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Resume Introduction L’utilisation des medias sociaux a ete un bouleversement majeur de nos modes de vie dans la derniere decennie, A l’avant-garde dans la crise du lymphome anaplasique a grandes cellules lie aux implants mammaires -LAGC–AIM-, des fevrier 2019, notre centre universitaire a pris des mesures pour identifier et contacter toutes les patientes porteuses d’implants macro-textures. L’objectif de ce rappel etait d’informer les patientes sur les signes d’alerte et d’etablir une modalite de surveillance. Le but de ce travail est d’analyser les decisions des patientes suite a ce processus et de voir si la participation a un des groupes Facebook influencait cette prise de decision. Methodes Une etude retrospective de la cohorte de patientes, ayant demande et assiste a des rendez-vous avec un chirurgien, a ete faite. Le nombre de patientes presentant des signes cliniques d’alertes de LAGC–AIM, le nombre de patientes qui ont demande une intervention chirurgicale d’explantation de l’implant, les diagnostics histologiques retrouves apres la chirurgie ont ete colliges. Nous avons ensuite calcule la proportion de membres du groupe Facebook chez les patientes ayant exige une ablation d’implant en l’absence de diagnostic ou meme de signes d’alerte. Resultats Sept cent soixante-dix femmes ont demande un rendez-vous avec l’un des chirurgiens de notre service. De toutes les femmes qui ont demande une consultation, 497 (64,55 %) ont presente des symptomes. Seules 25 % des patientes, ayant consulte, avaient frequente un des groupes de patientes sur le reseau Facebook. Au terme de la consultation avec leur chirurgien, pres d’un quart des patientes ont un pris une decision d’ablation de l’implant contre l’avis medical. Parmi ces patientes, 67 % faisaient partie d’un groupe de patientes sur le reseau Facebook. A ce jour, aucun patient n’a recu de diagnostic de LAGC–AIM. Conclusions Ces resultats viennent supporter l’hypothese que l’appartenance a des groupes de patientes sur Facebook devient pour certaines un element cle du processus de decision.

Background Opportunities for international missions are highly sought after by medical students, residents, and attending plastic surgeons. The educational benefits and ethical considerations of trainees participating in these ventures have been extensively debated. At the time of this writing, many surgical training programs lack the necessary infrastructure or funds to support missions of this sort. Despite the increasing interest, the perceived benefit of international work has not yet been well studied. The authors seek to evaluate residents' perspectives on the personal and educational benefits of international mission work. Methods A 24-item online questionnaire was designed to measure residents' perspectives on humanitarian missions. Residents' perceptions on how participation in these missions may have influenced their career path were also evaluated. This questionnaire was disseminated to the plastic surgery residents in Accreditation Council for Graduate Medical Education (ACGME) accredited programs in the United States during the 2015 to 2016 academic year. Results Of the 123 responses collected, 49 (40%) indicated that they had participated in international mission work prior to beginning residency, while 74 (60%) had not. Fifty-seven percent (n = 25) of those who had participated agreed that this experience impacted their choice to pursue plastic surgery as a specialty. Twenty-nine (24%) participated in 1 or more missions during residency. The most common type of mission work focused on cleft lip/palate repairs (n = 24) followed by nonsurgical medical relief (n = 18) and general plastics/combined (n = 6). Most respondents reported trips lasting 6 to 8 days (n = 29, 48%), though several reported trips lasting 9 to 10 days (n = 6, 10%) and 11 days or more (n = 16, 27%). When asked about the volume of procedures performed, 32 (65%) reported participating in more than 15 procedures, with 15 (31%) residents reporting participation in 26 procedures or more. When asked to evaluate the educational benefits in light of the 6 core competencies from the ACGME, there was an overwhelmingly positive response. Conclusions Residents perceive international mission experiences to be valuable for professional development as well as an effective tool for surgical education, particularly in the setting of competency-based education goals and these ventures should be supported by training programs. An appropriately planned mission experience can impact the professional and educational development of the trainee.

Background The double capsule is a complication mostly described in aggressive macrotextured implants. Mechanical shear stress applied onto an immature periprosthetic capsule has been linked to their formation. The authors aim to demonstrate the role of bacterial phenotype and biofilm in the development of the double capsule. Methods Seven double capsules formed at the interface of macrotextured breast expander implants were studied using scanning electron microscopy. Two samples for each surface of the inner capsule layer (the prosthesis interface and the intercapsular space) were analyzed for bacteria cell size, bacterial density, and biofilm deposition. Results Although all routine bacterial cultures were negative, the prosthesis interface had both higher bacteria load and biofilm deposition compared with the intercapsular space (Mann-Whitney U test, p = 0.004 and p = 0.008, respectively). Moreover, bacteria cell sizes were significantly smaller at the prosthesis interface in six of seven samples. Comparison of bacteria density and biofilm dispersion showed an increase of biofilm extracellular matrix deposition over 2000 cells/mm (linear regression, p = 0.0025). These results indicate a common trend among bacteria species. Conclusions Bacterial expression between the different surfaces of the double capsule displays significant differences; bacteria at the prosthesis interface are mostly in a biofilm state, whereas they demonstrate a planktonic phenotype at the intercapsular space. When a sufficient amount of bacteria are present at a specific location, quorum sensing may trigger a biofilm phenotypic switch in planktonic bacteria cells. Biofilm formation may alter capsule formation through immune response, thereby weakening capsule strength and facilitating extracellular matrix delamination and double-capsule formation. Clinical question/level of evidence Therapeutic, V.

Summary Introduction Despite positive outcomes reported in the literature, some surgeons remain reluctant to the systematic use of venous couplers in free flap tissue transfer. In our institution, the use of the coupler devices for venous anastomosis in free flap breast reconstruction has yet to be adopted by all surgeons. The purpose of the study was to compare postoperative outcomes of coupler-assisted venous anastomoses with hand-sewn techniques in free flap breast reconstruction. Methods An analysis of collected data was performed on cases of breast reconstruction with free tissue transfer after mastectomy in breast cancer or BRCA-positive patients from 2010 to 2016. Patients were divided into two groups: coupler device and hand-sewn. The primary outcome was survival rate of free flaps. Secondary outcomes included potential complications, as well as surgical characteristics (recipient artery/vein, coupler size, type of hand-sewn anastomosis, size of sutures, number of venous anastomoses, ischemia time, operative time) Results We included 289 cases in our study. There were no significant differences between groups in terms of post-operative complications or survival rate of the free flaps. Ischemia time was significantly lower in both immediate and delayed reconstruction cases. Operative and anesthesia times were significantly lower only in immediate unilateral cases. Conclusion Although ischemia time was reduced in the coupler group, we didn’t find any significant difference in the operative and anesthesia time in the subgroup analysis, except for the group of immediate unilateral breast reconstruction. Couplers are safe and efficient; nevertheless, our study shows that their qualities cannot yet justify the disappearance of the manual sutures.

Vascularized lymph node transfer (VLNT) has gained popularity over the last decade as a surgical treatment approach to chronic lymphedema. A flap containing lymph nodes is transplanted into an area of deficient lymphatic function to promote lymphangiogenesis, bridge the area of obstruction, and restore immunological function to the affected limb. VLNT to a lymphedematous extremity can significantly reverse the disease process while reducing its propensity for infection. In the upper extremity, it may also lead to improvement of brachial plexus neuropathies. When performed in appropriately selected patients, VLNT may obviate the need for lifelong massage therapy, compressive garments, and other supportive measures.

Music is commonly played in operating rooms (ORs) throughout the country. If a preferred genre of music is played, surgeons have been shown to perform surgical tasks quicker and with greater accuracy. However, there are currently no studies investigating the effects of music on microsurgical technique. Motion analysis technology has recently been validated in the objective assessment of plastic surgery trainees' performance of microanastomoses. Here, we aimed to examine the effects of music on microsurgical skills using motion analysis technology as a primary objective assessment tool.Residents and fellows in the Plastic and Reconstructive Surgery program were recruited to complete a demographic survey and participate in microsurgical tasks. Each participant completed 2 arterial microanastomoses on a chicken foot model, one with music playing, and the other without music playing. Participants were blinded to the study objectives and encouraged to perform their best. The order of music and no music was randomized. Microanastomoses were video recorded using a digitalized S-video system and deidentified. Video segments were analyzed using ProAnalyst motion analysis software for automatic noncontact markerless video tracking of the needle driver tip.Nine residents and 3 plastic surgery fellows were tested. Reported microsurgical experience ranged from 1 to 10 arterial anastomoses performed (n = 2), 11 to 100 anastomoses (n = 9), and 101 to 500 anastomoses (n = 1). Mean age was 33 years (range, 29-36 years), with 11 participants right-handed and 1 ambidextrous. Of the 12 subjects tested, 11 (92%) preferred music in the OR. Composite instrument motion analysis scores significantly improved with playing preferred music during testing versus no music (paired t test, P0.001). Improvement with music was significant even after stratifying scores by order in which variables were tested (music first vs no music first), postgraduate year, and number of anastomoses (analysis of variance, P0.01).Preferred music in the OR may have a positive effect on trainees' microsurgical performance; as such, trainees should be encouraged to participate in setting the conditions of the OR to optimize their comfort and, possibly, performance. Moreover, motion analysis technology is a useful tool with a wide range of applications for surgical education and outcomes optimization.

Resume Depuis plusieurs dizaines d’annees les taux d’echec de la microchirurgie restent relativement constants. A l’aide de deux cas cliniques nous presentons une nouvelle possibilite de sauver des lambeaux microchirurgicaux par des interventions d’angioradiologie. Le premier cas montre les effets benefiques potentiels de la thrombolyse in situ, notre deuxieme cas decrit la premiere utilisation de stent au sein d’une anastomose microchirurgicale. Dans les deux cas, le lambeau aurait ete voue a l’echec immediat, car les tentatives de reprise s’etaient revelees infructueuses. Ainsi, avant de deposer un lambeau microchirurgical en apparence non fonctionnelle, la simple angiographie pourrait nous orienter vers cette nouvelle possibilite pouvant ainsi reduire a long terme le taux d’echec global de la microchirurgie.

Resume But de l’etude Le microscope electronique a balayage (MEB) est un vieil allie dans notre comprehension des interactions entre les biomateriaux que nous utilisons et le corps humain. Avec le MEB conventionnel (HiVac), les echantillons biologiques ne peuvent etre observes directement du fait de leurs fortes hydratations. Le but principal de cet article est de presenter les revolutions recentes en MEB, notamment le mode environnemental (ESEM). L’objectif secondaire sera de definir les interets potentiels de ces technologies dans l’analyse des capsules periprothetiques. Patientes et methode Il s’agit d’une etude prospective sur dix patientes atteintes de cancer du sein en cours de reconstruction par expanseurs-protheses. Lors de l’exerese de l’expanseur, un echantillon de capsule periprothetique a ete preleve. Chaque echantillon a ete examine en HiVac ainsi qu’en ESEM. Une analyse spectroscopie X a dispersion d’energie (EDX) a ete effectuee afin d’identifier les composants chimiques dans le tissu capsulaire. Pour chaque modalite, nous avons compare les informations concernant la texturation de la surface capsulaire, le decompte cellulaire et la presence d’un biofilm sur l’interface. Pour chaque image un score de 1 a 3 selon une echelle de Likert a ete attribue par trois experts en microscopie electronique independant. Resultats Le mode HiVac apparait superieur au mode ESEM concernant la definition de la texturation, l’identification des cellules et la presence d’un biofilm. L’analyse EDX permet dans les deux modes une analyse equivalente. Conclusion Le mode HiVac s’avere etre plus approprie que le mode ESEM dans l’analyse des capsules periprothetiques. L’analyse EDX permet de mettre en evidence des elements chimiques atypiques.

The authors report the case of a 30-year-old male with 52% TBSA high-voltage electrical injury of the upper half of the body. Injuries included a cervical burn with associated alteration of the left brachial plexus as well as extensive soft tissue burn of the right hand. Three months later, he developed osteomyelitis of the right thumb metacarpal bone requiring amputation proximal to the metacarpophalangeal joint. Following initial management, the patient had a permanent distal left upper extremity paralysis with nonfunctional but relatively undamaged ipsilateral hand digits. The right hand remained functional with four intact digits and a thumb stump. Usually, late reconstruction of proximal thumb amputation is performed by pollicization or free toe transfer procedures. In this particular case, right thumb reconstruction was done by free transfer of the left little finger. Four months postoperatively, the patient demonstrated a functional pinch between the reconstructed thumb and the ipsilateral digits along with improving sensation. This uncommon surgical procedure restored a functional thumb with minimal donor site morbidity. The decision-making process and operative technique are presented in detail along with a review of the thumb reconstruction literature.

Flaps based on the subscapular vascular system are reliable and versatile tools that provide excellent coverage for a wide range of tissue deficits. Raising these flaps in the described dorsal decubitus position permits two surgical teams to work simultaneously while obviating the need for intra-operative position changes. In cases where a subscapular-based flap is deemed the most suitable option for reconstruction, the dorsal decubitus technique eliminates many of the limitations associated with the traditional lateral decubitus approach without compromising the range of tissue obtainable.

BACKGROUND In the first stage of expander-to-implant breast reconstruction, postoperative expansion is classically initiated at 10 to 14 days (conventional approach). The authors hypothesized that it may be beneficial to wait 6 weeks postoperatively before initiating serial expansion (delayed approach). Clinical and ultrastructural periprosthetic capsule analysis is first required before determining whether a delayed approach ultimately improves capsular tissue adherence and expansion process predictability. METHODS Patients undergoing two-stage implant-based breast reconstruction were enrolled prospectively in this study. During expander-to-implant exchange, the clinical presence of "Velcro" effect, biofilm, and double capsule was noted. Periprosthetic capsule samples were also sent for scanning electron microscopic observation of three parameters: surface relief, cellularity, and biofilm. Samples were divided into four groups for data analysis (group 1, conventional/Biocell; group 2, delayed/Biocell; group 3, conventional/Siltex; and group 4, delayed/Siltex). RESULTS Fifty-six breast reconstructions were included. Each group comprised between 13 and 15 breasts. In group 1, no cases exhibited the Velcro effect and there was a 53.8 percent incidence of both biofilm and double capsule. In group 2, all cases demonstrated the Velcro effect and there were no incidences of biofilm or double capsule. Group 3 and group 4 cases did not exhibit a Velcro effect or double-capsule formation; however, biofilm was present in up to 20.0 percent. All group 2 samples revealed more pronounced three-dimensional relief on scanning electron microscopy. CONCLUSIONS Variations in expansion protocols can lead to observable modifications in periprosthetic capsular architecture. There may be real benefits to delaying expander inflation until 6 weeks postoperatively with Biocell expanders.

Breast implants are amongst the most widely used types of permanent implants in modern medicine and have both aesthetic and reconstructive applications with excellent biocompatibility. The double capsule is a complication associated with textured prostheses that leads to implant displacement; however, its etiology has yet to be elucidated. In this study, 10 double capsules were sampled from breast expander implants for in-depth analysis; histologically, the inner capsular layer demonstrated highly organized collagen in sheets with delamination of fibers. At the prosthesis interface (PI) where the implant shell contacts the inner capsular layer, scanning electron microscopy (SEM) revealed a thin layer which mirrored the three-dimensional characteristics of the implant texture; the external surface of the inner capsular layer facing the intercapsular space (ICS) was flat. SEM examination of the inner capsule layer revealed both a large bacterial presence as well as biofilm deposition at the PI; a significantly lower quantity of bacteria and biofilm were found at the ICS interface. These findings suggest that the double capsule phenomenon's etiopathogenesis is of mechanical origin. Delamination of the periprosthetic capsule leads to the creation of the ICS; the maintained separation of the 2 layers subsequently alters the biostability of the macro-textured breast implant.

Objective: Interest in flaps based on the subscapular vascular system has decreased because of the need for intraoperative patient repositioning and the inability to employ a simultaneous 2-team approach. The aims of this study are to review our experience using dorsal decubitus patient positioning for subscapular-based flap harvest and to demonstrate the effectiveness and safety of this approach. Methods: A retrospective review of all subscapular-based flap cases performed by the senior author at 2 hospital centers from 1995 to 2010 was conducted. Variables studied included indications for reconstruction, flap characteristics, and postoperative complications. A longitudinal roll placed between the scapulae as well as an optional perpendicularly placed shoulder roll are used to achieve dorsal decubitus patient positioning. Results: One hundred five flaps were performed during the study period, and dorsal decubitus positioning was used in all cases. Eighty-four flaps were free and 21 were pedicled. Indications for reconstruction included cancer resection (n = 58), trauma (n = 32), infection (n = 9), and others (n = 6). A simultaneous 2-team approach was carried out in 70 cases. Major complications included 9 cases of arterial or venous thrombosis/insufficiency, 2 of which resulted in total flap failure. Intraoperative conversion to lateral decubitus positioning was never required. Conclusions: Dorsal decubitus harvesting for subscapular-based flaps is a practical and effective technique that enables a simultaneous 2-team approach in complex reconstructive cases. Previous limitations of these highly versatile flaps, such as the need for intraoperative patient repositioning, can thus be avoided. This approach is employed for all subscapular-based flap reconstructions performed by the senior author.