Autologous dermal graft in breast reconstruction.

INTRODUCTION: The role of allogenic dermis is well established in reconstructive breast surgery, where it acts as a hammock between the detached inferior border of pectoralis major and the inframammary fold. METHOD: The study reports on the outcome of 19 women (21 breasts as 2 were bilateral) in which autologous dermis was used rather than allogenic material. The autologous dermis was harvested from the abdomen, as a miniabdominoplasty in 15 patients, and from the contralateral breast in 4 patients having simultaneous breast reduction/mastopexy. In all, 15 women underwent immediate reconstruction (7 with tissue expanders, 8 with immediate prosthesis), whereas 4 patients underwent delayed reconstruction (with expanders). RESULTS: Two patients developed infection requiring explantation. There were no abdominal complications after the miniabdominoplasty. The coverage of the prosthesis or tissue expander by the dermal graft was achieved on average in three-quarters of cases (range, just under two-thirds to 100%). The mean follow-up was 17 months (range, 6-36 months). CONCLUSIONS: Autologous dermis is a useful alternative to allogenic dermis. It is cheap and readily available. In patients having a contralateral breast reduction, there is no donor site. The risk of complications is not dissimilar to allogenic dermis.

The Value of Tumescent Infiltration in Bilateral Breast Reduction: Optimizing Vasoconstriction.

Surgical adjuncts should improve surgical outcomes but should not increase complications. Epinephrine reduces bleeding in breast reduction, but various doses and volumes have been used. The ideal dose of epinephrine is still debated. The aim of this study was to assess blood loss after infiltration of 1 L of tumescent fluid containing epinephrine at a concentration of 1 in 100,000 (1 in 105) and 1200 mg of lignocaine in patients undergoing bilateral breast reduction. METHODS: Thirty-three consecutive patients undergoing bilateral breast reduction were included in the study. Data captured included age, mass of tissue removed, volume of blood loss, and surgical complications, especially hematoma formation. RESULTS: The mean age was 41 years (range, 17-74 years). The mean mass of tissue removed was 786 g (range, 307-1339 g). The mean total blood loss was 76 mL (range, 50-200 mL)-that is, 38 mL per side. One patient presented with a unilateral swelling and pain after 48 hours and underwent exploration. A venous pool of <100 mL of blood was evacuated. One patient suffered bilateral nipple loss of >50%, and another patient suffered loss of 30%. The mean follow-up is 9 months (range, 2-20). CONCLUSION: One liter of Ringer's lactate containing epinephrine at a concentration of 1 in 105, when injected into the breasts (500 mL per breast) before breast reduction, results in a massive reduction in blood loss.

Computational modeling of microarterial anastomoses with size discrepancy (small-to-large).

OBJECTIVE: Among causes of anastomotic failure in microvascular surgery is vessel size mismatch. Where the option of an end-to-side anastomosis is unavailable, an end-to-end construct must be used. Several end-to-end techniques are described to deal with size mismatch. The aim of this study was to numerically model arterial flow patterns and wall shear stresses in four idealized end-to-end anastomoses, where the upstream or recipient artery is smaller. The four techniques modeled were: an invaginating anastomosis; a fish-mouth incision of the smaller vessel; an oblique section of the smaller vessel; and a wedge excision of the larger vessel. MATERIALS AND METHODS: Flow rate in the right femoral artery of a single outbred male Wistar rat was recorded by transit time ultrasound. Initially, upstream vessel diameter in the models was set at 1 mm, and downstream at 2 mm. The wedge technique was further modeled using a shorter wedge, and using a downstream vessel diameter of 3 mm. Walls were deemed noncompliant. Flow was modeled by the finite volume method using the commercially available computational fluid dynamics code Fluent (Fluent Inc., Lebanon, NH; http://www.fluent.com). RESULTS: Ring vortices were seen in the invagination and fish-mouth models and showed similar characteristics, although they were less pronounced in the fish-mouth model. The oblique section model demonstrated complex, spiral, counter-rotating vortices that dissipated downstream. Flow separation was least in the first wedge model, with centralization of flow during high but decelerating flow rate. Shortening the wedge length or increasing the downstream vessel diameter to 3 mm led to flow separation. Wall shear stresses were broadly similar for all constructs. CONCLUSION: Of those modeled, excision of a wedge of the larger vessel proved the best construct. Where a vessel diameter ratio is 1:2, wedge length should be twice the diameter of the larger vessel. A vessel ratio of 1:3 leads to flow separation when using the wedge technique.

Full-thickness skin grafts: maximizing graft take using negative pressure dressings to prepare the graft bed.

BACKGROUND: Full thickness skin grafts (FTSGs) remain a good option for resurfacing defects of the face, neck, and dorsum of the feet. It results in soft, pliable, functional skin with minimal contraction. However, FTSG may result in patchy or irregular "take" resulting in recurrent contractures and pigmentary discrepancies. This study examines the use of a negative pressure dressing (NPD) to increase FTSG take. METHODS: Wounds resulting from trauma, postburn contracture release, and an excision of a congenital nevus were included in the study. The wounds were prepared by surgical excision or debridement. A NPD was then applied for a period of 7 days, at which time the wounds were inspected and, if there was sufficient granulation tissue, covered with a FTSG. If the wound had not yet granulated sufficiently another NPD was placed and reassessed in 7 days. The FTSGs were harvested from the groin and abdominal area exactly to the size of the defect. A sponge bolster dressing was then applied. The take of the FTSG was judged using a grid of 1 x 1-cm squares. The wounds were measured and the amount of graft take was calculated as a percentage of the wound size. Complications in both the wound as well as the donor sites were noted. RESULTS: Twenty-four patients were included in the study. The mean age was 6 years (range 1-14 years), including 9 burn contracture excisions, 14 road traffic accident-related injuries, and 1 excision of a congenital nevus. The site involved was the foot (6 patients), ankle (9 patients), axilla (2 patients), forearm (4 patients), face (2 patients), and the neck (1 patient). The average surface area of the defect was 78 cm2 (range 18-264 cm2). Groin skin was harvested in all the cases. The NPD was applied on average for 8 days (range 7-15 days). The mean graft take was 95% (range 70%-100%). Only 1 patient had significant graft loss of 30%. Donor site morbidity was low, attaining primary closure in all but 2. Mean follow-up was 9 months. CONCLUSION: The results of this study confirm that the use of NPD enhances FTSG take.

A study of the patient factors affecting reconstruction after mastectomy for breast carcinoma.

Breast shape may be retained after surgery for breast cancer with either wide local excision (WLE) and radiotherapy or mastectomy (M) and immediate reconstruction (M+R). We determined the proportions of patients who would be suitable for these options, would accept them, and if they declined M+R their reasons for doing so. Over a 10-month period 177 women were assessed at a combined breast clinic by general and plastic surgeons and by radiation oncologists. A prospective record was made of the patient demographic data, the clinical decisions (and their reasons), and the patient choices (and their reasons). A transverse rectus abdominis myocutaneous flap was the commonest method of reconstruction. One hundred thirty-five (76%) were judged to be suitable for locoregional surgery. Of these M+R was offered to 83 patients, whereas 53 were not considered because of combinations of cosmetic considerations (31), risk factors (25), old age (13), and oncological factors (nine). Fifty-one of the 83 (61%) offered M+R declined it because they preferred a simpler procedure (34), regarded breast appearance as unimportant (15), preferred breast conservation (five), did not have a partner (three), felt that they were too old (two), or had religious reasons (two). Ultimately 69 (51%) underwent M, 34 (25%) WLE, and 32 (24%) M+R. There was no correlation between acceptance or not of M+R and age, race, employment, education level, or marital status. We conclude that many patients were suitable for M+R, but fewer than half accepted it; this decision was unrelated to age, race, employment, or marital status.