Physical properties of Scarpa's fascia.

Preservation of Scarpa's fascia has improved clinical outcomes in abdominoplasty procedures and in other body contour surgeries. However, the physical properties of Scarpa's fascia have not yet been described, and grafts are still underexplored. Fresh surgical specimens from five female patients subjected to classical abdominoplasty were dissected and analyzed. A grid was drawn on the fascia surface, dividing it into equal upper and lower halves; four Scarpa's fascia samples (30 × 10 mm) were collected from each half, 40 mm apart. The thickness was measured with a caliper. A strain/stress universal testing machine was used for mechanical tests. Twenty-five samples were obtained (nine from the upper half, 16 from the lower). The average thickness was 0.56 ± 0.11 mm. The average values for stretch, stress, strain, and Young's Modulus were, respectively, 1.436, 4.198 MPa, 43.6%, and 23.14 MPa. The upper half showed significantly greater thickness and strain values (p = 0.020 and p = 0.048; Student's t-test). The physical and biomechanical properties of Scarpa's fascia can make it a donor area for fascial grafts as an alternative to fascia lata, as it is always available and has minimal donor-site morbidity. Further studies are needed to validate this statement. It seems advantageous to use the lower half of the abdomen instead of the upper part as a donor site.

Use of Infrared Thermography for Abdominoplasty Procedures in Patients with Extensive Subcostal Scars: A Preliminary Analysis.

Subcostal scars may increase the risk of healing complications in abdominoplasty. The authors evaluated the use of thermography as a potential tool for patient selection and surgery planning to avoid complications and improve abdominoplasty outcomes. Two candidates for abdominoplasty procedures who presented with extensive subcostal scars were submitted to an infrared thermography protocol at all phases of the procedure: preoperative, intraoperative, and postoperative at 1 and 6 months. The preoperative thermography for both patients revealed near-normal abdominal wall perfusion. The thermograms captured intraoperatively during flap elevation did not show perfusion deficits on the upper abdominal flap. At 1 month and 6 months postoperative, dynamic thermography for both patients showed normal to near-normal perfusion. The procedures had a complication-free course with a good aesthetic result. Plastic surgeons may be reluctant to perform a full abdominoplasty in patients with a previous subcostal incision. In this preliminary analysis, we raise the potential usefulness of thermography for patients with recent subcostal scars and/or important comorbidities as a strategy for adequate patient and technique selection, avoiding possible complications. Future studies, with an increased number of patients and adequate statistical analysis, may allow us to validate the utility of thermography in these cases and reassure that the presence of previous extensive subcostal scars may not be a contraindication for a full abdominoplasty, especially if they are not recent.

Classic Versus Scarpa-sparing abdominoplasty: An infrared thermographic comparative analysis.

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to have several clinical advantages. The mechanisms behind its efficiency have been the subject of several studies. Three theories have been proposed, relating to mechanical factors, lymphatic preservation, and improved vascularization. This study aimed to further investigate the possible vascular impact of Scarpa fascia preservation by using a thermographic analysis. METHODS: A single-center prospective study was conducted, involving 12 female patients randomly and equally assigned to one of two surgical procedures: classic (Group A) and Scarpa-sparing abdominoplasty (Group B). Dynamic thermography was applied before and after surgery (one and six months), and two regions of interest (ROIs) were considered. The latter had the same location on every sample, and corresponded to areas where different surgical planes had been used. Static thermography was applied intraoperatively, and four ROIs were considered, located over Scarpa and over the deep fascia. The respective thermal data were analyzed. RESULTS: The general characteristics of both groups were identical. Preoperative thermography demonstrated no differences between groups. Intraoperative higher thermal gradients between lateral and medial ROIs were observed in Group B (P = 0.037, right side). Dynamic thermography at one month demonstrated a trend for better thermal recovery and better thermal symmetry (P = 0.035, 1-min mark) in Group B. No other differences were found. CONCLUSION: Dynamic thermography presented a better response when Scarpa fascia was preserved: stronger, faster, and more symmetric. Based on these results, improved vascularization may have a role in explaining the clinical efficiency of a Scarpa-sparing abdominoplasty.

Dissection Technique for Abdominoplasty With Scarpa Fascia Preservation: Comparative Study on Avulsion Technique Versus Diathermocoagulation.

BACKGROUND: Many strategies have been developed to lower the high complication rate associated with a full abdominoplasty. The dissection technique may have a role to achieve this goal. OBJECTIVES: The present study compared 2 different dissection techniques to perform a full abdominoplasty with Scarpa fascia preservation: avulsion technique and electrodissection. METHODS: A retrospective observational cohort study was performed in 2 health institutions from January 2005 to January 2019. A total of 251 patients were involved: 122 patients submitted to abdominoplasty employing the avulsion technique (Group A) and 129 with diathermocoagulation (coagulation mode) (Group B). The latter was further divided into group B1 (57 patients with device settings according to surgeon's preferences) and B2 (72 patients with a specific regulation aiming at minimal tissue damage). Several variables were analyzed: population characteristics, time of hospital stay, time to drain removal, total and daily drain output, emergency department visits, readmission, reoperation, and local and systemic complications. RESULTS: The general characteristics of both groups did not statistically significantly differ except for previous abdominal surgery. The diathermocoagulation group had a significantly lower length of hospital stay and time to drain removal. Moreover, these advantages were maximized when electrocautery was conducted with a specific low-voltage setting as significant differences were found. The other outcomes were identical. CONCLUSIONS: Limiting the extension of electrodissection with the avulsion technique did not present any advantage. Utilizing diathermocoagulation (coagulation mode) during a full abdominoplasty with Scarpa fascia preservation, especially when it is aimed at minimal tissue damage, reduces patients' time with drains.

Abdominoplasty with Scarpa Fascia Preservation: Randomized Controlled Trial with Assessment of Scar Quality and Cutaneous Sensibility.

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to reduce complications associated with the traditional technique. As an extension of a previously published randomized controlled trial, this study aims to clarify whether preservation of Scarpa fascia during abdominoplasty has an influence on scar quality or sensibility recovery. METHODS: This was a single-center clinical trial, involving 160 patients randomly assigned to one of two surgical procedures: classic full abdominoplasty (group A) and abdominoplasty with preservation of Scarpa fascia (group B). Patients were later convoked to assess scar quality and abdominal cutaneous sensibility. Scar quality was evaluated through the Patient and Observer Scar Assessment Scale. Cutaneous sensibility was measured on the upper and lower abdomen, using light touch, Semmes-Weinstein testing (5.07/10-g monofilament), and a 25-gauge needle. RESULTS: A total of 99 patients (group A, 54 patients; group B, 45 patients) responded to contact, with a mean follow-up time of 44 months. Concerning scar quality, Patient and Observer Scar Assessment Scale scores were similar between groups. On the upper abdomen, there was a statistically significant difference between groups on cutaneous sensibility, on the examination with the Semmes-Weinstein 5.07/10-g monofilament (group A, 79.6 percent; group B, 93.3 percent; p = 0.046) and pain (group A, 90.7 percent; group B, 100 percent; p = 0.044). No statistically significant differences were found between groups on the lower abdomen. A considerable proportion of patients (two-thirds) still presented sensibility alterations in the subumbilical area 3½ years after abdominoplasty. CONCLUSION: Scarpa fascia preservation during abdominoplasty does not influence scar quality, but it improves sensibility recovery in the supraumbilical area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Arm malignant peripheral nerve sheath tumour: a rare clinical presentation.

Soft tissue sarcomas account for about 1% of malignant tumours. More than 50 subtypes of these tumours have been described with some being extremely rare, namely malignant peripheral nerve sheath tumours (MPNST). The authors present a case of a man aged 81 years with a medical history of an adenocarcinoma of the rectum, which was referred to our clinic due to a growing painless mass on the right arm. An MRI showed a well-delimited encapsulated mass involving the long head of the biceps muscle. Biopsy findings revealed a spindle cell tumour with cytonuclear pleomorphism. The patient underwent wide tumour excision and was successfully reconstructed with a latissimus dorsi functional muscle transfer. The presence of two pulmonary nodules on CT scan staging implied a lung biopsy that showed rectum primary tumour metastases. With these additional findings, the pathology department reassessed the case and reclassified the arm tumour as an MPNST, synchronous with pulmonary adenocarcinoma metastases of the rectum.

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure.

When an auricular defect is caused by high-energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year-old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A "printed" ear made of silicone, based on the patient's CT-scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.

Abdominoplasty with Scarpa fascia preservation - comparative study in a bariatric population.

BACKGROUND: Abdominoplasty techniques using a more superficial plane of dissection with Scarpa fascia preservation have been shown to improve recovery and reduce complications in nonbariatric patients. Patients who have experienced massive weight loss frequently need body contour procedures and represent a high-risk group. OBJECTIVE: To evaluate the effect of this technique in patients with massive weight loss after bariatric surgery. SETTING: University hospital, Portugal. METHODS: This was a single-center retrospective study of 51 postbariatric patients who had been undergone either a classic full abdominoplasty (group A) or a similar procedure except for the preservation of Scarpa fascia below the umbilicus (group B). General characteristics of both groups were analyzed, and recorded outcomes were total and daily volume of drain output, time until drain removal, time until hospital discharge, and local and systemic complications. RESULTS: There were no statistically significant differences between groups regarding general characteristics or complications. The Scarpa fascia preservation group had a highly significant reduction of 79% on the total drain output, 7 days until drain removal, and 5 days' hospital stay. Long drainers (7 days or more with drains) were eliminated (reduction from 52% in group A to 3% in group B) and seroma had a 65% reduction. CONCLUSION: Preserving Scarpa fascia during a full abdominoplasty in postbariatric patients improves recovery by reducing total drain output and hospital stay, allowing earlier drain removal, eliminating long periods with suction drains, and reducing seroma incidence. Clear benefits for the patient were obtained.

Dissection Technique for Abdominoplasty: A Prospective Study on Scalpel versus Diathermocoagulation (Coagulation Mode).

BACKGROUND: The purpose of this study was to evaluate the effect of the dissection technique on outcomes and complications after a full abdominoplasty, comparing 2 different techniques used to raise the abdominal flap: the steel scalpel and the diathermocoagulation device on coagulation mode. METHODS: A prospective study was performed at a single center from January 2009 to December 2011 of patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, abdominoplasty performed with steel scalpel/knife; and group B, abdominoplasty performed with diathermocoagulation on coagulation mode. Several variables were determined: general characteristics, time until drain removal, daily and total volume of drain output, length of hospital stay, operative time, readmission, reoperation, emergency department visits, and local and systemic complications. RESULTS: A total of 119 full abdominoplasties were performed in women (group A, 39 patients; group B, 80 patients). There were no statistically significant differences between groups with respect to general characteristics, except for body mass index, comorbidities, and weight of the surgical specimen; there were no differences for operative time, systemic complications, hematoma, and necrosis incidence. The scalpel group had a highly significant reduction of 54.56% on total drain output, and a 2.65 day reduction on time to drain removal and no reported cases of seroma or healing problems (difference of 81.25% and 90.00%, respectively, between the 2 groups). CONCLUSIONS: Performing abdominal dissection with scalpel had a beneficial effect on patient recovery, as it reduced time requested for drain removal, total drain output, and incidence of seroma and wound healing problems.

Multi-staged flap reconstruction for complex radiation thoracic ulcer.

INTRODUCTION: Chest wall reconstruction due to previous radiation therapy can be challenging and complex, requiring a multidisciplinary approach. PRESENTATION OF CASE: The authors present the case of a 84-year-old woman with a right chest wall radionecrosis ulcer, that was submitted to an ablative surgery resulting in a full-thickness defect of 224cm(2), firstly reconstructed with a pedicled omental flap. Due to partial flap necrosis, other debridements and chest wall multi-staged flap reconstruction were performed. DISCUSSION: This case highlights that the reconstructive choice should be individualized and dependent on patient and local factors. The authors advise that surgical team should work closely and be well versed in chest wall reconstruction with a variety of pedicled flaps, when a complication occurs. CONCLUSION: A multi-staged flap reconstruction could be a salvage procedure for the coverage of complex, great and complicated chest wall defects due to previous radiation therapy.

Chimeric flaps and "their variations": different options for immediate reconstruction of massive facial defects.

The reconstruction of massive head and neck defects is a difficult challenge, requiring restoration of bone, skin, and oral lining. Their complex three-dimensional nature often dictates the need of more than a single osteocutaneous flap for intra- and extra-oral reconstruction.Conventional reconstructive options can be considered, but there is no single ideal osteocutaneous free or pedicled flap providing an unlimited length of bone and skin paddle, or that could orient the skin paddle independently of the vascularized bone. The surgeon should then be aware of more complex options for reconstruction of extensive three-dimensional defects, namely chimeric free flaps and "their variations." They can be stratified in three types, either based on their intrinsic vasculature-perforated-based, branch-based, or whether they are prefabricated (surgical junction by microanastomosis).Despite morbidity and not perfect matching in terms of skin texture and pliability, these techniques are a good alternative in the presence of partial defects, especially in the context of immediate oncological reconstruction, where facial transplantation is not considered.

Facial allotransplantation procurement using a transparotid approach: a new anatomical model.

BACKGROUND: Full face transplantation is a complex procedure and a detailed plan is needed. Coaptation of motor nerve branches at more distal sites instead of the level of the main trunk is highly desirable, but may be difficult to find, are thin, fragile and have limited length for safe and tension-free coaptation. In addition, nerve grafts may be necessary. In this study, the technical feasibility of facial allotransplantation procurement using a transparotid approach was investigated. METHODS: Three mock cadaver dissections were performed, procuring full face transplants with en bloc facial nerve dissection. The facial nerve (main trunk, temporofacial/cervicofacial divisions, and individual facial branches) was elevated en bloc as part of the allograft, dissected out from the parotid completely, and left as loose attachments to the allograft specimen. RESULTS: Full face transplantation with en bloc facial nerve dissection was technically feasible, allowing for more proximal or distal nerve section, and to achieve the desired length and diameter for appropriate matching during nerve coaptation. CONCLUSION: This technique follows principles of targeted nerve reinnervation. It allows to select the level of facial nerve section to the temporofacial and cervicofacial divisions or final branches, with further adaptation to the remaining recipient's anatomic structures, and avoiding the need for nerve grafts; it also excludes the parotid gland (reduces bulk). Despite a small increase in the time required for dissection, this disadvantage may be compensated by an improved functional recovery.