Effects of subepineural hyaluronic acid injection on nerve recovery in a rat sciatic nerve defect model.

BACKGROUND: Maintenance of epineural integrity is very important for nerve healing. Reports on the use of substances consid-ered to have positive effects on nerve healing in experimental nerve defect models are increasing. The present study assessed the effects of sub-epineural hyaluronic acid injection in a rat sciatic nerve defect model that was created while maintaining epineural integrity. METHODS: The study included 40 Sprague Dawley rats. The rats were randomly divided into a control group and three experimental groups (10 rats in each group). In the control group, the sciatic nerve was dissected and no additional surgery was performed. In experimental group 1, the sciatic nerve was transected in the middle, and then, primary repair was performed. In experimental group 2, a 1-cm defect was created while preserving the epineurium, and then, the defect was repaired with end-to-end suturing of the pre-served epineurium. In experimental group 3, the surgical procedure for experimental group 2 was performed, and then, sub-epineural hyaluronic acid injection was carried out. Functional and histological evaluations were performed. RESULTS: On functional evaluation, there was no statistically significant difference among the groups during the 12-week follow-up period. On histological evaluation, nerve recovery was poorer in experimental group 2 than in experimental groups 1 and 3 (p<0.05). CONCLUSION: Although the functional analysis did not reveal any significant results, the histological findings suggest that hyaluronic acid increases the regeneration capacity of axons through its anti-fibrotic and anti-inflammatory effects.

Nasal Anthropometric Analysis in Turkish Rhinoplasty Patients.

This study aimed to determine the mean values of the nasal anthropometric measurements through 2-dimensional photogrammetry in for rhinoplasty patients. The study group included 72 healthy individuals, 36 men, and 36 women. The patients were aged 18 to 42 years. All patients had undergone primary rhinoplasty in our clinic between 2013 and 2020. Seven landmarks were identified from the preoperative photographs taken with the patient's head in neutral position in the frontal and lateral planes. Five distances (total nasal length, nasal bridge length, morphological nose width, alar length, and nasal tip protrusion) and 2 angles (nasofrontal and nasolabial) measurements were calculated. We noted a statistically significant difference between the male and female sexes in terms of total nasal length and morphological nose width (P<0.05). The results were compared with the nasal anthropometric measurements reported in the literature for the Turkish population as well as other ethnic groups. We believe results of this study may facilitate preoperative planning in Turkish patients who request rhinoplasty and improve the success rate of the surgery.

Reconstruction of soft tissue defects around the Achilles region with distally based extended peroneal artery perforator flap.

INTRODUCTION: Achilles tendon rupture and soft tissue infections with wound dehiscence and tendon exposure following the tendon repair are not infrequent. Various procedures have been described for the reconstruction of soft tissue defects at the Achilles tendon region, yet there is lack of consensus on the ideal method. In this article we report our experience using the distally based peroneal artery perforator flap in reconstruction of combined defects of the Achilles tendon and overlying soft tissue. METHODS: 7 patients with Achilles tendon injury and full-thickness soft tissue defects over the Achilles region underwent tendon repair and soft tissue reconstruction with the distally based peroneal artery perforator flap. Perforator vessels were identified at the septum between the peroneus longus and soleus muscles. After choosing the perforator with the largest diameter, meticulous deep dissection of the perforator was performed and completed 6 cm proximal to the lateral malleolus. The peroneal artery was transected and ligated and transposition of the flap to the defect was performed through a subcutaneous tunnel. RESULTS: The size of the soft tissue defects and flaps ranged between 2×3 cm to 4×10 cm and 4×5 cm to 5×12 cm, respectively. Six out of 7 flaps survived completely without any complications. Post-operative venous congestion was observed in one patient which resulted in partial tip necrosis of the flap. The resulting wound healed with conservative treatment. Donor sites healed uneventfully in all patients. All flaps had excellent contour and provided stable soft tissue coverage. CONCLUSION: Distally based peroneal artery perforator flap can be considered as a reliable alternative for the reconstruction of soft tissue defects around the Achilles tendon region. Advantages include (1) extended reach of the flap for the defects around the plantar and dorsal aspects of the foot, provided by the perforator dissection, (2) convenience with footwear and walking, provided by the skin texture similarity with the target region, (3) creating a protective surface to allow tendon gliding and prevent tissue adhesions after the tendon repair, provided by the crural fascia included in the flap, (4) obviating the need for microsurgical anastomosis and associated length of the operation.

Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis.

BACKGROUND: Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group. METHODS: Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction. RESULTS: There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500 cc (p = 0.008). CONCLUSIONS: When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500 cc). LEVEL OF EVIDENCE: IV. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Factors Associated With Complications in Immediate Breast Reconstruction in 1 Stage With Completely Submuscular Implants.

BACKGROUND: Immediate breast reconstruction in 1 stage using permanent implants is gaining popularity and can be performed with or without the use of acellular dermal matrices. This study aimed to investigate the results of breast implants placed submuscularly without acellular dermal matrix and assess the factors affecting surgical complications. METHODS: From November 2009 to March 2018, 138 patients underwent immediate breast reconstruction with permanent submuscular implants after concomitant skin-sparing or nipple-sparing mastectomies in a single institution. All implants were covered with sufficient soft tissue under a submuscular pocket. RESULTS: One hundred thirty-eight patients were enrolled, and a total of 196 breasts were operated. The average age and body mass index (BMI) of the patients were 44.9 ± 8.8 years and 23.7 ± 3.6 kg/m, respectively. The majority of the mastectomies were therapeutic (81%). The average volume of implants was 389 ± 89 mL, and the mean follow-up was 33 months. The overall complication rate was 17% (n = 23), with skin necrosis being the most common complication followed by infections. Having a BMI equal to or greater than 25 kg/m was found to be a statistically significant predictor for overall complications (P = 0.002), whereas smoking history, age, and implant volume were not statistically significant. CONCLUSIONS: Immediate breast reconstruction in 1 stage using permanent implants can be performed with acceptable complication rates and cosmetic outcomes. Our study demonstrated that high BMI is a risk factor for overall complications. With proper patient selection and surgical technique, implants could be completely covered under a submuscular pocket.

Reconstruction of extensive scalp defects with anterolateral thigh flap.

BACKGROUND: Extensive scalp defects caused by various etiologies often require free-tissue transfer. We aimed to review our experience in the reconstruction of extensive scalp defects with free anterolateral flaps. METHODS: A retrospective analysis was performed on all patients with extensive scalp defects that were reconstructed with free anterolateral thigh flaps from November 2007 to April 2015. Eleven patients with a mean age of 44 years were included in this study. RESULTS: Eleven free-tissue transfers were used to reconstruct the extensive scalp defects. The flaps were 7-14 cm in width and 10-34 cm in length. CONCLUSION: Microvascular free-tissue transfer is the mainstay for the treatment of extensive scalp defects. We recommend anterolateral thigh free flap use for challenging and complex cases, given the method's numerous advantages, including reliability and safety.

Risk Factor Analysis for Survival of Becker-Type Expander in Immediate Breast Reconstruction.

BACKGROUND: Breast reconstruction with a Becker-type expander is a common technique following mastectomy. However, inconsistency remains in the literature regarding risk factors for the survival of a Becker-type expander following immediate breast reconstruction. This study's purpose is to investigate possible risk factors for the Becker-type expander survival and to evaluate the complications related to expander removal following immediate breast reconstruction. METHODS: We performed a retrospective chart review of consecutive women who underwent a mastectomy followed by immediate breast reconstruction with a Becker-type expander from November 2010 to November 2016. Electronic medical records were analyzed retrospectively for demographic, clinical, operative characteristics, and outcomes. Univariate Cox regression analysis was performed to determine the risk factors for the survival of the Becker-type expander following immediate breast reconstruction. RESULTS: A total of 74 Becker-type expanders were used in 72 patients who underwent immediate breast reconstruction. The patients' ages ranged from 27 to 71 years, with a mean ± standard deviation age of 44.6 ± 9.1 years. The most frequent complication was capsular contracture which occurred in 25 breasts (33.8%) followed by mastectomy skin flap necrosis in 6 breasts (8.1%), seroma in 4 breasts (5.4%), nipple-areolar complex necrosis in 4 breasts (5.4%), hematoma in 3 breasts (4.1%), and infection in 2 breasts (2.7%). The mean intraoperative expander fill volume (109.6 ± 66.9 cc [p = 0.039]) and mean total volume (386.5 ± 94.7 cc [p = 0.034]) were both significantly lower for patients with capsular contracture compared with those without capsular contracture. In patients with partial NAC necrosis, the mean mastectomy specimen volume (737.5 ± 242.8 cc) was significantly higher compared with patients without partial NAC necrosis (489.8 ± 219.0 cc; p = 0.027). A univariate Cox regression analysis showed that smoking and neoadjuvant therapy were significantly associated with expander removal (p = 0.023 and p = 0.006, respectively). CONCLUSION: The total volume of the expander and intraoperative fill volume of the expander appear to be predictive factors in the development of capsular contracture. However, there is no statistically significant association between radiotherapy and capsular contracture or expander survival in contrast with other published reports. Our findings reveal that the main risk factors for the survival of Becker-type expanders following immediate breast reconstruction are smoking and neoadjuvant therapy. To our knowledge, this is the first study to evaluate the most likely risk factors associated with Becker-type expander survival in immediate breast reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Simple Flap Design for the Salvage of Immediate Implant-Based Breast Reconstruction.

BACKGROUND: Breast reconstruction with implants is a real challenge in patients with large breast volume. Skin-reducing inverted-T mastectomy is the best solution for these patients. Delayed wound healing or necrosis at the T-junction area can be seen in this procedure, although it may also lead to severe conditions such as the exposure and loss of implant. In this article, the use of local pedicled flap for the management of these situations was discussed. METHODS: Between April 2010 and July 2015, 54 patients underwent breast reconstruction by inverted-T skin-reducing mastectomy and immediate implant-based breast reconstruction at our clinic. During the postoperative follow-up period, necrosis at the T-junction area was observed in 8 patients. All the patients received proper wound care, and the necrosis was surgically debrided. The defect was closed with Limberg-like rectangular flap. RESULTS: The mean age was 45.2 (range, 33-54) years. The mean body mass index was 25.57 ± 6.53 (range, 21.2-35.2) kg/m. The mean follow-up was 10.9 (range, 4-19) months. Two patients had implant exposure at the defect site after the debridement. There was no implant loss in any of the patients. CONCLUSIONS: The Limberg-like rectangular flap can be used as a salvage option in complicated skin-reducing mastectomies and can be considered as a safe and effective method because of its easy-to-use nature, low cost, and no need for microsurgery experience.