detailed.     

Comorbidity trends in patients requiring sternectomy and reconstruction

INTRODUCTION: The predisposing risk factors for sternal wound infection have been well delineated. However, the indications and comorbidity of patients who require cardiac surgery via the median sternotomy approach have changed over time and subsequently have changed the patient population presenting with sternal wound complications. These trends in cardiac surgery may require an adjustment of the plastic surgical approach and methods to optimize outcomes in the patient population. METHODS: A retrospective review was performed to identify patients who had undergone sternectomy or sternal debridement followed by flap coverage. A total of 93 cases performed between 1999 and 2004 examined to collect data about the initial presentation, operative procedure, and postoperative care of each patient. The data were then analyzed to identify population characteristics using logistic regression variables to determine univariate and adjusted (multivariable) measures of association with mortality. RESULTS: Results of the review indicated that 53% of the patients were male and 47% were female, with a median age of 62 years. Preoperative comorbidities included 64% of the patients were over age 60, 43% had diabetes, 51% had hypertension, 13% had renal insufficiency, and 6% were transplant recipients. The method of reconstruction varied, but the majority were pectoralis advancement flaps. Of the patients who underwent debridement and reconstruction, there was a 16% 30-day mortality. Among these mortalities, the distribution was 33% (5/15) male and 66% (10/15) female. CONCLUSIONS: Though the incidence of sternal wound problems is rare (about 1%-5%), there is a significant population of older, renal-insufficient, malnourished patients who present days or weeks after one would normally diagnose and treat a deep sternal wound infection who have a significant mortality rate. Appropriate identification of risk factors, preoperative management and timing for aggressive surgical treatment is required to maximize successful outcomes in this problematic patient population.     

Laparoscopy in the evaluation of penetrating thoracoabdominal trauma

The evaluation of penetrating thoracoabdominal trauma for the presence of a diaphragmatic injury presents a diagnostic challenge to the trauma surgeon. The use of diagnostic laparoscopy (DL) in this setting was reviewed at a level-one trauma institution. Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. This subset of patients underwent a mandatory celiotomy to rule out an associated intra-abdominal injury. Seventeen out of 22 (77.2%) patients had a positive exploration requiring surgical intervention, representing an associated intra-abdominal injury rate of 21.2 per cent. Intra-abdominal injuries requiring repair included small bowel, colon, spleen, liver, and stomach, in descending order. There were no missed injuries or deaths. One patient with a left diaphragmatic injury secondary to a stab wound developed a subdiaphragmatic abscess. Respiratory insufficiency secondary to atelectasis was the most common complication. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoracoabdominal trauma.     

Life-threatening cellulitis,or Fournier's gangrene of the perineum

The global mortality for Fournier's gangrene is one in five. In half the cases, the infection is polymicrobial with either anaerobes or gram negative bacilli. Factors which worsen prognosis include renal insufficiency, streptococcal infection, or need for hospital admission. Diagnosis must be prompt and treatment multidisciplinary involving the surgeon, intensivist, and infectious disease specialist; early and adequate surgical debridement must be accompanied by well-chosen antibiotics and hyperbaric oxygen therapy. Post-debridement therapy requires a long period of dressing changes and skin grafting to achieve final wound closure. This is an aggressive disease with a high mortality, but the depth and extent of invasive infection does not determine prognosis; the first priority is prompt and wide surgical excision/debridement of infected tissues to pre-empt the development of systemic sepsis; this should not be deferred while arranging transfer to a facility with a hyperbaric chamber.     

Wound healing problems in total knee arthroplasty

It is important to avoid underestimating the significance of wound complications following total knee arthroplasty (TKA). Expedient and aggressive care is recommended. Understanding the blood supply to the skin around the knee and measures to prevent wound complications are fundamental to preventing wound problems. A detailed patient history and physical examination will identify high-risk patients and any modifiable risk factors. Operative techniques such as raising full-thickness skin flaps and judicious placement of skin incisions in the presence of pre-existing scars can greatly reduce the incidence of wound problems. The first step in treating wound problems is recognizing when a problem is present and knowing when a minor problem can turn into a major one. Superficial infections or stitch abscesses can be treated with conservative treatment. However, the surgeon should have a low threshold to revert to surgical management if drainage persists. Skin necrosis or non-viable skin must be excised in the operating room, and the presence of a deep infection must be diagnosed by joint aspiration. The appropriate course of action in dealing with deep infection is dependent on the duration elapsed since the index procedure. The ability to perform a medial gastrocnemius muscle flap and skin graft is an invaluable skill in complex cases where primary wound closure cannot be achieved. Meticulous attention to detail during surgery and aggressive surgical treatment of wound complications can be the difference in saving the knee.     

Reintervention in abdominal surgery. Personal experience in emergency

The Authors, regarding their emergency surgical experience, examine the need of reintervention in abdominal surgery at a distance (operations carried out not less than 30 days after previous procedure), a controversial situation, usually dealt with empirical approach. Such a feature is not rare in the experience of a surgeon; nevertheless still few are the studies concerning the severity of the disease and related complications requiring surgery. Occasionally it is really difficult--quite impossible- in these often complex clinical conditions, to identify the aetiology and even to perform a pre-operative diagnosis. Sometimes other factors may inhibit an exhaustive evaluation (acute onset of the symptoms, time spent from the former procedure, choice of the patient to refer to another surgeon) thus conditioning an adequate review of the first surgical act. The Authors study the more frequently observed clinical features, post-surgical abdominal adhesive syndrome, cancer recurrence, incisional hernia. Former surgical diseases and the latter one may be the same, but not necessarily. Surgery is only a feature of the treatment (multimodal treatment) in case of neoplastic recurrence. Morbidity and mortality concerning the latter surgical procedure are higher than the mere sum of those related to both the former and last operation performed (pre-operative disease understaging). Finally it must be stressed the need for early and accurate diagnosis to clearly steer the choice and course of surgical action.