An Algorithm in Managing Deep Inferior Epigastric Vessel Interruption in Free Flap Breast Reconstruction.

Previous surgical procedures in the abdomen are no longer contra-indications for free flap breast reconstruction using the deep inferior epigastric artery perforator flap. Nonetheless, a possible consequence of previous surgical procedures may be trauma to the deep inferior epigastric (DIE) pedicle, leading to interruption. In these cases, a modification in operative strategy may be required. Methods: A study was performed across two centers, during a 10-year period between January 1, 2010 and December 2019. Patient and outcome data were collected from the patient file and operation notes. Results: Four cases with clear evidence of DIE pedicle interruption were found, with an average age of 54 years and an average body mass index of 28.9. Three patients had a preoperative diagnosis of DIE pedicle interruption on CT angiography, whereas in one case this was found peroperatively. For three cases, unilateral reconstruction was performed, and for one, bilateral reconstruction. Four flaps (in three cases) were unipedicled; the contralateral DIE pedicle was used in three, and the superficial system was used in one. For the bipedicled case, two hemiflaps were used, with the interrupted DIE pedicle anastomosed to a branch of the contralateral DIE pedicle. Conclusions: Interrupted DIE vessels remain a challenge for free flap breast reconstruction. The four cases demonstrated in this article highlight different surgical strategies, with an emphasis on detailed preoperative planning, including CT angiography. We present an algorithm to aid the reader in approaching cases with an interrupted DIE pedicle.

Use of free radial forearm and pronator quadratus muscle flap: Anatomical study and clinical application.

The authors present an anatomical study and clinical experience with radial forearm flap (RFF) and pronator quadratus muscle (PQM) application in the reconstruction of various body areas. The aim was to describe the anatomical placement and proportions of the PQM, the anatomical location of the major arterial branch of the radial artery supplying the PQM, and the application of this knowledge in clinical practice. The anatomical study was based upon an analysis of 13 fresh adult cadaver upper extremities, of which nine were female and four male; both arms from the same donors were used in four cases. The study of the PQM was performed using a dye-containing intraarterial injection, standard macro- and micro-preparation techniques, and chemical digestion. The data on the PQM size in males and females, thickness of the radial artery branch (the principal artery nourishing the muscle), and its position were analysed. The radial artery branch nourishing the PQM was identified in all cadaveric specimens of the anatomical study. In addition, 12 patients underwent reconstructions of soft and bony tissue defects using a RFF + PQM (pedicled or free flap). The radial artery branch perfusing the PQM was identified in all cases. The flap was used for the management of defects of the head (seven cases), arm (three cases) and lower leg (two cases). The harvest site healed well in all cases and, with the exception of one case in which a partial necrosis of the flap was observed, all flaps remained viable, which demonstrated the safety of the method.

Human Infections by Wohlfahrtiimonas chitiniclastica: A Mini-Review and the First Report of a Burn Wound Infection after Accidental Myiasis in Central Europe.

Wohlfahrtiimonas chitiniclastica are bacteria that cause rare infections, typically associated with the infestation of an open wound with fly larvae. Here, we present a unique case report of the first W. chitiniclastica isolation from a burn wound with accidental myiasis in a 63-year-old homeless man and a literature review focused on human infections caused by these bacteria. So far, 23 cases of infection with W. chitiniclastica have been reported; in 52% of these, larvae were found in the wound area. Most of these cases suffered from chronic non-healing wound infections but none of these were burn injuries. The overall fatality rate associated directly with W. chitiniclastica in these cases was 17%. Infections with parasitic larvae occur in moderate climates (especially in people living in poor conditions); therefore, an infection with rare bacteria associated with accidental myiasis, such as W. chitiniclastica, can be expected to become more common there. Thus, in view of the absence of recommendations regarding the treatment of patients with accidental myiasis and, therefore, the risk of infection with W. chitiniclastica or other rare pathogens, we provide a list of recommendations for the treatment of such patients. The importance of meticulous microbial surveillance using molecular biological methods to facilitate the detection of rare pathogens is emphasized.

Long-term donor-site morbidity after thumb reconstruction with twisted-toe technique.

BACKGROUND: Traumatic thumb loss is a serious injury affecting patient´s ability to work and participate in activities of daily life. The main goal for a plastic surgeon is to restore hand grip, often by microsurgical methods. However, patients should be informed of all effects associated with tissue harvesting. The aim of the study was to assess the impact on donor foot and gait cycle in patients who have undergone thumb reconstruction using twisted-toe technique modified by Kempný. MATERIAL AND METHODS: Twelve patients participated in the study: all suffered a thumb loss between the years 2003 and 2011 and the twisted-toe technique for thumb reconstruction was utilized. The changes in foot pressure distribution and lower extremity joint loading were evaluated. RESULTS: The differences in total maximal plantar pressure, pressure time integral, contact area, and maximum force between the affected and non-affected foot were statistically significant (P 0.1). No significant differences of temporal gait parameters between the affected and non-affected extremity were observed; however, statistically significant differences in kinetics parameters, frontal ankle and knee moments were detected. CONCLUSION: Donor limb functionality and anatomical disability were assessed using pedobarography systems and 3D-gait analysis. The recorded differences in plantar pressure distribution (increased pressure in I., IV. and V. metatarsal areas) and overload of the medial compartment of the knee joint were the most significant findings. Therefore, wearing individually adapted shoe insoles as prevention of osteoarthrosis might be beneficial for patients after thumb reconstruction by a twisted-toe technique.

Occult Pathologic Findings in Reduction Mammaplasty in 5781 Patients-An International Multicenter Study.

Breast cancer is among the most commonly diagnosed cancers in the world, affecting one in eight women in their lifetimes. The disease places a substantial burden on healthcare systems in developed countries and often requires surgical correction. In spite of this, much of the breast cancer pathophysiology remains unknown, allowing for the cancer to develop to later stages prior to detection. Many women undergo reduction mammaplasties (RM) to adjust breast size, with over 500,000 operations being performed annually. Tissue samples from such procedures have drawn interest recently, with studies attempting to garner a better understanding of breast cancer's development. A number of samples have revealed nascent cancer developments that were previously undetected and unexpected. Investigating these so-called "occult" findings of cancer in otherwise healthy patients may provide further insight regarding risk factors and countermeasures. Here, we detail occult findings of cancer in reduction mammaplasty samples provided from a cohort of over 5000 patients from 16 different institutions in Europe. Although the majority of our resected breast tissue specimens were benign, our findings indicate that there is a continued need for histopathological examination. As a result, our study suggests that preoperative imaging should be routinely performed in patients scheduled for RM, especially those with risk factors of breast cancer, to identify and enable a primary oncologic approach.

Treatment of Second to Third-Degree Burns in A 2-Day-Old Infant: A Case Report.

Burn injuries in newborns are particularly complex cases. Since these patients are rare, there is little experience and no existing standardized treatment. This report examines a case of accidental second to third-degree burning of the heel and toes on the left foot in a new-born girl. The burns covered an estimated 1% of the total body surface area (TBSA). After an initial debridement and 32 days of non-surgical wound therapy with Adaptic® fat gauze dressings, we were able to achieve an aesthetically and functionally satisfactory result including the complete preservation of all toes. Modern wound treatment following the principle of less frequent dressing changes allows the burn wound to have better re-epithelialization. New findings in stem cell research indicate that the high proportion of mesenchymal stem cells (MSC) in postnatal blood is also involved in the regeneration and healing of burns. To our knowledge, this is the first case report dealing with initial non-surgical combustion therapy in a newborn. In order to eliminate a scar contracture, we carried out a Z-plasty one year later.

Treatment of second to third-degree burns in a 2-day-old infant: A case report.

INTRODUCTION: Burn injuries in newborns are particularly complex cases. Since these patients are rare, there is little experience and no existing standardized treatment. PRESENTATION OF CASE: This report examines a case of accidental second to third-degree burning of the heel and toes on the left foot in a new-born girl. The burns covered an estimated 1% of the total body surface area (TBSA). After an initial debridement and 32 days of non-surgical wound therapy with Adaptic® fat gauze dressings, we were able to achieve an aesthetically and functionally satisfactory result including the complete preservation of all toes. In order to eliminate a scar contracture, we carried out a Z-plasty one year later. DISCUSSION: Modern wound treatment following the principle of less frequent dressing changes allows the burn wound to have better re-epithelialization. New findings in stem cell research indicate that the high proportion of mesenchymal stem cells (MSC) in postnatal blood is also involved in the regeneration and healing of burns. To our knowledge, this is the first case report dealing with initial non-surgical combustion therapy in a newborn. CONCLUSION: There is evidence that newborns have a much higher potential for wound healing than adults. Proper position in long-term immobilization of toes is important to prevent scar contracture and deformity.

Further developments in the twisted-toe technique for isolated thumb reconstruction: our method of choice.

BACKGROUND: Posttraumatic loss of the thumb is devastating. Toe-to-hand transfer is considered the criterion standard of reconstruction but is associated with donor-site issues. The twisted-toe technique uses parts from the great toe and the second toe, which allows for almost anatomical restoration of the donor foot. The authors present their experience and technical modifications of this method. METHODS: Between January of 2003 and November of 2011, 18 patients suffering from loss of thumb because of a variety of indications were treated with the authors' modification of the twisted-toe technique. The neothumb was constructed with a partial onychocutaneous flap from the great toe and an osseotendinous flap from the second toe. RESULTS: Of 18 transplanted twisted-toe flaps, 17 survived completely (5.6 percent flap loss rate). Similarity of the reconstructed thumb compared with the healthy side was very acceptable in all cases. All patients in whom the procedure was successful were able to use the neothumb in daily life without constraints. Reconstruction of the donor site yielded very acceptable outcomes with a distinct reduction in morbidity and disfigurement compared with conventional toe harvest. CONCLUSIONS: The modified twisted-toe technique is the authors' preferred choice of thumb reconstruction. It allows the reconstructive surgeon to construct a very natural-appearing neothumb with good stability and grip force. In addition, it eliminates many of the donor-site problems associated with pure great toe harvest, by recreating a "neo-great toe" at the donor foot. Although the procedure is more complicated and time-consuming compared with single toe harvest, the authors firmly believe that this extra effort takes thumb reconstruction to a next level. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.