Comparison of the viscoelastic properties of human abdominal and breast adipose tissue and its incidence on breast reconstruction surgery. A pilot study.

BACKGROUND: Breast cancer is the leading malignant tumor in women in the world. Reconstruction after mastectomy plays a key role in the physical and psychological recuperation, being the abdominal skin and adipose tissue the best current option for the DIEP surgery. The aim of the surgery is to obtain a reconstructed breast which looks and behaves naturally. Therefore, it would be useful to characterize the mechanical behaviour of the adipose tissue in the abdomen and breast to compare their mechanical properties, also investigating possible regional differences. METHODS: Experimental tests have been carried out in breast and abdominal adipose tissue samples, obtaining their viscoelastic properties. The specimens have been subjected to uniaxial compression relaxation tests and a mechanical behaviour model has been fitted to the experimental curves. Afterwards, statistical analyses have been used to detect differences between different individuals' abdominal fat tissue and finally between different areas of the same individual's breast and abdominal adipose tissue. FINDINGS: Several conclusions could be extracted from the results: 1) inter-individual differences may exist in the abdominal adipose tissue; 2) the breast fat could be regarded as a unique tissue from the mechanical point of view; 3) significant differences were detected between the superficial breast and all the locations of the abdomen, except for the superficial lateral one and 4) the mechanical properties of the abdominal adipose tissue seem to change with the depth. These conclusions can be of great value for DIEP surgeries and other surgeries in which the adipose tissue is involved.

A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital.

BACKGROUND: Postmastectomy breast reconstruction involves the use of large amounts of hospital resources. This study provides comparative data on the clinical results and long-term economic costs of two methods of breast reconstruction in a public hospital. METHODS: A prospective cohort study was performed to evaluate the costs incurred by delayed unilateral breast reconstruction performed using either the two-stage sequence expander/prosthesis (E-P) or autologous deep inferior epigastric flap (DIEP) method during 2005-2013 in 134 patients. The major evaluated variables included previous clinical records, history of radiotherapy, and number of surgical procedures. Total costs accounted for both direct intra- and extra-hospital costs derived from the initial reconstruction and those resulting from associated reoperations due to aesthetic retouches and/or complications. RESULTS: Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction (3.07 vs. 2.32, p < 0.001) and showed higher rates of surgery-related complications (40.29% vs. 32.82%). No statistically significant differences were found between the two surgical methods in terms of total costs (€18857.77 DIEP vs. €20502.08 E-P; p = 0.89). In the E-P cohort, active smoking and history of radiotherapy were statistically significant risk factors of complications. In the DIEP group, only active smoking was significantly associated with complications. CONCLUSIONS: Compared to the E-P method, breast reconstruction using the DIEP method is more cost-effective and involves fewer serious complications that result in reconstruction failure or undesirable aesthetic results. E-P reconstruction presents a higher number of complications that may cause surgical failure or poor outcomes.

3D surgical planning in patients affected by lipodystrophy.

Lipodystrophy is a pathological condition characterized by the focal or general absence of adipose tissue. Surgeons reset the patient's surface contours using injectable materials to recreate a normal physical appearance. However, due to difficulties in preoperative planning and intraoperative assessment, about 15% of the surgical procedures involved are reinterventions to improve volume or symmetry. This increases the need for an available, efficient tool capable of providing the surgeon with a good estimation of the volumes to be injected before the intervention proper begins. This work describes a virtual reality-based application for the surgical planning of facial lipodystrophy correction (FLIC). The tool uses points selected interactively by the surgeon to compute a curve that delimits the surface area to be operated on. It then automatically computes an estimated natural reconstructed surface and the quantity of volume that needs to be implanted during the intervention. Experiments have been carried out in which the filling volumes estimated using FLIC and ZBrush software were compared with the real volumes injected by the surgeon. ICCs higher than 0.97 indicate that there were no significant differences between the respective measurements, thus validating the tool proposed in this paper.

Reconstruction of a severe facial defect by allotransplantation in neurofibromatosis type 1: a case report.

BACKGROUND: On January 26, 2010, our team performed a facial transplant for a patient with neurofibromatosis type 1. We detail the perioperative surgical strategies for the composite tissue allograft (CTA) of the lower parts of the face to restore a severe defect after excision of bilateral massive plexiform neurofibromas. The main distinctive feature included an innovative provisional heterotopic transplantation (PHT) technique of the facial allograft to the femoral vessels before its final orthotopic transplantation. CASE REPORT: A 35-year-old Caucasian man received a CTA of the lower two-thirds of the face, including a chin osseous segment. The face was obtained from a non-heart-beating donor. The sequence of microsurgical procedures began by performing a PHT of the CTA to the recipient's femoral vessels in the right thigh. Intraoperatively, he experienced considerable blood loss that required transfusion of 24 units of packed cells. Surgical revision was required at day 7 to remove an extensive hematoma in the right side of the CTA. The maintenance immunosuppressive regimen included steroids, mycophenolate mofetil, and tacrolimus. CONCLUSION: We have reported a case of successful provisional transplantation of a human facial allograft onto the thigh as an alternative technique in human face transplantation. PHT was a reliable alternative procedure to obtain the facial allograft from a cadaveric donor.

Severe rhabdomyolysis after allogeneic transplantation of facial structures: a case report.

We present a patient with panfacial neurofibromatosis type 1 who underwent allogeneic transplantation of facial structures, which was complicated by severe rhabdomyolysis and temporary oligoanuria. Because of his underlying disease, this 35 year-old man, weighing 68 kg and with a body mass index (BMI) of 27, had undergone 17 operations for resection modeling of hypertrophied tissues, either alone or combined with static suspension techniques. He finally underwent allogeneic transplantation of facial structures. In the early hours of the postoperative period, in the context of a systemic inflammatory response syndrome, he experienced severe rhabdomyolysis, with elevation of the muscle enzyme creatine kinase producing a minor impact on kidney function. The patient was discharged home at 12 weeks after the transplantation.

The virtual reality tool VirSSPA in planning DIEP microsurgical breast reconstruction.

BACKGROUND: The significant variation in the vascular anatomy of the abdominal wall makes preoperative imaging essential when raising a DIEP (deep inferior epigastric artery perforator) flap due to the potential for maximizing operative success, reducing intraoperative error and minimizing operative complications. Variability in perforator anatomy makes DIEP flap surgery a suitable candidate for computer and virtual reality bio models. In this context, a study was undertaken to determine the feasibility of CTA-guided by VirSSPA application. VirSSPA is a virtual reality tool developed in our Hospital for surgical planning and training. This application allows surgeons to generate the three-dimensional (3D) model of the patient. OBJECTIVE: In this paper, we present a study about VirSSPA tool for virtual reality navigation in DIEP flap surgery and compare findings with operative measurements. METHODS: We recruited 12 consecutive patients planned for an elective DIEP flap for breast reconstruction. Each patient underwent preoperative imaging of the anterior abdominal wall vasculature with both conventional CTA and VirSSPA 3D reconstruction. Imaging findings were compared to operative findings. RESULTS: 3D reconstruction of the abdominal wall with VirSSPA demonstrated a significant good correlation with perforator location compared to operative findings, showing an average error rate of 0.228 cm (95% CI, 0.17-0.30). The Pearson product-moment correlation coefficient was found to be 0.99 (p = 0.01), reflecting an almost linear relationship between the two distances, intraoperative and the one measured in the 3D reconstruction. CONCLUSION: VirSSPA provides additional and potentially more accurate data over conventional CTA with regard to the site of the best perforators and its course through the muscle for DIEP micro-vascular surgery.

Hand blood supply in radial forearm flap donor extremities: a qualitative analysis using doppler examination.

This retrospective study evaluated the contribution of the forearm arteries to the blood supply of the hand after radial forearm flap surgery. Doppler ultrasound examinations of the radial, ulnar, anterior interosseous and posterior interosseous arteries were performed in the distal forearm using a continuous emission directional Doppler and a modified Allen test. Twenty-seven patients were included in this investigation which demonstrated a significant contribution of the anterior interosseous artery to hand vascularity after radial forearm flap surgery.

Flow changes in forearm arteries after elevating the radial forearm flap: prospective study using color duplex imaging.

The aim of the present study was to assess the changes in flow patterns of forearm arteries produced by excision of the radial artery when harvesting the radial forearm flap. A prospective study using color duplex imaging for quantitative flow measurements was accomplished in 11 patients. After raising the radial flap, the forearm flow tended to increase overall, the ulnar (P = 0.04), the posterior interosseous (P = 0.003), and the anterior interosseous (P = 0.003) arteries being responsible for this tendency. Therefore, harvesting of a radial flap must not be considered as causing vascular morbidity in terms of blood supply to the hand.

Analysis of flow changes in forearm arteries after raising the radial forearm flap: a prospective study using colour duplex imaging.

The purpose of this study is to assess the changes in flow patterns of forearm arteries produced by excision of the radial artery when harvesting the radial forearm flap, in order to clarify its vascular morbidity rationally. Eleven patients with elective surgery using the radial flap were included in this investigation. A prospective study was designed using colour duplex imaging for quantitative flow measurement in two stages: a few days before the operation, a first colour duplex scanning examination was done recording flow velocity and vessel section area from the radial, ulnar, posterior interosseous and anterior interosseous arteries around the wrist. Volumetric parameters and relative blood flow percentages were calculated and compared to those obtained from a second similar vascular investigation accomplished in the same limb 4-5 months after the operation. Statistical analysis was done using the Wilcoxon matched pairs test. After raising the radial forearm flap there was a trend for increased overall forearm flow (from 162 to 215 ml/min, P = 0.09 N.S.), the ulnar (P = 0.04), the posterior interosseous (P = 0.004) and the anterior interosseous (P = 0.003) arteries being responsible for this tendency. The anterior interosseous artery showed the greatest increase in blood (from 8.2 to 67.7 ml/min), reaching a relative flow percentage (33%) close to that of the radial artery before its excision (39%). Results of this study indicate that another 'major vascular axis' based on the anterior interosseous artery develops after sacrificing the radial artery and that global arterial inflow to the hand is not impaired.

[Insulin-like growth factor I as a marker of nutritional status in patients on enteral nutrition]. / El factor de crecimiento insulínico tipo 1 como marcador de estado nutricional en pacientes con nutrición enteral.

In order to appraise type 1 insulin growth factor (IGF-1) as nutritional state marker in comparison with other known markers, seric IGF-1 (RIA), albumin, prealbumin, transferrin and retinol-bound protein were determined weekly in 15 patients with oropharyngeal neoplasm and 7 in the burns unit, all being administered enteral nutrition. At the beginning of the study, IGF-1 seric levels were significantly lower in the burns group compared with the neoplasm group (82.28 +/- 23.36 vs 137.58 +/- 66.2 ng/ml, p < 0.01). IGF-1 values in the first group were initially significantly lower in comparison with those for the same group at the end of the study (82.28-23.36 vs 177.11 +/- 53.87 ng/ml, p < 0.01 for paired data). No significant change was demonstrated in IGF-1 seric levels in the neoplasm group. IGF-1 seric levels showed a significant multiple correlation with albumin, prealbumin, transferrin and retinol-bound protein in both the group with burns (r = 0.696, p < 0.001) and that with neoplasms (r = 0.615, p < 0.001). The nitrogen balance revealed a univariant and significant linear correlation with IGF-1 (r = 0.373, p < 0.05) and with prealbumin (r = 0.377, p < 0.05). According to the data obtained, seric IGF-1 has a significant correlation with other well-known nutritional markers. In the burns group, the hypercatabolism was accompanied by a significant increase in seric IGF-1 levels.