Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach.

The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.

The effect of host tissue and radiation on fat-graft survival: A comparative experimental study.

Because lipofilling is often associated with various reconstructive procedures, especially breast reconstructions, improving fat-graft retention remains a major concern for plastic surgeons. We conducted an experimental protocol in a rat model simulating an autologous breast reconstruction method using the fat-augmented latissimus dorsi myocutaneous (LDM) flap. This study aimed to compare the survival rates of autologous adipocytes when injected subcutaneously and intramuscularly and to evaluate the role of recipient host tissue, volume of the injected fat, and postoperative radiation on fat-graft retention. Thirty rats were divided into five groups (A, B, C, D, and E), of six rats each. All animals underwent a pedicled LDM flap transfer to the anterior thoracic wall, and different volumes of autologous fat were injected into three recipient areas, namely, the pectoralis major and latissimus dorsi muscles and the subcutaneous tissue of the flap's skin island, as follows: 1 mL of fat was injected in total in group A, 2 mL in groups B and D, and 5 mL in group C. Group D animals received postoperative radiation (24 Gy), whereas group E animals (controls) did not undergo any fat grafting procedure. Eight weeks after surgery, adipocyte survival was assessed in all groups using histological and immunochemistry techniques. The results showed that the pectoralis major muscle was the substrate with the highest adipocyte survival rates, which were proportional to the amount of fat injected, followed by the latissimus dorsi muscle and the subcutaneous tissue. Increased volumes of transplanted fat into the subcutaneous tissue did not correspond to increased adipocyte survival. Irradiation of host tissues resulted in a statistically significant decrease in surviving adipocytes in all three recipient sites (p<0.001). Our study strongly suggests that muscle ensures optimal fat-graft retention, whereas postoperative radiation negatively affects adipocyte survival following fat transplantation.

Consecutive bilateral breast reconstruction using different autologous flaps: can symmetrical results still be achieved? A case report.

We report a 60-year-old patient who underwent bilateral mastectomy at different times, followed by immediate autologous reconstruction with different flaps: deep-inferior epigastric-perforator flap on one breast, and fat-augmented latissimus dorsi on the contralateral side. At 20-month follow-up, good symmetry was recorded; patient-reported outcome measurements revealed high satisfaction scores.

Long-Term Outcomes of Lymph Node Transfer in Secondary Lymphedema and Its Correlation with Flap Characteristics.

BACKGROUND: This retrospective study aimed to assess the impact of certain flap characteristics on long-term outcomes following microsurgical treatment in Breast Cancer-Related Lymphedema (BCRL) patients. METHODS: Sixty-four out of 65 BCRL patients, guided by the "Selected Lymph Node" ("SeLyN") technique, underwent Vascularized Lymph Node Transfer (VLNT) between 2012 and 2018. According to their surface size, flaps were divided into small (<25 cm2, n = 32) and large (>25 cm2, n = 32). Twelve large and six small flaps were combined with free abdominally based breast reconstruction procedures. Lymphedema stage, flap size, vascular pedicle and number of lymph nodes (LNs) were analyzed in correlation with long-term Volume Differential Reduction (VDR). RESULTS: At 36-month follow-up, no major complication was recorded in 64 cases; one flap failure was excluded from the study. Mean flap size was 27.4 cm2, mean LNs/flap 3.3 and mean VDR 55.7%. Small and large flaps had 2.8 vs. 3.8 LNs/flap (p = 0.001), resulting in 49.6% vs. 61.8% VDR (p = 0.032), respectively. Lymphedema stage and vascular pedicle (SIEA or SCIA/SCIP) had no significant impact on VDR. CONCLUSION: In our series, larger flaps included a higher number of functional LNs, directly associated with better outcomes as quantified by improved VDR.

Fat-Augmented Latissimus Dorsi versus Deep Inferior Epigastric Perforator Flap: Comparative Study in Delayed Autologous Breast Reconstruction.

BACKGROUND: The use of autologous tissues is considered the mainstay for delayed breast reconstruction. Aside the free abdominal flaps, which are most commonly used, the fat-augmented latissimus-dorsi (FALD) flap has been recently shown a reliable alternative option for pure autologous breast reconstruction. In this retrospective study, we aim to compare outcomes of autologous breast reconstructions using the extended FALD and deep inferior epigastric perforator flap (DIEP) flap, with an emphasis on patients' characteristics, demographic data, complications, and patients' satisfaction after a minimum 12-month follow-up. METHODS: Our series consists of 135 women who underwent a delayed postmastectomy unilateral autologous breast reconstruction from 2011 to 2017: 36 patients (Group A) had an extended FALD flap and 99 (Group B) a free DIEP flap performed by the same surgeons. Demographic data, breast volume, medical history, smoking, complications, and patients' satisfaction were recorded and analyzed. Student's t-test for independent variables, Mann-Whitney U-test, and Chi-squared test were used to compare the reported variables. RESULTS: Patients' age, body mass index (BMI), and pregnancy history were statistically different between groups (p < 0.001, p = 0.004, p < 0.001, respectively); younger age (35.1 vs. 41.2 years), lower BMI (25.6 vs. 28.4), and fewer pregnancies were recorded in Group A. Breast volume was also found significantly smaller in Group A patients (p = 0.009). Past medical history using the ASA physical status classification score, previous radiation therapy, history of smoking, and incidence of overall complications were similar in both groups. Overall satisfaction scores were found slightly higher, but not statistically significant, in the free-flap group (p = 0.442). CONCLUSION: The use of the FALD flap may provide comparable outcome to the DIEP flap in delayed breast reconstruction in terms of complications and patients' satisfaction; it should be considered a good reconstructive option for young and thin nulliparous patients, with small to medium size opposite breast.

An effective device and method for enhanced cell growth in 3D scaffolds: Investigation of cell seeding and proliferation under static and dynamic conditions.

Cell adhesion on 3D-scaffolds is a challenging task to succeed high cell densities and even cell distribution. We aimed to design a 3D-cell Culture Device (3D-CD) for static seeding and cultivation, to be used with any kind of scaffold, limiting cell loss and facilitating nutrient supply. 3D printing technology was used for both scaffold and device fabrication. Apart from testing the device, the purpose of this study was to assess and compare static and dynamic seeding and cultivation methods, of wet and dry scaffolds, under normoxic and hypoxic conditions and their effects on parameters such as cell seeding efficiency, cell distribution and cell proliferation. Human adipose tissue was harvested and cultured in 3D-printed poly(epsilon-caprolactone) scaffolds. Micro-CT scans were performed and projection images were reconstructed into cross section images. We created 3D images to visualize cell distribution and orientation inside the scaffolds. The group of prewetted scaffolds was the most favorable to cell attachment. The 3D-cell Culture Device (3D-CD) enhanced cell seeding efficiency with almost no cell loss. We suggest that the most favorable outcome can be produced with static seeding in the device for 24 h, followed either by static cultivation in the same device or by dynamic cultivation.

Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction.

Introduction Reverse neurocutaneous and propeller perforator flaps are both used to reconstruct diabetic distal lower limb defects. Our study aims to compare outcomes between these two groups of flaps with an emphasis on indications and complication rates. Method A retrospective analysis was conducted, reviewing data from 54 diabetic patients who underwent reconstruction of acute or chronic wounds of the foot and ankle between 2005-2018. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF): nineteen sural and fifteen lateral supramalleolar flaps. Twenty patients (Group B) had a propeller flap (PF) based on peroneal (n = 13) or posterior tibial artery perforators (n = 7). All patients had a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients' demographics, characteristics of the defect, postoperative complications and time to heal. Follow-up ranged from 6 to 59 months. Student's t-test and chi-squared test were used for statistical analysis. Results Mean patients' age was 59.1 and 50.8 years for Group A and B, respectively. Defects were located at the Achilles zone (n = 16), posterior heel (n = 14), foot dorsum (n = 9), lateral and medial malleolar areas (n = 8), anterior ankle (n = 5) and lateral foot (n = 2). Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B. Uneventful healing was recorded in 20/34 neurocutaneous flaps and in 12/20 propeller flaps; complications included two complete flap losses (one NCF, one PF), seventeen distal flap necroses (10 NCFs, 7 PFs), fifteen delayed wound healing events over the donor or recipient site (12 NCFs, 3 PFs). Secondary surgeries were required in 15 NCF and 8 PF patients. Mean healing time was 48.1 and 40.7 days for Group A and B, respectively. All patients, except one NCF case, which resulted in leg amputation, returned to previous levels of ambulation. Conclusion Reverse neurocutaneous and propeller flaps may provide stable reconstruction of diabetic lower limb defects; neurocutaneous flaps are specially indicated for larger and more distally located defects, although they might be associated with longer healing time and additional revision surgeries. Propeller flaps were more frequently used in younger patients for smaller and more proximally located defects.

Functional lymphatic reconstruction with the "Selected Lymph Node" technique guided by a SPECT-CT lymphoscintigraphy.

BACKGROUND: A new technique named "Selected Lymph Node" ("SeLyN") was evaluated, aiming to identify the most functional groin lymph nodes (LNs) for an effective LN transplantation. METHODS: Bilateral lower-limb SPECT-CT was performed in the upper-limb lymphedema patients, to select the most radioactive inguinal LN. Recorded data included demographics, stage, etiology of lymphedema, flap consistency in accordance to preoperative findings, flap size, number of LN, and harvesting time. Infection episodes per year and volume changes of the upper limbs were documented. Donor-site complications were recorded and lower-limb evaluation was performed through clinical examination, volume analysis, and lymphoscintigraphy. RESULTS: A total of 41 patients underwent a "SeLyN" transfer technique. The mean flap size was 28.34 cm2 containing a mean of 3.4 LNs. The mean time spent on flap harvest was 39 minutes. A mean 56.5% volume reduction (P < .001) and a mean 1.41 to 0.29 infection episodes per patient per year (P < .001) were recorded. Clinical evaluation and lymphography of the donor site advocated no major complications for a mean follow-up period of 42.5 months. CONCLUSIONS: "SeLyN" is a safe and effective technique in selecting the most suitable LNs, minimizing the donor-site morbidity, and decreasing the overall operating time.

Hyaline cartilage next generation implants from adipose-tissue-derived mesenchymal stem cells: Comparative study on 3D-printed polycaprolactone scaffold patterns.

We used additive manufacturing to fabricate 3D-printed polycaprolactone scaffolds of different geometry topologies and porosities. We present a comparative analysis of hyaline cartilage development from adipose-tissue-derived mesenchymal stem cells (ADMSCs) on three different, newly designed scaffold geometry patterns. The first scaffold design (MESO) was based on a rectilinear layer pattern. For the second pattern (RO45), we employed a 45° rotational layer loop. The design for the third scaffold (3DHC) was a three-dimensional honeycomb-like pattern with a hexagonal cellular distribution and small square shapes. We examined cell proliferation, colonization, and differentiation, in relation to the scaffold's structure, as well as to the mechanical properties of the final constructs. We gave emphasis on the scaffolds, both microarchitecture and macroarchitecture, for optimal and enhanced chondrogenic differentiation, as an important parameter, not well studied in the literature. Among the three patterns tested, RO45 was the most favourable for chondrogenic differentiation, whereas 3DHC better supported cell proliferation and scaffold penetration, exhibiting also the highest rate of increase onto the mechanical properties of the final construct. We conclude that by choosing the optimal scaffold architecture, the resulting properties of our cartilaginous constructs can better approximate those of the physiological cartilage.

Outcomes of Fat-Augmented Latissimus Dorsi (FALD) Flap Versus Implant-Based Latissimus Dorsi Flap for Delayed Post-radiation Breast Reconstruction.

BACKGROUND: Although free abdominal flaps constitute the gold standard in post-radiation delayed breast reconstruction, latissimus dorsi-based methods offer alternative reconstructive options. This retrospective study aims to compare outcomes of delayed breast reconstruction using the fat-augmented latissimus dorsi (FALD) autologous reconstruction and the latissimus dorsi-plus-implant reconstruction in irradiated women. METHODS: We reviewed the files of 47 post-mastectomy irradiated patients (aged 29-73 years), who underwent delayed latissimus dorsi-based breast reconstruction between 2010 and 2016. Twenty-three patients (Group A) had an extended FALD flap and twenty-four patients (Group B) an implant-based latissimus dorsi reconstruction. Patients' age, BMI, pregnancies, volume of injected fat, implant size, postoperative complications, and secondary surgical procedures were recorded and analyzed. RESULTS: Age, BMI, pregnancies, and donor-site complications were similar in both groups (p > 0.05). Mean fat volume injected initially was 254 cc (ranged 130-380 cc/session); mean implant volume was 323 cc (ranged 225-420 cc). Breast complications were significantly fewer in Group A (one wound dehiscence, two oily cysts) compared to Group B (three cases with wound dehiscence, two extrusions, thirteen severe capsular contractions). Non-statistically significant difference was documented for secondary procedures between groups; although the mean number of additional surgeries/patient was higher in Group A, they referred to secondary lipofilling, whereas in Group B they were revision surgeries for complications. CONCLUSIONS: The FALD flap constitutes an alternative method for delayed autologous reconstruction after post-mastectomy irradiation, avoiding implant-related complications. Although additional fat graft sessions might be required, it provides an ideal autogenous reconstructive option for thin nulliparous women, with a small opposite breast and adequate fat donor sites. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 .

Donor-Site Lymphedema Following Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review of the Literature.

Abstracts Background: Among current surgical options used for treating breast cancer-related lymphedema (BCRL), autologous lymph node transfer (ALNT) is shown to provide favorable results. However, postoperative donor-site lymphedema (DSL), following the lymphatic flap harvesting from the groin area, has already been reported. Our aim is to summarize the recent literature for evidence of DSL following an ALNT for BCRL. METHODS AND RESULTS: A PubMed bibliographic search was performed for published studies evaluating donor-site complications following LNT in BCRL patients. We recorded demographic data of the patients, the type of flap used, the follow-up, the donor-site morbidity, and the diagnostic tests performed pre- and postoperatively. Statistical analysis was conducted to document any correlation between the incidence of DSL and the abovementioned recorded parameters. According to our results, 11 studies met the inclusion criteria. From a total of 189 patients, three cases with DSL of the lower limb were reported (1.6%). No statistically significant correlations were found. CONCLUSION: ALNT has become increasingly popular and is considered an effective surgical option for treating BCRL of the upper limb. Although the incidence of postoperative DSL is low, insufficient data on patients' demographics, surgical details, and postoperative assessment do not allow extracting significant correlations. Meticulous technique of lymph node harvesting should be seriously considered to further minimize this infrequent but debilitating complication.

Severe Extravasation Injuries in Neonates: A Report of 34 Cases.

INTRODUCTION: Extravasation injuries are a common and challenging problem in hospitalized newborns. Accidental infusion leakage into the surrounding tissues in immature infants may frequently result in skin necrosis, with significant risk of functional and cosmetic impairment. MATERIAL AND METHODS: In the present study we reviewed 34 cases of severe extravasation injuries occurring in 1,409 neonates hospitalized in a single neonatal unit over 24 months (incidence 2.4%). Total parenteral nutrition solutions were involved in most cases. All patients were treated within 30 minutes after the injury was recorded using a flush-out technique with normal saline irrigation and occlusive paraffin dressings of the infiltrated area. RESULTS: The majority of injuries affected preterm, low-birthweight infants (mean gestation 32 wks + 6 days, mean birth weight 1,885 g), with a mean age at the time of injury of 11.6 days and a mean weight of 2,045 g. Neither gestational age (p = 0.87) or birthweight significantly affected (p = 0.07) the incidence of extravasation injuries, although the incidence of skin necrosis had a significant correlation with gestational age (p = 0.009) and birthweight (p < 0.001). All patients responded well to treatment and their wounds healed uneventfully within a maximum of 25 days without the need for secondary surgery for skin coverage. CONCLUSION: Extravasation injuries in extremely preterm and low-birthweight infants are more likely to lead to skin necrosis. Peripheral venous catheterization should be performed with caution in these patients to prevent such injuries. Immediate irrigation with normal saline is recommended to reduce toxic sequelae in the infiltrated area.

Predesigned breast shaping assisted by multidetector-row computed tomographic angiography in autologous breast reconstruction.

BACKGROUND: Free abdominal flaps are the first option in autologous breast reconstruction using the multidetector-row computed tomographic angiography for mapping the abdominal perforators. The authors aim to evaluate the impact of using a preoperative design for shaping the new breast symmetrical to the contralateral breast, assisted by multidetector-row computed tomographic angiography. METHODS: Thirty-two consecutive patients who underwent delayed unilateral breast reconstruction with free abdominal flaps were divided into two groups. In group A, the new breast was shaped intraoperatively and inset, whereas in group B, a preoperative design of the new breast was used. All patients underwent multidetector-row computed tomographic angiography before the operation and the flaps were centralized around the selected perforators. Both groups were evaluated for the time spent on flap harvest, time spent on breast shaping and inset, complication rates, and secondary operations required for breast symmetrization. Independent surgeons evaluated the final aesthetic outcome. RESULTS: The mean time spent on harvesting the flap was not significantly different between the two groups (p > 0.05); the mean time spent on breast shaping and inset was significantly shorter in group B (p < 0.001). There were no differences between the two groups regarding complications recorded, whereas symmetrization surgery was significantly less in group B (p < 0.05). At a mean follow-up 17.3 months, the final aesthetic outcome was greater in group B. CONCLUSION: Predesigned breast shaping assisted by multidetector-row computed tomographic angiography promotes a significant reduction in the overall operative time and the need for secondary symmetrization procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.