Use of licap and ltap flaps for breast reconstruction.

Breast conserving surgery has been reserved for patients with favorable proportion between tumor dimensions and breast size. Introduction of local flaps from the lateral thoracic region has widened the indications for breast conserving surgery, by allowing surgeons to perform wider excisions, thus yet be able to ensure tumor-free surgical margins and a good aesthetic result. We have used lateral intercostal perforator flaps and flaps harvested on the lateral thoracic artery and lateral thoracic artery axial flap in patients with small breasts and an unfavorable tumor to breast size proportion. From May 2015 to October 2016, 19 patients with breast tumors have been treated with BCS and immediate volume replacement reconstruction by pedicle perforator flaps from the lateral thoracic region. In 15 patients lateral intercostal artery perforator flaps or lateral thoracic artery perforator flaps were used after quadrantectomy or wide local excision, in 3 patients as volume replacement after mastectomy and in 1 patient after mastectomy following previous augmentation mammoplasty. In all patients, good breast symmetry was achieved, with no major complications. Fibrosis of the flap and residual breast parenchyma, with volume reduction were noticed after postoperative radiotherapy in thin patients or flaps with little subcutaneous fat. Perforator flaps from the lateral thoracic region should become the gold standard for reconstructions after breast conserving surgery involving less than 20% of the breast volume or after mastectomy in patients with small breasts. The operating procedure is safe, quick and allows sparing of the latissimus dorsi muscle and thus minimal donor site morbidity, as well as an excellent aesthetic result.

PATIENT SATISFACTION AFTER BREAST RECONSTRUCTION: IMPLANTS VS. AUTOLOGOUS TISSUES.

INTRODUCTION: Breast reconstruction is increasingly present in the treatment of breast cancer. It may be accomplished with implants or autologous tissues. This cross-sectional study evaluates patients satisfaction and quality of life in women after successful autologous or implant breast reconstruction. MATERIAL AND METHODS: 109 women who successfully underwent breast reconstruction between 2007 and 2016 were included. The patients completed the BREAST-Q questionnaire at follow-up visits. Additional data were collected retrospectively from the hospital charts regarding complications, smoking, chemotherapy, radiotherapy, unilateral or bilateral reconstruction, BMI and comorbidities. Mann-Whitney U Test was applied to evaluate differences between the autologous breast reconstruction group (n = 50) and the implant breast reconstruction group (n = 59). RESULTS: Women with a successful autologous reconstruction were significantly more satisfied with their reconstructed breasts than women with successful alloplastic breast reconstruction as measured by the BREAST-Q breasts module (p = 0. 00596), psycho-social well-being module (p=0.04) and sexual well-being module (p=0.00068). Furthermore, there is a higher degree of satisfaction in patients who have not undergone radiotherapy, with no complications and with a normal BMI for implant reconstruction group as well as in non-smokers, and bilateral reconstructions for flap reconstruction group. DISCUSSION: The findings of our study are in agreement with the data found in the literature, attributing greater satisfaction with physical, mental and social wellbeing, as well as with elements having repercussion on sexual wellbeing, to autologous breast reconstruction. CONCLUSIONS: Autologous breast reconstruction leads to higher patient satisfaction than implant breast reconstruction. This study may help patients and medical teams in their decision-making process regarding breast reconstruction. This pilot study opens several questions that need further investigations in a larger prospective studyKeywords: Breast reconstruction, breast-Q, satisfaction, implant, autologous tissue.

Compared to coverage by STSG grafts only reconstruction by the dermal substitute Integra® plus STSG increases TcPO2 values in diabetic feet at 3 and 6 months after reconstruction*.

AIM: Purpose of this retrospective comparative study is to evaluate the results of reconstruction of diabetic feet by split thickness skin graft (STSG) and by dermal substitute Integra® covered by STSG in terms of vascularity of the reconstructed wound-bed by measurements of tissue oxygenation (TcPO2). PATIENTS AND METHODS: 23 patients were included into the study (12 were reconstructed by STSG only and 11 with Integra® and STSG three weeks later). In each patient TcPO2 measurements were performed at the same spot of the reconstructed area at 14 days, one month, 3 months, 6 months, 12 months and 24 months after reconstruction. RESULTS: Wound beds reconstructed by Integra® showed on average 10 mmHg higher TcPO2. CONCLUSIONS: Our study estimated in an objective way, by TcPO2 value measurements, the oxygenation of the wound bed in diabetic feet after reconstruction by STSG only and after adding dermal substitute Integra® to the wound bed before final STSG coverage. During first month after reconstruction no statistically significant differences were found. After 3 months TcPO2 studies revealed statistically significant higher oxygen tissue pressure in diabetic feet covered by Integra® plus STSG. These findings endorse in an objective way the clinical findings already reported while using the dermal substitute. It remains to explain the role of this increase of oxygen tissue pressure in redefine the indications for the use of dermal substitutes in reconstruction of poor vascularized regions.

Effect of vascular endothelial growth factor gene therapy on post-traumatic peripheral nerve regeneration and denervation-related muscle atrophy.

Functional recovery after peripheral nerve injury depends on both improvement of nerve regeneration and prevention of denervation-related skeletal muscle atrophy. To reach these goals, in this study we overexpressed vascular endothelial growth factor (VEGF) by means of local gene transfer with adeno-associated virus (AAV). Local gene transfer in the regenerating peripheral nerve was obtained by reconstructing a 1-cm-long rat median nerve defect using a vein segment filled with skeletal muscle fibers that have been previously injected with either AAV2-VEGF or AAV2-LacZ, and the morphofunctional outcome of nerve regeneration was assessed 3 months after surgery. Surprisingly, results showed that overexpression of VEGF in the muscle-vein-combined guide led to a worse nerve regeneration in comparison with AAV-LacZ controls. Local gene transfer in the denervated muscle was obtained by direct injection of either AAV2-VEGF or AAV2-LacZ in the flexor digitorum sublimis muscle after median nerve transection and results showed a significantly lower progression of muscle atrophy in AAV2-VEGF-treated muscles in comparison with muscles treated with AAV2-LacZ. Altogether, our results suggest that local delivery of VEGF by AAV2-VEGF-injected transplanted muscle fibers do not represent a rational approach to promote axonal regeneration along a venous nerve guide. By contrast, AAV2-VEGF direct local injection in denervated skeletal muscle significantly attenuates denervation-related atrophy, thus representing a promising strategy for improving the outcome of post-traumatic neuromuscular recovery after nerve injury and repair.

Preoperative vascular mapping with multislice CT of deep inferior epigastric artery perforators in planning breast reconstruction after mastectomy.

PURPOSE: Our aim was to evaluate the usefulness of computed tomography angiography (CTA) in vascular mapping for planning breast reconstruction after mastectomy using a free flap made with the deep inferior epigastric perforators (DIEP). MATERIALS AND METHODS: We retrospectively evaluated 41 patients, mean age 57 years, scheduled for mastectomy. CTA was performed with a 64-row scanner (Aquilion 64, Toshiba Medical Systems, Japan), with injection of 100 ml of contrast medium (iomeprol 350 mgI/ml, Bracco, Italy) at 4.5 ml/s. Maximum intensity projection (MIP) and three-dimensional volume-rendering (VR) reconstructions were made to mark perforator positions. Presentation frequency, anatomy and artery opacification quality were evaluated. RESULTS: DIEP were always depicted (n=81) and subdivided according to Taylor's classification into type I (65%), type II (28%), and type III (7%). We observed a mean of three (range, 1-5) DIEP arteries on the right and two (range, 1-5) on the left side. The superficial inferior epigastric artery (SIEA) was depicted in 6/41 patients, bilaterally in three cases. Opacification was optimal in 30/41 cases, venous contamination due to late arterial phase in eight and low opacification due to early scan in three. CONCLUSIONS: Studying DIEP with CTA is useful in the surgical planning of breast reconstruction, even though it requires careful optimisation owing to the critical timing of opacification typical of that vascular district.

Use of piezoelectric bone scalpel in hand and reconstructive microsurgery.

Performing osteotomies with piezoelectric bone scalpel is also possible with bones of larger diameter/thickness. At the same time, adjacent soft tissues are not in danger from cutting or thermal damage, reducing the risk of damaging neurovascular structures - which is of primary importance in hand and reconstructive microsurgery. These features contribute to the safety and easy execution of the procedure. The resulting bony cut is precise and permits immediate and safe bone fixation. Osteotomy of bones of >1 cm thickness takes 20-30% longer than when using a conventional oscillating saw, though the increased safety of the procedure more than compensates for this. Three cases are presented, illustrating of the use of Genera Ultrasonic for cutting bones of major thickness (metacarpal, fibula and rib) without any complication. Because of its selectivity for bony tissue, precision and ability to protect soft tissues we also advocate the use of the Genera piezoelectric bone scalpel in hand and reconstructive microsurgery.

Reconstruction of large upper lip defects by free tissue transfer.

Reconstruction of a large upper lip defect is a demanding procedure and can be performed by a variety of local flaps or by microvascular free tissue transfer. We present our experience in reconstructing near total or total upper lip defects by free tissue transfer. In 11-year period seven patients underwent microvascular reconstruction of upper lip, six with non-innervated radial forearm flap and one with non-innervated anterolateral thigh flap. In all patients good functional and acceptable aesthetic results, with oral competence at rest and during eating and speaking, were achieved. Deglutition and articulation were not affected in any patient. Sensory evaluation of reconstructed upper lips was performed in four patients and in three a reasonable recovery of sensation was recorded. In our opinion subtotal or total upper lip reconstructions with folded thin fascio-cutaneous free flaps produce very good functional and aesthetically acceptable results and avoid additional scars on lower lip and cheek. Further, because the size of the mouth is not altered, microstomia is avoided, which is especially important for patients using dentures. The remaining disadvantage of this method is non-competence of orbicularis oris muscle sphincter.

Breast reconstruction following mastectomy for invasive breast cancer by free flaps from the abdomen is oncologically safe.

AIMS: To report the long-term results of oncological safety of breast reconstruction by autologous tissue following mastectomy for invasive breast cancer. METHODS: One-hundred-fifty-six consecutive patients with invasive breast cancer treated with mastectomy and reconstruction by autologous tissue were reviewed throughout (from 1987 to 2003 with median follow up time of 66 months). RESULTS: Median patient age was 45.9 years (range 26-68). The 157 observed tumors had mean diameter of 25+/-19 mm, 70 of them were poorly differentiated, and 137 were invasive ductal carcinoma. Multifocal disease was present in 44 patients. Breast reconstruction was carried out only by autologous tissue (free flaps were used in 95% and free TRAM flap transfer was the most common reconstructive procedure). There was only one local recurrence as first site of recurrence, thus yielding a local recurrence rate of 0.6%. CONCLUSIONS: Breast reconstruction by autologous tissue following mastectomy for invasive breast cancer is an oncologically safe procedure.

Prevalance of and risk factors for hospital-acquired infections in Slovenia-results of the first national survey, 2001.

A one-day survey was conducted in all (19) Slovenian acute-care hospitals in October 2001 to estimate the prevalence of all types of hospital-acquired infections (HAIs) and to identify predominant micro-organisms and risk factors. Among 6695 patients surveyed, the prevalence of patients with at least one HAI was 4.6%. The prevalence of urinary tract infections was highest (1.2%), followed by pneumonia (1.0%), surgical wound infection (0.7%), and bloodstream infection (0.3%). In intensive care units (ICUs) the prevalence of patients with at least one HAI was 26.9% and the ratio of episodes of HAI per number of patients was 33.3%. One or more pathogens were identified in 55.8% of HAIs episodes. Among these, the most frequently single isolated micro-organisms were Staphylococcus aureus (18.2%) and Escherichia coli (10.2%). Risk factors for HAI included central intravascular catheter (adjusted odds ratio (OR) 3.2; 95% confidence intervals (CI) 2.1-4.9), peripheral intravascular catheter (adjusted OR 1.7; 95% CI 1.2-2.4), urinary catheter (adjuster OR 2.4; 95% CI 1.6-3.4), and hospitalization in ICUs (adjusted OR 2.5; 95% CI 1.4-4.3). The results provide the first national estimates for Slovenia.

External osteotomy in rhinoplasty.

OBJECTIVES: To compare external and internal lateral osteotomy in rhinoplasty. STUDY DESIGN: Retrospective review and study on cadavers. METHODS: One hundred forty-two patients who underwent aesthetic rhinoplasty were examined. The following criteria were taken into consideration: edema and ecchymosis around the eyes, the degree of closure of the roof, symmetry and level of fractures, solidity of the bone pyramid, and any scarring at the access point of the osteotome. In the last 25 patients who had surgery, a nasal endoscopy with optical fibers was carried out to evaluate any damage to the mucosa caused by the 2-mm osteotome. Furthermore, to compare the two routes in vivo, for five of these patients a lateral osteotomy was carried out externally for one side and internally for the other. Lateral osteotomy were performed on five cadavers by an external route on one side and by an internal one on the other. A midface degloving procedure was performed to expose the osteotomy sites. RESULTS: Edema and ecchymosis were always much less severe in patients who were treated with external osteotomy. The control of the fracture line was always excellent. Endoscopic evaluation and study on cadavers revealed damages to the mucosa caused from the internal osteotomy and a better control of fracture line in external osteotomy. CONCLUSIONS: External osteotomy is an easy and precise approach. Because the fracture is of a greenstick type, the bone stumps are stable. The reduced bleeding reduces the formation of edemas and ecchymosis around the eyes. The damage to the nasal mucosa is minimal, and the cutaneous scars are virtually invisible a month after surgery.

Immediate reconstruction of the lower extremity--an update.

The objective of emergency free-tissue transfer of complex lower extremity injuries is to provide primary coverage of the wound at the time of the first surgical procedure during the first 24 hours after the accident. This is achieved by meticulous debridement of soft tissues and bone in the zone of injury, by fracture stabilization by either external or internal fixation, by assuring good circulation with a direct artery repair or by the use of venous or arterial grafts, and by closure of the soft-tissue defect with a suitable free flap with microvascular anastomoses. Such a repair on an emergency basis requires cooperation between orthopedic and plastic surgeons and organization of a continuous microsurgical service. With these prerequisites fulfilled, emergency treatment of complex lower leg injuries gives predictably better results than delayed primary treatment in terms of lower free flap failure rate, lower infection rate, lower number of operations required to obtain the final result, shorter time of hospitalization, shorter time to bone healing and weightbearing, and lower cost of treatment. Emergency free-tissue transfer is not indicated in life-threatening situations.

The posterior interosseous arterial graft.

The posterior interosseous artery is a suitable donor vessel for harvesting autogenous arterial grafts which are often necessary for thumb or finger revascularization or replantation. Grafts 8 to 10 cm long can be taken from the dorsal ulnar aspect of the forearm ranging in caliber from 1 to 1.5 mm. The arterial graft can be harvested together with the lateral branch of the posterior interosseous nerve, offering the possibility of vascularized nerve transfer. Removal of the posterior interosseous artery does not influence peripheral perfusion or leave functional deficits. During dissection, care must be taken not to harm motor branches of the posterior interosseous nerve. We report a patient in whom this technique was used successfully.

Arterial T and Y grafts.

Presented is the use of an autogenous arterial T graft for the salvage of a thrombosed arterial end-to-side anastomosis. The T-graft concept also offers the possibility of replacing a segment of artery in patients with arterial vessel wall defects, stenosis, obliteration, or disease during free latissimus dorsi or scapular flap transfer. The arterial T graft is harvested from the axilla and consists of segments of the subscapular, circumflex scapular, and thoracodorsal arteries. The large diameter of these vessels offers a good match with the arteries of the lower leg and forearm. The arterial Y graft consists of the same arteries and is used as an interpositional graft to revascularize two distal vessels from one proximal vessel.

Preferential use of the posterior approach to blood vessels of the lower leg in microvascular surgery.

A posterior approach to the vessels of the lower leg, with particular emphasis on the posterior tibial artery, is presented as the method of choice for microvascular free-tissue transfer to the region. This approach offers wide exposure, better definition of the zone of injury, appropriate selection of the recipient vessel and of the site of anastomosis, and enough room for microsurgical work. Exposing the large posterior tibial artery down to the distal third of the lower leg facilitates the use of end-to-side anastomosis and makes the transfer of large muscle flaps to that region more predictable, in part by obviating the need for long vein grafts. This exposure leaves no functional and few aesthetic deficits.

Experience with 50 free TRAM flap breast reconstructions.

The data from the first 50 patients undergoing free TRAM flap breast reconstruction in two units were examined. Average patient age was 42 years, and average weight was 62 kg. Forty percent of patients were chronic smokers, and 26 percent had low abdominal scars. Twelve percent exercised their abdominal muscles regularly. Eighteen percent had undergone radical mastectomy, whereas 76 percent had undergone modified radical mastectomy and 6 percent had undergone subcutaneous mastectomy. Postoperative radiotherapy had been given in 16 percent of patients, and 54 percent had received postoperative chemotherapy. The average time from mastectomy was 32 months, whereas six breasts were reconstructed immediately. Average operating time was 5.6 hours, and average blood loss was 2.4 units. Average hospital stay was 11.2 days. Complications included three total flap losses (6 percent) and two partial flap losses (4 percent). Abdominal hernia occurred in two patients (4 percent).

Free lateral arm osteocutaneous neurosensory flap for thumb reconstruction.

Three cases are described to illustrate the use of the lateral arm osteocutaneous neurosensory flap in thumb reconstruction. The merits of such a method and its place in the repertoire of techniques for this problem are discussed.

Intraoperative blood loss after tangential excision of burn wounds treated by subeschar infiltration of epinephrine.

To assess the operative blood loss after tangential excision of burn wounds treated by subeschar infiltration of epinephrine solution, the medical records of 85 consecutive patients were analysed retrospectively. All patients were given epinephrine. The median (range) blood loss was 0.9 (0.3 - 4%) of the blood volume of each patient of the body surface excised and grafted (blood loss from donor sites included). Multiple regression analysis showed strong correlation between the blood loss and the extend of the excision (p < 0.001). The correlation between age and blood loss was significant (p < 0.05). Neither the weight of the patients nor the amount of epinephrine injected significantly influenced the amount of blood lost. Operative blood loss was accurately predicted by multiple regression analysis in 62% of cases.

Physiological differences for distinct somatic sensory modalities and sweating among the donor sites of cutaneous and fasciocutaneous free flaps.

Differences of sensation and sweating among the typical sites of cutaneous and fasciocutaneous flaps (scapular, lateral arm, radial forearm, groin and dorsalis pedis) were assessed in 30 healthy volunteers (20 males and 10 females) aged 17-62 years (mean 38.2 years). Standard clinical methods were used: Semmes-Weinstein monofilaments for testing light touch threshold, discriminator and blunt caliper for evaluation of static and dynamic two-point discrimination and the Marstock quantitative method for assessing the normative values of warm-cold difference limen and heat and cold pain thresholds. Spontaneous sweat secretion was observed and documented by the ninhydrin test. We established various physiological differences for distinct somatic sensory modalities and sweating among the body regions (donor sites of cutaneous and fasciocutaneous free flaps).

Classification of soft-tissue degloving in limb trauma.

Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction.