The reinforced pedicle technique: a case report of secondary mastopexy following nipple-sparing mastectomy with autologous breast reconstruction.

Background: Immediate autologous reconstruction after nipple-sparing mastectomy (NSM) is challenging in the ptotic breast due to the large skin envelope and reduced vascular supply to the nipple areolar complex (NAC). Patients with significant ptosis who want to preserve their NACs are often advised to undergo a two-stage procedure: first, a mammoplasty is performed to lift the NAC, and second, a delayed NSM with autologous reconstruction is performed. Unfortunately, patients with active cancer cannot delay their mastectomy; as such, they are often treated with skin-sparing mastectomy (SSM) instead. Case Description: The reinforced pedicle is an innovative technique that allows the NAC to be safely raised after NSM with immediate free flap reconstruction. In the first stage, patients with ptotic breasts undergo NSM and immediate autologous reconstruction. The reconstruction itself also appears ptotic, but the dermal blood supply to the NAC is preserved. In the second stage, the ptotic free flap reconstruction is revised using the reinforced pedicle technique, which allows the flap to be reduced and the nipple raised in the manner of a standard superior pedicle breast reduction. Using this technique, we have successfully raised a patient's NAC by 2.5 cm. Conclusions: The reinforced pedicle technique adds to the scant literature on secondary revision techniques after autologous breast reconstruction. While further research on this technique is needed, it has the potential to alter the paradigm of immediate autologous reconstruction in the ptotic breast, allowing such patients to preserve their native NACs.

The effectiveness of targeted muscle reinnervation in reducing pain and improving quality of life for patients following lower limb amputation.

BACKGROUND: Globally, over 1 million lower limb amputations are performed annually, with approximately 75% of patients experiencing significant pain, profoundly impacting their quality of life and functional capabilities. Targeted muscle reinnervation (TMR) has emerged as a surgical solution involving the rerouting of amputated nerves to specific muscle targets. Originally introduced to enhance signal amplification for myoelectric prosthesis control, TMR has expanded its applications to include neuroma management and pain relief. However, the literature assessing patient outcomes is lacking, specifically for lower limb amputees. This systematic review aims to assess the effectiveness of TMR in reducing pain and enhancing functional outcomes for patients who have undergone lower limb amputation. METHODS: A systematic review was performed by examining relevant studies between 2010 and 2023, focusing on pain reduction, functional outcomes and patient-reported quality of life measures. RESULTS: In total, 20 studies were eligible encompassing a total of 778 extremities, of which 75.06% (n = 584) were lower limb amputees. Average age was 46.66 years and patients were predominantly male (n = 70.67%). Seven studies (35%) reported functional outcomes. Patients who underwent primary TMR exhibited lower average patient-reported outcome measurement information system (PROMIS) scores for phantom limb pain (PLP) and residual limb pain (RLP). Secondary TMR led to improvements in PLP, RLP and general limb pain as indicated by average numeric rating scale and PROMIS scores. CONCLUSION: The systematic review underscores TMR's potential benefits in alleviating pain, fostering post-amputation rehabilitation and enhancing overall well-being for lower limb amputees.

Use of Rare Anatomical Variant of the Free Fibula Flap to Reconstruct the Nasal Septum.

The osteocutaneous fibula free flap (FFF)'s skin paddle is commonly vascularized by the septocutaneous (SC) perforators of the peroneal artery that course through the posterior intercrural septum. However, a rare anatomical variant exists in which the skin paddle is vascularized via a separate arterial system to the fibula. We report the case of a 31-year-old man who was planned for osteocutaneous FFF reconstruction of his anterior maxilla and hard palate following resection of nasal septal chondrosarcoma. Intraoperatively, he was found to have a rare anatomical variant: the perforator to the skin paddle arose proximal to the peroneal artery, off the tibioperoneal trunk. This was a fortuitous, rare anatomical variant, as it enabled a double free flap reconstruction from a single donor site-an intraoral fasciocutaneous free flap oriented with its long axis perpendicular to that of an osseous FFF. This particular defect enabled reconstructive freedom beyond that of the standard osteocutaneous free flap, in which the skin paddle orientation is limited by the risk of kinking the septal perforator. This case report summarizes the flap raising technique and the learning points relevant to the osteocutaneous FFF with no SC perforators. The extant literature on this anatomical variant is then summarized. The average estimated rate of FFF with no SC perforators is between 3% and 25%, based on four published studies.