Earlobe Correction of the Pierced Ear: A Systematic Review of the Literature and Principles for Surgical Reconstruction.

Background: Surgical reconstruction of the earlobe after gauge ear piercing can be challenging especially in cases of large defects. Objective: By performing a systematic review of the current literature, we aimed to identify available surgical approaches for earlobe reconstruction after gauge piercing and provide a surgical classification system with regard to defect size. Methods: A literature review was performed including MEDLINE and PubMed databases to identify articles describing reconstruction after stretched earlobe piercing. Articles referring to traumatic, congenital, and acquired cleft deformities were excluded. Surgical techniques were summarized and categorized with regard to different defect sizes. Drawings of each method were performed. Results: A total of 17 different surgical approaches were found and described. Based on the authors' descriptions of each technique, a classification system for small to medium, large, and extralarge defects was established and special benefits of each method were highlighted. Conclusion: A simple classification of available techniques for stretched earlobe reconstruction with regard to defect size might help physicians to choose the appropriate surgical management especially in cases of large defects.

Anterograde Injection of Alteplase Salvages Deep Inferior Epigastric Perforator Flap in Reconstructive Breast Surgery.

The DIEP flap is currently considered the gold standard for autologous reconstructive breast surgery. Postoperative flap failure due to microvascular postanastomotic thrombotic occlusion is a rare but severe complication. Alteplase, a thrombolytic agent typically used in the setting of an ischemic stroke, myocardial infarction, or pulmonary embolism, has also been injected into the microcirculation of flaps as a rescue procedure due to imminent flap loss. The purpose of this article is to provide an overview and detailed guidance for such a thrombolytic procedure due to suspected thrombotic microsurgical failure in free flap surgery. We report the case of a 43-year-old woman who underwent unilateral breast reconstruction with a DIEP flap at our department. Approximately 12 hours postoperatively, an arterial inflow problem was suspected and revision surgery was performed. Peripheral flap perfusion remained absent without an obvious cause and distal thrombosis was assumed to be present. Therefore, alteplase was gradually injected into the arterial pedicle in the anterograde direction just distal to the anastomosis while clamping the artery proximally. About 3 hours after selective flap thrombolysis, microcirculation of the flap was successfully restored without complications. Anterograde injection of alteplase can successfully salvage a free flap. To our knowledge, evidence for optimal dosing and delivery of alteplase for the treatment of thrombosed DIEP flaps has not been published to date. Our approach presents a therapeutic option that both maximizes alteplase concentration in the flap and minimizes the dosage required for flap salvage to significantly reduce systemic adverse effects.

Microsurgical Scalp Replantation: Lessons Learned and Technical Considerations.

Total scalp avulsion is defined as a severe soft-tissue injury which involves the hairy scalp and commonly occurs in women as a result of the entrapment of long hair in high-speed rotating industrial machinery. The first microvascular replantation of an avulsed scalp was described by Miller et al in 1976 when both superficial temporal arteries along with five veins were successfully reanastomosed. Our patient was managed with a vein graft measuring 8 cm in length for reanastomosis of the superficial temporal artery. Furthermore, after successful replantation, we used an expander for aesthetic refinement and achieved an excellent outcome. A scalp replantation should be performed in every possible case. Despite partial skin necrosis, hair growth in the remaining areas is possible. In cases of partial skin necrosis, it is possible to eliminate the hairless areas by implanting an expander and excising the hairless area. A pressure-related ulcer at the occiput is likely due to immobility of the head postoperatively and may be avoided by using a halo fixation device.

Age and Overweight Are Not Contraindications for a Breast Reconstruction with a TMG-Flap-A Risk and Complication Analysis of a Retrospective Double Center Study Including 300 Patients.

INTRODUCTION: The transverse myocutaneous gracilis (TMG) flap has become a popular and reliable alternative for autologous breast reconstruction. Initially described as a valuable tissue source for women with low body-mass index, indications nowadays have widely expanded. The Western civilization demographic development with its aging population and the steady growing average BMI has led to increasing breast reconstructions with TMG flaps in overweight and aged individuals. PATIENTS AND METHODS: A total of 300 TMG free flaps for unilateral autologous breast reconstruction were evaluated in the form of a retrospective double center cohort study. Data extraction, study group formation and statistical analysis (One-way analysis of variance (ANOVA), Pearson's chi-squared statistical analysis and relative risk calculation) were done specifically to evaluate age and BMI as risk factors for postoperative complications and outcome. RESULTS: No significant differences in patients' age and BMI in the complication groups compared to the no-complication group could be found. No significant difference regarding the occurrence of complications could be found in any of the formed risk-groups. No significant increase of minor-, major- or overall complications, flap loss or revision surgeries were found in the elderly patient groups or for patients with overweight. CONCLUSION: Age and overweight do not significantly increase the risk for postoperative complications after breast reconstructions with free TMG flaps. The findings of this study support the fact that microsurgical breast reconstruction with a free TMG flap should not solely be reserved for younger patients and females with a lower BMI.

Management of Radial Nerve Lesions after Trauma or Iatrogenic Nerve Injury: Autologous Grafts and Neurolysis.

BACKGROUND: Proximal radial nerve lesions located between the brachial plexus and its division into the superficial and deep branches are rare but severe injuries. The majority of these lesions occur in association with humerus fractures, directly during trauma or later during osteosynthesis for fracture treatment. Diagnostics and surgical interventions are often delayed. The best type of surgical treatment and the outcome to be expected often is uncertain. METHODS: Twelve patients with proximal radial nerve lesions due to trauma or prior surgery were included in this study and underwent neurolysis (n = 6) and sural nerve graft interposition (n = 6). Retrospective analysis of the collected patient data was performed and the postoperative course was systematically evaluated. The Disabilities of the Arm, Shoulder, and Hand (DASH) and the LSUHS (Louisiana State University Health Sciences) scores were used to determine regeneration after surgery. Comparison between the patients' and calculated normative DASH scores was performed. RESULTS: All patients had a traumatically or iatrogenically induced proximal radial nerve lesion and underwent secondary treatments. The average time from radial nerve lesion occurrence to surgical intervention was approximately four months (1.5-10 months). Eight patients (66.67%) had a humeral fracture. During follow up, no statistically significant difference between the calculated normative and the patients' DASH scores was observed. The LSUHS scores were at least satisfactory. CONCLUSIONS: Neurolysis or sural nerve graft interposition performed within a specific period of time are the primary treatment options for radial nerve lesions. They should be performed depending on the lesion type. Regeneration to a satisfactory degree was observed in all patients, and the majority achieved full recovery of sensory and motor functions. This was the first study to highlight the efficiency of neurolysis and sural nerve graft interposition as secondary treatment interventions, especially for radial nerve lesions.

Occult papillary thyroid cancer presenting as cystic metastasis of the lateral neck: A case report.

RATIONALE: Papillary thyroid cancer accounts for up to 85% of all cases of thyroid carcinoma. This disease entity is notorious for metastatic invasion of adjacent lymph nodes, including the cervical lymph nodes, potentially presenting as a growing lateral neck mass. However, these lesions tend to be recognized and diagnosed soon due to the palpable mass. PATIENT CONCERNS: This report describes a very rare case of a huge slow-growing neck metastasis based on a 6 mm papillary thyroid microcarcinoma. This patient presented with a painless, but continuously growing right lateral neck mass. Aside from that, no specific complaints were mentioned. DIAGNOSIS: The underlying cause of this patient's neck mass turned out to be an occult papillary thyroid microcarcinoma (Ø 6 mm) with metastatic invasion and subsequent cystic degeneration of cervical lymph nodes. Accurate diagnosis was made after surgical intervention through histopathological analysis. INTERVENTIONS: The patient underwent complete resection of the cervical mass in conjunction with total thyroidectomy and right cervical neck dissection, followed by adjuvant iodine- and chemotherapy. OUTCOME: Margin free surgical resection without any postoperative complications could be achieved. The patient received iodine supplementation and remained free of recurrence during regular clinical follow-ups for 2 years. The therapy was curative. LESSONS: This case report emphasizes the importance of a thorough diagnostic work-up including preoperative tissue sampling of any cervical neck mass, since a benign appearance on imaging does not exclude a malignant process.

A double-blind randomized prospective study comparing prilocaine versus ropivacaine in upper blepharoplasty.

BACKGROUND: Upper blepharoplasties are a common procedure in plastic surgery. This procedure can be performed effectively under local anesthesia with or without sedation. The ideal local anesthetic should cause less intraoperative bleeding and less postoperative edema. Our study aimed to show the difference between the two local anesthetics 1% prilocaine (Xylonaest) in combination with epinephrine 1:100,000 and ropivacaine (Naropin) in combination with epinephrine 1:100,000 including sodium chloride, particularly in regard to swelling and bleeding in patients undergoing upper blepharoplasties. MATERIAL AND METHODS: In this double-blind, prospective, randomized study, 31 patients between March 2014 and September 2014 were included. The anesthetic agents used in all cases were 1% prilocaine (Xylonaest) in combination with epinephrine 1:100,000 for one side and ropivacaine consisting of 10-mg Naropin, 5-ml sodium chloride, and 1-ml epinephrine for the other side. The data presented in this study were collected by one of the surgeons performing the surgery. Intraoperative bleeding and postoperative edema were both calculated using a score of five points for each. RESULTS: The average bleeding tendency was 3.39 for prilocaine and 1.71 for local ropivacaine, showing a significant difference (p < 0.0001) between both local anesthetics in bleeding tendency. There was also a significant minor swelling at all times on the side on which ropivacaine was used. DISCUSSION: In our study, we demonstrated that ropivacaine (Naropin) has less intra- and postoperative side effects including swelling and bleeding compared with prilocaine (Xylonaest).