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INTRODUCTION: Surgical tourism is a growing phenomenon, causing a surge demand for the management of its complications. In this study, we aimed to evaluate complications that occur after cosmetic breast surgery abroad; and their costs for the public health system. MATERIAL AND METHODS: We reviewed the medical files of patients treated in our department for a complication after cosmetic breast surgery outside Switzerland and assessed all complications requiring hospitalization; and estimated the overall medical costs. RESULTS: Over a two-year period, 26 patients were treated for 39 complications. The main complication was infection (71% of cases), mainly with a multidrug-resistant organism (47%) and atypical mycobacteria. Of the 16 patients with breast prosthesis, 7 implants were removed. The effective average costs incurred for the hospital care of these cases was estimated to 14'724 Swiss Francs (∼12'963 Euros) per patient. CONCLUSION: The high rate of multidrug-resistant and mycobacterial atypical infections are a major public health problem. It is necessary to inform patients much better about the risks of surgical tourism. Furthermore, the danger of transfer of multidrug-resistant or atypical germs from abroad should not be overlooked. Physicians should be informed about this risk and take necessary measures for treatment and diagnosis of these complications.

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Extraarticular ankylosis occurs frequently in children suffering from noma sequelae. Over 20years of operating on these patients, we observed high recurrence of mouth opening limitation. We therefore progressively changed our surgical strategy. This retrospective study compares the impact of different parameters (types of surgery, noma type, physiotherapy compliance, age and sex) on immediate and long-term mouth opening. It includes a series of 121 patients with extraarticular ankylosis operated on between 1990 and 2015. Soft tissue reconstruction evolved from local and pedicled flaps to large free flaps. Mouth opening was performed by bone-bridge excision, sometimes associated to contralateral coronoidectomy. Mouth opening technique including bilateral coronoidectomy with free flap reconstruction was the only independent factor for significantly better immediate mouth opening with a mean increase of 8.7mm [95% confidence interval (CI) 4.3-13.1, P<0.001) and this effect was maintained in the 3years of follow-up. Another positive factor related to long-term results was excellent physiotherapy, while noma type 4 was a negative factor. Recurrence remains problematic in the management of noma sequelae. If physiotherapy and long-term follow-up cannot be offered, patients should not be operated on, because if limitation of mouth opening recurs, oral feeding may become impossible when a facial defect has been reconstructed.

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BACKGROUND: Patient candidates for breast reconstruction with free deep inferior epigastric perforator flap (DIEP) may present several risk factors for venous thromboembolism (VTE). Risk identification is essential for appropriate VTE prophylaxis measures to be put in place. This study aims to investigate VTE incidence after DIEP flap breast reconstruction and to assess the accuracy of the Caprini Risk Assessment Model (RAM), which is the unique score validated to assess the VTE risk for plastic surgery procedures and identify patients at high VTE risk. METHODS: A chart review was conducted of 192 consecutive patients who underwent breast reconstruction with a DIEP flap from 1999 to 2016. VTE rate was assessed and the Caprini score was calculated for each patient and correlated with the VTE incidence. RESULTS: During the 90 post-operative days, four patients presented a pulmonary embolism (2.1%) and two patients (1%) had deep venous thrombosis (overall VTE incidence of 3.1%). Most patients (92.2%) were assessed as high-risk (Caprini score >5) and all VTE occurred among this group. Apart from the Caprini score, no specific single risk factor could be identified for VTE. CONCLUSIONS: Our data confirm that the Caprini RAM is a valuable assessment tool for VTE risk measurement among all patients undergoing autologous breast reconstruction. As most candidates for DIEP flap belong to the high-risk group, combined anticoagulation prophylaxis methods are required for most cases, particularly chemoprophylaxis up to four weeks postoperatively.

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BACKGROUND: The prevalence of breast lesions (benign, precancerous and cancer lesions) in reduction mammaplasty (RM) specimens has rarely been reported in Europe and never in the Swiss population. METHODS: Personal and histopathological data from 534 female patients who underwent RM were reviewed. RESULTS: Benign and/or malignant lesions were detected in 76.2% of all patients. Benign breast lesions associated with an increased risk of developing breast cancer represented 2.8% of all lesions. Breast cancer in situ was identified in 5 (0.9%) patients. Patient age and previous history of breast cancer were risk factors for incidental breast cancer. CONCLUSION: The rate of incidental carcinoma in situ was higher for patients with breast cancer history. Probably due to preoperative breast cancer investigation, no occult invasive breast cancer was found in reduction mammary specimens. Therefore before RM, breast cancer evaluation should be considered for all patients, especially for those with breast cancer risk factors (e.g., patient age, personal history of breast cancer).

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Diabetic patients are at risk for spontaneous foot ulcers, chronic wounds, infections, and tissue necrosis. Current theories suggest that the development and progression of diabetic foot ulcers are mainly caused by arteriosclerosis and peripheral neuropathy. Tissue necrosis plays a primordial role in the progression of diabetic foot ulcers but the underlying mechanisms are poorly understood. The aim of the present study was to investigate the effects of hyperglycemia per se on the susceptibility of ischemic tissue to necrosis, using a critical ischemic hind limb animal model. We inflicted the same degree of ischemia in both euglycemic and streptozotocin-induced hyperglycemic rats by resecting the external iliac, the femoral, and the saphenous arteries. Postoperative laser Doppler flowmetry of the ischemic feet showed the same degree of reduction in skin perfusion in both hyperglycemic and euglycemic animals. Nevertheless, we found a significantly higher rate of limb necrosis in hyperglycemic rats compared to euglycemic rats (71% versus 29%, resp.). In this study, we revealed that hyperglycemia per se increases the susceptibility to limb necrosis in ischemic conditions. Our results may help to better understand the physiopathology of progressive diabetic wounds and underline the importance of strict glycemic control in patients with critical limb ischemia.

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BACKGROUND: Excess skin after massive weight loss impairs patient's health-related quality of life (HRQoL). Therefore, body-contouring surgeries can be proposed. However, few data exist concerning the effect of body contouring after bariatric surgery on HRQoL, including control group with a long-term follow-up. METHODS: In a prospective study, 98 consecutive patients who had body contouring after gastric bypass for obesity (BMI > 40) were included (group A). A matched control-group containing 102 patients who had only gastric bypass was selected (group B). HRQoL was measured by Moorehead-Ardelt questionnaire before (group A1) and after (A2) body contouring, and at different time points for group B until 8 years post-gastric bypass. To evaluate the effect of body contouring by two parallel methods, HRQoL was compared between groups A1 and A2, and between A2 and B. RESULTS: We found that body contouring procedures improved significantly patients' HRQoL, in comparison to those who had only gastric bypass. Of the patients who had body contouring (group A2), 57 % evaluated their HRQoL "much better" in comparison to only 22 % of patients before body contouring (group A1) or those who never had body contouring (group B) (p < 0.001). The improvement was significant in all sub-domains of HRQoL: self-esteem, social life, work ability, sexual activity and physical activity (p < 0.001), and remained stable over time. CONCLUSIONS: Our study confirms the important role of plastic surgery in treatment of patients after massive weight loss. We demonstrated that body contouring, despite important scars, significantly improves satisfaction and HRQoL of patients after gastric bypass. Therefore, the treatment of morbid obesity should not be deemed achieved unless plastic surgery has been considered.

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INTRODUCTION: First aid treatment for thermal injuries with cold water removes heat and decreases inflammation. However, perfusion in the ischemic zone surrounding the coagulated core can be compromised by cold-induced vasoconstriction and favor burn progression. The aim of this study is to evaluate the effect of local warming on burn progression in the rat comb burn model. METHODS: 24 male Wistar rats were randomly assigned to either no treatment (control) or application of cold (17 °C) or warm (37 °C) water applied for 20 min. Evolution of burn depth, interspace necrosis, and microcirculatory perfusion were assessed with histology, planimetry, respectively with Laser Doppler flowmetry after 1 h, as well as 1, 4, and 7 days. RESULTS: Consistent conversion from a superficial to a deep dermal burn within 24 h was obtained in control animals. Warm and cold water significantly delayed burn depth progression, however after 4 days the burn depth was similar in all groups. Interspace necrosis was significantly reduced by warm water treatment (62±4% vs. 69±5% (cold water) and 82±3% (control); p<0.05). This was attributed to the significantly improved perfusion after warming, which was present 1 h after burn induction and was maintained thereafter (103±4% of baseline vs. 91±3% for cold water and 80±2% for control, p<0.05). CONCLUSION: In order to limit damage after burn injury, burn progression has to be prevented. Besides delaying burn progression, the application of warm water provided an additional benefit by improving the microcirculatory perfusion, which translated into increased tissue survival.

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The beneficial effects of the delay phenomenon have been evaluated extensively and are widely known. However, no study has quantified the vascular changes seen in an abdominal cutaneous island flap following a surgical delay by vascular pedicle ligation. We evaluated the effect of unilateral superficial inferior epigastric and deep inferior epigastric pedicle ligation on the vascularity of a rabbit abdominal cutaneous island flap. Thirty rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. A 19 x 15 cm abdominal cutaneous island flap was elevated at the time of sacrifice, based solely on the right superficial inferior epigastric pedicle. The flap vasculature was then evaluated by methylene blue injection and lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Methylene blue studies revealed perfusion of only the right (nonligated) side of the flap on day 0 and perfusion of the entire flap by day 15. This "capture" of the left (ligated) superficial inferior epigastric artery angiosome by day 15 could only have been achieved through enhanced cross-midline perfusion. Lead oxide microangiography revealed an increase in the number of vessels from day 0 to day 27 on both the ligated and nonligated sides in all the following: the number of large "choke" vessels (> 0.5 mm) crossing the flap midline, total number of vessels (all sizes) crossing the flap midline, and total number of vessels (all sizes) at the medial aspect of the right and left superficial inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the flap that were relatively more ischemic following left superficial inferior epigastric pedicle ligation (medial aspect of the caudad half of the left superficial inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (medial aspect of the cephalad half of the right superficial inferior epigastric artery angiosome).

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The transverse rectus abdominis muscle (TRAM) flap has become the "gold standard" for autogenous breast tissue reconstruction. Complications are reported in 10 to 40 percent of patients undergoing this procedure, and many are related to soft-tissue necrosis secondary to ischemia. Various methods have been proposed to improve TRAM flap survival, including surgical delay of the flap. The beneficial effects of the delay phenomenon have been well established in laboratory studies and clinical evaluations. Many investigators agree that the delay phenomenon will enhance arterial inflow and venous outflow from the TRAM flap. No study has quantified the changes seen in the rectus abdominis muscle following a delay procedure. In this prospective, controlled, and blinded experiment, we evaluate the effect of a unilateral superficial inferior epigastric and deep inferior epigastric artery and vein ligation on the vascularity of the rectus abdominis muscles in rabbits. Thirty-eight rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. The rectus abdominis muscle vasculature was then evaluated by lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Magnification (x 2) was used to count the number of vessels at the periphery of the deep inferior epigastric artery angiosomes in the microangiograms. An increase in the number of vessels from day 0 to day 27 was seen on both the ligated and nonligated sides in all the following: the number of large (> 0.5 mm) "choke" vessels and total number of vessels (all sizes) crossing the abdominal wall midline and the total number of vessels (all sizes) at the medial, superior, and lateral aspects of the right and left deep inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the rectus abdominis muscles that were relatively more ischemic following left deep inferior epigastric pedicle ligation (medial aspect of the left deep inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (lateral aspect of the right deep inferior epigastric artery angiosome).

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Total anterior tenoarthrolysis was originally described by Saffar to treat flexion contractions of the fingers. This procedure consists of releasing the entire flexor apparatus and the interphalangeal volar plates through a lateral incision and a volar subperiosteal dissection. The anterior flap slides proximally in relation to the bone, leaving a pulpar defect. To maintain the digital pulp intact, we proposed advancing the volar flap and transposing the defect at the base of the finger. A series of 16 patients who underwent total anterior tenoarthrolysis are presented; 6 patients underwent surgery according to our modification. Postoperative range of motion was improved in 11 of 16 patients and correlated with subjective patient appreciation. Fingers that had a preoperative interphalangel total active motion greater than 55 degrees were significantly improved. No improvement was seen among patients with stiff, crooked fingers. The average total extension deficit decreased from 33 degrees at the proximal interphalangeal joint level and 6 degrees at the distal interphalangeal joint level. Total anterior tenoarthrolysis is considered a salvage procedure to treat flexion contractures of the fingers with articular cartilages that are in good condition and tendons that are still working.

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