Facial Allograft Donation: An Interpretative Phenomenological Analysis of the Experiences of Family Members.

Facial allograft transplantation can be regarded as a particular and complex type of donation because of its perceptibility and the importance of the face as an identity characteristic. As research on this topic is currently lacking, the objective of this study is to explore the experiences of the family members of the donor in facial allograft donation. In-depth, semi-structured interviews were conducted separately with the donor's family members and analyzed using interpretative phenomenological analysis. Six themes were identified: (1) Contrasting facial donation to that of more commonly donated organs; (2) Consenting to facial donation; (3) Expectations towards the recipient of the facial graft; (4) Expectations and consequences of restoration of the donor's face; (5) Relationship with the medical team during the process; and (6) Media attention. The findings of our study help to better support donor families through the facial donation process and to improve facial transplantation procedures.

Benefits of Using Magnetic Resonance Imaging During Breast Tissue Expansion: Literature Review and Case Series.

Breast cancer results in up to 1.6 million new candidates for yearly breast reconstruction (BR) surgery. Two-stage breast reconstruction surgery with the use of a tissue expander (TE) is a common approach to reconstructing the breast after mastectomy. However, a common disadvantage encountered with the traditional breast TE is the magnetic injection port, which has been reported to cause injuries in patients undergoing magnetic resonance (MR) imaging. Therefore this type of breast TE is labeled "MR unsafe." Recent technological advances have incorporated radio-frequency identification (RFID) technology in the TE to allow for the location of the injection port without magnetic components, resulting in an MR-conditional TE. This paper aims to review the information regarding the safety profile of TEs with magnetic ports and to gather distinct clinical scenarios in which an MR-conditional TE benefits the patient during the BR process. A literature review ranging from 2018 to 2022 was performed with the search terms: "tissue expander" OR "breast tissue expander" AND "magnetic resonance imaging" OR "MRI." Additionally, a case series was collected from each of the authors' practices. The literature search yielded 13 recent peer-reviewed papers, and 6 distinct clinical scenarios were compiled and discussed. Most clinicians find MRI examinations to be the state-of-art diagnostic imaging modality. However, due to the preexisting risks associated with TEs with magnetic ports, the MRI labeling classification should be considered when deciding which TE is the most appropriate for the patient requiring MRI examinations.

Lumbar artery perforators: an anatomical study based on computed tomographic angiography imaging.

BACKGROUND: The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted. METHODS: An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid. RESULTS: Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7-10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm). CONCLUSION: This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

The Lumbar Artery Perforator Flap in Breast Reconstruction.

SUMMARY: The lumbar artery perforator flap is a valuable alternative in breast reconstruction whenever the deep inferior epigastric perforator flap is not feasible because of insufficient or unavailable abdominal tissue. The advantage is the ideal shape and consistency of the flap, in addition to the option to perform a nerve anastomosis with the cluneal nerve. The anatomy is consistent, but there are some technical issues related to the short perforator and difficult surgical exposure in the lower back region. The inclusion of a vascular interposition graft improved the authors' results and facilitated their technical challenges and final inset of the flap. These videos guide the surgeon through the different steps involved in a breast reconstruction with the lumbar artery perforator flap.

Technical recommendations for penile replantation based on lessons learned from penile reconstruction.

Penile amputation is an exceptional surgical emergency. Immediate replantation yields a high success and low complication rate. We report a case of a self-inflicted penile amputation treated with successful microsurgical replantation. Postoperative edema caused minor skin slough and temporary venous congestion was treated with medicinal leech therapy. Follow-up at 18 months showed normal subjective sensation; voiding and erectile function were present. Surgical management and technique refinements are discussed, based on a review of the literature and on our experience in penile reconstruction.

The Prepectoral, Hybrid Breast Reconstruction: The Synergy of Lipofilling and Breast Implants.

Breast reconstruction modalities are based on autologous tissue transfer, implants, or a combination of both. The aim of an allogeneic breast reconstruction is to minimize the impact of the implant on surrounding tissues to achieve an aesthetically pleasing result. Accurate tissue coverage, proper implant selection, and implant location are the absolute concerns in planning an implant-based reconstruction. METHODS: A single surgeon's experience with the ergonomic, hybrid approach in primary and secondary breast reconstructions is presented. The hybrid approach is based on tissue expansion followed by serial sessions of fat grafting to augment the residual autologous (subcutaneous) compartment. The last step included the insertion of a prepectoral, ergonomic implant to obtain central core projection and additional volume. RESULTS: Fifty-six hybrid breast reconstructions were performed with a mean follow-up of 24.1 months. Aesthetic outcomes and patient satisfaction have been good with pleasing breast projection, natural breast motion, and optimal coverage of the prepectoral implants. CONCLUSIONS: The hybrid reconstructive approach is a reliable technique to improve the outcomes in implant-based breast reconstructions. The 2-step, prepectoral approach with expander-to-implant exchange allows better control of the final breast shape, and complications related to submuscular approaches are avoided. Fat grafting adds an autologous benefit to obtain natural results.

Adipose tissue induction in vivo.

Engineering adipogenic tissue in vivo requires the concomitant induction of angiogenesis to generate a stable long-term three-dimensional construct. Histioconductive tissue engineering strategies have been used. The disadvantage of using biodegradable scaffolds is a delayed angiogenic induction resulting in ischemic necrosis of the central cell population in the scaffold. We evaluated an histioinductive approach for adipose tissue engineering by combining essential key components for adipogenic induction: (1) a precursor cell source, (2) a vascular pedicle, (3) a supportive matrix, and (4) a chamber to preserve space for the new tissue to develop. We observed concomitant adipogenic and angiogenic induction after 6 weeks in three-dimensional adipose tissue constructs.

Bipedicled DIEAP flaps for reconstruction of limb soft tissue defects in male patients.

BACKGROUND: Extensive soft tissue deficiencies involving the limbs can be difficult to reconstruct and may require more than one microsurgical flap transfer to cover the defect. This can be particularly challenging in male patients, where the sacrifice of a donor muscle could result in considerable comorbidity. This paper describes the use of the bipedicled deep inferior epigastric artery perforator (DIEAP) flap to perform a one-stage reconstruction of extensive soft tissue defects in male patients. METHODS: By using preoperative multidetector computed tomographic (MDCT) angiography, the dominant perforators of the abdominal wall were identified and the bipedicled DIEAP flap was used for a one-stage reconstruction of complicated tissue loss in 12 male patients. In seven of these flaps, a microsurgical anastomosis between the two epigastric pedicles of the DIEAP flap was carried out. The feasibility of the procedure, clinical outcome, and possible associated comorbidities were evaluated. RESULTS: Successful large tissue reconstructions were performed using all four traditional zones of the DIEAP flap, with dimensions of flaps ranging from 20 × 8 to 50 × 17 cm. Venous congestion was seen to develop in two flaps, one of which was salvaged by performing an additional venous anastomosis, but the other flap failed to survive. Apart from this, complications were minimal. CONCLUSIONS: Soft tissue coverage of extensive wounds in male patients without sacrificing muscle flaps can be challenging. This extended utilization of the entire DIEAP flap has helped us to address this issue.

Intratissular expansion-mediated, serial fat grafting: A step-by-step working algorithm to achieve 3D biological harmony in autologous breast reconstruction.

BACKGROUND: Breast reconstruction involves the use of autologous tissues or implants. Occasionally, microsurgical reconstruction is not an option because of insufficient donor tissues. Fat grafting has become increasingly popular in breast surgery. The challenge with this technique is how to reconstruct a stable and living "scaffold" that resembles a breast. METHODS: Breast reconstruction (n = 7) was performed using intratissular expansion with serial deflation-lipofilling sessions. Mean age of the patients was 41 years (22-53). The expander generated a vascularized capsule at 8 weeks, which demarcated a recipient site between the skin and the capsule itself, and functioned as a vascular source for angiogenesis. Serial sessions of deflation and lipofilling were initiated at 8 weeks with removal of the expander at the completion of the treatment. An average of 644 ml (range, 415 ml-950 ml) of lipoaspirate material was injected to reconstruct the breast mound. An average of 4 (range, 3 to 5) fat-grafting sessions with a 3-month interval was needed to achieve symmetry with the contralateral breast. The average follow-up was 14 months (range, 9-29 months). MRI examination was performed at 8 months to analyze tissue survival and the residual volume. RESULTS: MRI examination retained tissue survival and the mean reconstructed breast volume was 386 ml (range, 231 ml-557 ml). An aesthetically pleasant breast mound was created, with a high satisfaction rate. CONCLUSION: We could reconstruct an aesthetically pleasant and stable breast mound in a selected group of patients by using intratissular expansion and fat grafting.

Complex facial reconstruction by vascularized composite allotransplantation: the first Belgian case.

INTRODUCTION: Complex injuries to the central part of the face are difficult to reconstruct with the current plastic surgery methods. The ultimate one-staged approach to restore anatomy and vital facial functions is to perform a vascularized composite allotransplantation (VCA). METHODS: A 54-year-old man suffered from a high-energy ballistic injury, resulting in a large central facial defect. A temporary reconstruction was performed with a free plicated anterolateral thigh (ALT) flap. Considering the goal to optimally restore facial function and aesthetics, VCA was considered as an option for facial reconstruction. A multidisciplinary team approach, digital planning, and cadaver sessions preceded the transplantation. RESULTS: A digitally planned facial VCA was performed involving the bilateral maxillae, the hard palate, a part of the left mandible, and the soft tissues of the lower two-thirds of the face. Due to meticulous preparations, minimal adjustments were necessary to achieve good fitting in the recipient. At week 17, a grade 4 rejection was successfully treated; sensory and motor recovery was noted to occur from the fourth postoperative month. Several serious infectious and medical problems have occurred until 15-months postoperatively; following that, the clinical situation has remained stable. Two years postoperatively, the patient and his family are very satisfied with the overall outcome and social reintegration in the community is successful. CONCLUSION: The first face transplant in Belgium (#19 worldwide) was successful because of a meticulous 3-year preparation by a large multidisciplinary team. In our experience, preparatory cadaver dissections and three-dimensional (3D) computed tomographic (CT) modeling were valuable tools for an optimal intraoperative course and good alignment of the bony structures. Continuous long-term multidisciplinary follow-up is mandatory for surveillance of the complications associated with the immunosuppressive regime and for functional assessment of the graft.

Pedicled perforator flaps in the trunk.

Trunk defects can be approached through a multitude of regional flaps that can be harvested from the shoulder girdle, the epigastric axis, the paraspinal region, or the pelvic girdle. The aim of the reconstruction is to provide adequate and tension-free restoration of tissue integrity with minimal functional morbidity, water- and airtight closure of cavities, and coverage of exposed vital structures. Potential donor sites should be estimated for their tissue quality and anticipated donor site morbidity. The prototypical pedicled flap has a constant, reliable anatomy; however, the pedicled flap should have a configuration that is versatile and adequate for coverage and should resist infection. Also, the surgical technique should be uncomplicated.

Intrinsics and dynamics of fat grafts: an in vitro study.

BACKGROUND: Despite a revived interest in fat grafting procedures, clinicians still fail to demonstrate clearly the in vivo behavior of fat grafts as a dynamic tissue substitute. However, the basic principles in cellular biology teach us that cells can survive and develop, provided that a structural matrix exists that directs their behavior. The purpose of this in vitro study was to analyze that behavior of crude fat grafts, cultured on a three-dimensional laminin-rich matrix. METHODS: Nonprocessed, human fat biopsy specimens (approximately 1 mm) were inoculated on Matrigel-coated wells to which culture medium was added. The control group consisted of fat biopsy specimens embedded in medium alone. The cellular proliferation pattern was followed over 6 weeks. Additional cultures of primary generated cellular spheroids were performed and eventually subjected to adipogenic differentiation media. RESULTS: A progressive outgrowth of fibroblast-like cells from the core fat biopsy specimen was observed in both groups. Within the Matrigel group, an interconnecting three-dimensional network of spindle-shaped cells was established. This new cell colony reproduced spheroids that functioned again as solitary sources of cellular proliferation. Addition of differentiation media resulted in lipid droplet deposition in the majority of generated cells, indicating the initial steps of adipogenic differentiation. CONCLUSIONS: The authors noticed that crude, nonprocessed fat biopsy specimens do have considerable potential for future tissue engineering-based applications, provided that the basic principles of developmental, cellular biology are respected. Spontaneous in vitro expansion of the stromal cells present in fat grafts within autologous and injectable matrices could create "off-the-shelf" therapies for reconstructive procedures.