New technique of immediate nipple reconstruction during immediate autologous DIEP or MS-TRAM breast reconstruction.

BACKGROUND: Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Usually considered a secondary complement to breast reconstruction, nipple-areola creation is ordinarily done after an interval of several months using different techniques involving local flaps or composite graft from the opposite nipple. METHODS: Because the position of the nipple-areola complex is well defined from the outset in skin-sparing mastectomy, the authors propose a new technique of immediate nipple reconstruction using the skin envelope after skin-sparing mastectomy. A modified wise pattern design of skin-sparing mastectomy with 3 local flaps is used. The dermal-fat flaps are lifted and sutured together to form the new nipple. RESULTS: Seventeen patients (average age, 47 years; range, 33-58 years) underwent immediate nipple reconstruction between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). Average follow-up was 13 months (range, 2-25 months). Aesthetic results were evaluated retrospectively from photographic documentation. A minimum average score of 7.2 points was achieved in all evaluated criteria using a 10-point scale. Patient satisfaction with nipple reconstruction was studied by means of a questionnaire. The shape of the nipple received an average of 9.7 points and the position of the nipple 9.9 points on the 10-point scale; 77% of patients were also very satisfied with nipple sensitivity. CONCLUSIONS: One-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local flaps on skin envelope flap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction using deep inferior epigastric perforator or muscle-sparing transverse rectus abdominis myocutaneous flap. Our technique is suitable for patients with ptotic or hypertrophic breasts.

The importance of preoperative hemoglobin evaluation in large volume liposuction: lessons learned from our 15-year experience.

Liposuction of >5 L of total aspirate at one setting is defined as large volume liposuction (LVL). A retrospective chart review was performed on all patients who underwent LVL from January 1990 to June 2005. Sixty-two patients underwent LVL. The mean volume of total aspirate was 8 L (5.0-11.7 L). There were a total of 6 patients who had complications. These included symptomatic postoperative anemia requiring blood transfusions on postoperative day 1 (n = 5), and an expanding hematoma requiring operative evacuation without transfusion (n = 1). Two of the patients who had blood transfusions had a history of gastric bypass and all of the patients were preoperatively anemic (<11.5 mg/dL). The mean follow up was 38 months. LVL is safe when performed in healthy patients under strict guidelines. Hemoglobin levels of all potential LVL patients should be checked preoperatively, and surgery should be withheld for levels <12 g/dL.

Vasospasm of the flap pedicle: the effect of 11 of the most often used vasodilating drugs. Comparative study in a rat model.

BACKGROUND: There has been no review study published yet comparing the effects of the vasodilating drugs that are most often used in clinical practice empirically. The aim of the authors' study was to perform this comparison and to select the drugs that are able to release vasospasm and the drugs that reduce vasospasm duration most effectively in an experimental model in vivo. METHODS: Pedicled groin flaps were dissected in 300 male Wistar rats. Vasospasm was induced by tension applied on the pedicle in the axial direction using a 15-g weight. The blood perfusion of the flap was monitored using a laser Doppler device. The duration of vasospasm was defined as the time from the release of tension until blood flow began to rise. These times were detected using automated computerized detection. The effects of 11 different drugs were studied in 14 groups. The drugs were applied locally; some of them were tested in different concentrations or applied parenterally. RESULTS: Ten percent magnesium sulfate reduced the duration of vasospasm most effectively (p < 0.01). Verapamil applied locally and also pentoxifylline applied parenterally were also very effective. In contrast, the duration of vasospasm was extended after local application of 2% lidocaine (p < 0.01). CONCLUSIONS: The authors concluded that 10% magnesium sulfate applied locally has the best ability to relieve surgically induced vasospasm because of the highest level of significance and reliability. The finding that local application of 2% lidocaine prolongs vasospasm may be surprising.

The effect of smoking on post-operative finger range of motion in patients with tendon grafts.

BACKGROUND: The finger range of motion (ROM) was evaluated in patients with hand flexor tendon replacement using a tendon graft and the effect of smoking was investigated. The first hypothesis was: a tendon graft increases the post-operative ROM. The second hypothesis was: smoking has a negative effect on the final finger ROM. PATIENTS AND METHODS: Fifty seven autologous tendon grafts in 48 patients were included. The patients were grouped as non-smokers or smokers ("light" or "heavy"). The modified Strickland system and Total Active Motion (TAM) system, were chosen for the evaluation. RESULTS: The first hypothesis was proved by all the measurements. The post-operative status assessed by the Strickland method was different between the non-smokers and smokers with a better score in the smokers. CONCLUSION: A significant ROM improvement occurs after reconstruction and is even slightly better in smokers than in non-smokers.

Bilateral breast reconstruction with DIEP flaps: 4 years' experience.

UNLABELLED: Bilateral prophylactic mastectomy without reconstruction is not accepted by the majority of patients. Successful reconstruction is therefore a mandatory condition for prophylactic mastectomy. Of the many options for autologous breast reconstruction, the deep inferior epigastric perforator (DIEP) flap best meets requirements for bilateral reconstruction in selected patients. The goal of this study is to verify the feasibility of the procedure in our conditions and to find out how it is accepted by patients. We present 55 consecutive patients who were scheduled for bilateral DIEP flap reconstruction during a 4-year period. We reviewed medical charts, performed clinical assessments and processed anonymous questionnaires. There were 77 immediate and 33 delayed breast reconstructions. There was 100% flap survival and no microanastomoses revisions. In 11 patients (10%) the surgeon preferred to convert the DIEP into a mini transverse rectus abdominis muscle (miniTRAM) flap in order to provide adequate blood supply. COMPLICATIONS: revision for haematoma under the flap in four patients (7.2%), excessive blood loss in four patients (7.2%) and partial mastectomy skin flap necrosis in 10 immediate breast reconstructions (12.9%). Patients' evaluation of the aesthetic result was good or excellent in 96.2% of cases. In 33.9% of patients the postoperative quality of life was considered unchanged and 50.9% of them it even improved. The DIEP flap is recommended for bilateral breast reconstruction. Occasional conversion into a miniTRAM flap can increase the total flap survival rate. Bilateral prophylactic mastectomy and DIEP flap reconstruction are very well accepted by patients.

Primary vein grafting in treatment of ring avulsion injuries: a 5-year prospective study.

Out of 262 hands with total finger amputations treated by replantation of finger/fingers from January 2001 until January 2006, there were only 6 cases of type III ring avulsion injuries, all of which were replanted. Radical resection of the damaged part of the artery with primary vein grafting was used in each case; only 1 artery and 2 veins were anastomosed for each finger. The survival rate was 100%. Mean total active motion was 195 degrees (ranging from 175 degrees to 220 degrees ). Mean 2-point discrimination was 8.6 mm static (ranging from 4 to 11 mm) and 6.2 mm moving (ranging from 3 to 9 mm), and mean grip strength was 37.4 kg. We believe that liberal resection of the "zone of contusion" of vessels and primary vein grafting for arterial repair can improve the overall survival rate of replantation in type III ring avulsion injuries, and replantation can be attempted in majority of the cases; good hand function can be expected.

New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals.

From December 2001 to September 2005, the technique of total penile reconstruction with a reinnervated free latissimus dorsi myocutaneous flap was used in 22 patients (24-38 years old) with gender dysphoria. These patients were followed up for at least 11 months (range, 11-44 months). All flaps survived. Complications include hematoma (7 cases), vascular thrombosis (2 cases), partial necrosis (1 case), excessive swelling of the neophallus (3 cases), and skin graft loss at the donor site (1 case). Of the 19 patients included in the final evaluation, the transplanted muscle was able to obtain contraction in 18 (95%) cases and 8 patients (42%) had sexual intercourse by contracting the muscle to stiffen and move the neopenis. The described technique of neophalloplasty proved to be a reliable technique and the muscle movement in the neophallus can be expected in almost all cases. The muscle contraction in the neophallus leads to "paradox" erection-stiffening, widening, and shortening of the neopenis, which allows for sexual intercourse in some patients. Subsequent reconstruction of the urethra is possible.

The bilobed arterialized venous free flap for simultaneous coverage of 2 separate defects of a digit.

We report a case of a 17-year-old patient who sustained multiple finger contusions on the left hand. After thorough debridement, the volar and dorsal defects of the middle finger were covered simultaneously with bilobed arterialized venous free flap from the left forearm. The flap was composed of 2 paddles, which were connected by a subcutaneous bridge containing a subcutaneous venous network. The subdermal plexus in the bridge was interrupted with no impairment of blood supply to the second cutaneous paddle. The flap survived completely with only temporary mild venous congestion. Excellent functional and cosmetic result was reached. We consider bilobed arterialized venous free flap as a useful option for coverage of concomitant volar and dorsal digital defects.