The reverse latissimus dorsi flap: An anatomical study and retrospective analysis of its clinical application.

The segmental paraspinous and intercostal blood vessels form the blood supply and represent the pivot point for the reverse latissimus dorsi flap. Aim of this study was to confirm the exact location of the blood supply and the most caudal pivot point to assess the suitability of the reverse latissimus dorsi flap for pedicled reconstructions of the trunk as well as sacral area. Our study comprised a human cadaver study, where 30 latissimus dorsi flaps were assessed in 15 specimens, and a clinical study with 49 patients who underwent distally based latissimus dorsi flap reconstructions in our division. 74% of all perforators were located in a bilateral 7 cm broad area, which spread from the 6th intercostal space to the subcostal plane. In a second clinical part of this study we evaluated forty-nine patients, who underwent reconstruction with the reverse latissimus dorsi flap. We demonstrated that the pivot point can also be planned below the 12th rib, thus reaching tissue defects in the sacral area. To the best of our knowledge, this is the first study to define a caudal "hotspot" for the safest blood supply of the reverse latissimus dorsi flap.

First experience using contrast-enhanced ultrasound to evaluate vascularisation of acellular dermal matrices after implant-based breast reconstruction.

UNLABELLED: Acellular dermal matrices (ADM) have been used frequently in therapeutic and prophylactic breast procedures. To date there have been no reports on vascularisation of ADMs and formation of tissue around them as seen with modern non-invasive imaging techniques such as contrast-enhanced ultrasound (CEUS). In this case series, we used CEUS to investigate the features of ADM in relation to vascular ingrowth and scaffold for "new" tissue formation. This is a retrospective evaluation of patients who underwent successful skin- and nipple-sparing mastectomy (SSM, NSM) with immediate IBBR using ADM from May 31, 2010, through December 28, 2012. Over a 24-month period, 16 patients, with an average age of 44 years (range 27-70 years), were evaluated with CEUS. No contrast agent allergies or side effects were reported for the ultrasound examination. After contrast agent injection (1-18 months postoperatively), homogeneous normal enhancement in the ADM and peripheral region with physiological tissue formation was seen in all patients. In this small study, the most obvious contribution of CEUS is the in vivo evaluation of vascular ingrowth and tissue formation after IBBR with ADM after follow-up of 1-18 months postoperatively. LEVEL OF EVIDENCE III: Retrospective cohort or comparative study; case-control study; or systematic review of these studies.

The posterior interosseous artery flap: clinical results with special emphasis on donor site morbidity.

This study evaluated the clinical results, and especially the donor site morbidity of the posterior interosseous artery flap. A retrospective study included 40 patients with defects covered with posterior interosseous flaps. Twenty-one patients were available for a follow-up examination to assess donor site morbidity by evaluating the dimensions and quality of the donor site scar and the forearm contour as well as complaints and subjective satisfaction with the aesthetic result. The flaps and related donor sites healed uneventfully in 29 cases (72.5%); healing was delayed in 11 cases (27.5%), with total flap loss in two cases. Further surgery was required in six cases. The quality of the donor site scar rated with the Vancouver Scar Scale averaged 2.4 points. Eleven patients (55%) reported impaired sensibility around the donor site and four patients (20%) had physical complaints. Subjective and objective donor site evaluation revealed significantly lower donor site morbidity for directly closed as opposed to skin grafted donor sites, although subjectively, there was a high level of satisfaction in both groups. Our data indicated that the posterior interosseous flap is a valuable option for the management of soft-tissue defects on the dorsum of the hand, due to its anatomical reliability and soft and pliable tissue, its low donor site morbidity and high patient acceptance.

Analysis of functional outcome after posttraumatic thumb reconstruction in comparison to nonreconstructed amputated thumbs at the proximal phalanx of the thumb ray: a mid-term follow-up with special attention to the Manchester-modified M2 DASH questionnaire and effect size of Cohen's d.

BACKGROUND: Pollicization, toe to thumb transfer, and osteoplastic thumb reconstruction, along with free tissue transfer, are the most reported reconstructive procedures after traumatic amputation at the proximal and middle third of the thumb. We will present our clinical studies on functional outcomes with special attention to the M2 DASH questionnaire and effect size of Cohen's d. METHODS: Eleven patients (2 women and 9 men) with posttraumatic thumb reconstruction (three pollicizations of the index or index stump, four free lateral arm osteocutaneous neurosensory flaps, and four microvascular second toe to thumb transfers), performed during the period 2000 to 2007, were reexamined after 4.2 (SD ±2.1) years (range, 2-7 years postinjury). To ensure homogeneity among the patients' data, we selected only patients with isolated thumb amputations at the level of the proximal phalanx. RESULTS: The total M2-DASH score after thumb reconstruction was 18.55 (SD ±16.79). The M2-DASH score of patients with nonreconstructed thumbs was 32.77 (SD ±18.87). Pairwise comparisons between reconstructed and amputated thumbs showed statistically significant differences (Wilcoxon rank-sum test, p value = 0.03) and a highly effective improvement of hand function (Cohen's d = 1.10) after thumb reconstruction relative to amputated thumbs. CONCLUSION: Before selecting a candidate for thumb reconstruction, it is critical to decide on an individualized treatment plan. Factors such as the patient's occupation and the importance of the aesthetic appearance of the thumb must be carefully considered. The surgeon must investigate the patient's current use pattern and functional requirements before considering a reconstructive treatment.

Clinical experience with a tensor fasciae latae perforator flap based on septocutaneous perforators.

BACKGROUND: Based on an anatomical study of the perforators of the tensor fasciae latae (TFL) perforator flap, a clinical study was undertaken to confirm our data in a clinical trial and to demonstrate the ability to harvest a TFL perforator flap on septocutaneous perforators. METHODS: A retrospective case series analysis was performed of patients, who had undergone reconstruction of soft-tissue defects of the extremities, the groin and the head in 17 cases with a TFL perforator flap based on septocutaneous perforators; in three cases, a combined flap was used. The size of the flaps, the number of perforators, their external diameter, the length of the pedicle and the location and the distance from the anterior superior iliac spine (ASIS) were recorded. RESULTS: The average number of septocutaneous perforators per flap was 1.3 (range, 1-3); the average distance from the ASIS was 11 cm (range, 8-14 cm). The pedicle length varied between 4 and 10 cm, with an average of 7 cm; the average diameter of the pedicle was 4 mm (range, 1-5 mm). The average length of the flaps was 14 cm (range, 4.5-25), and the average width was 7 cm (range, 4.5-19). Donor site closure was achieved by direct closure in 14 patients, and in three patients with a split-thickness skin graft. In one case, at least two-thirds of the flap became necrotic because the septocutaneous perforator was located too far laterally from the flap centre. In one case of a combined flap, one skin island became partly necrotic due to compression after the pedicle was placed beneath the tendon of the extensor tibialis anterior muscle. One flap was successfully revised after venous thrombosis. CONCLUSIONS: The reliability and consistency of the septocutaneous perforators of the TFL flap make planning of this flap easy and the dissection straightforward. Although the number of complications is high in this series, only one complication is related to the flap and the planning itself. With the proposed modifications, we recommend this flap as an interesting alternative to other fasciocutaneous flaps.

Radiation induced cutaneous ulcer on the back in a patient with congenital anomaly of the upper cava system.

Recent years have seen the introduction of a number of additive diagnostic and therapeutic procedures in invasive cardiology. Cardiac catheterization procedures using fluoroscopy reduce patient morbidity and mortality compared to conventional surgical interventions. The associated radiation exposure for the patient is, however, often underestimated, while implantation of cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillator (ICD) pacemaker systems sometimes entails even higher radiation exposures due to prolonged fluoroscopic studies. Radiation induced skin injuries including ulceration are mainly dose dependent effects of ionizing radiation and can be acute, subacute or chronic. The time between radiation exposure and manifestation of skin injuries varies greatly, from a few days up to months or even years. We report a 54-year-old male patient who presented to the Department of Dermatology in the year 2006, with erythema in the interscapular area associated with occasional pruritus. His medical report included several diagnostic cardiac catheterization procedures. Several attempts to implant CRT and ICD had failed owing to an undetected congenital anomaly of the upper vena cava system; these attempts had entailed prolonged fluoroscopy. The patient's history, clinical presentation and histopathological findings finally led to the diagnosis of radiation induced cutaneous ulcer.

The vascular anatomy of the tensor fasciae latae perforator flap.

BACKGROUND: The purpose of this study was to differentiate between musculocutaneous and septocutaneous perforators of the tensor fasciae latae perforator flap; to evaluate their number, size, and location; and to provide landmarks to facilitate flap dissection. An additional injection study estimated the skin area of the flap. METHODS: The anatomical study was performed on 23 fixed and injected cadavers. The perforators of the tensor fasciae latae were identified and classified as septocutaneous or musculocutaneous. Diameter, location, and numbers were measured and the perforators were dissected up to their origin. The injection study was performed on 10 fresh cadavers. On one side, the ascending branch of the lateral circumflex femoral artery was injected with methylene blue; on the other side, the septocutaneous perforators were injected selectively. The size, location, and borders of the stained skin were measured. RESULTS: Forty-five thighs were included in this study. All perforators emerged from the ascending branch of the lateral circumflex artery. The average number of musculocutaneous perforators was 2.3 (range, 0 to 5), the distance from the anterior superior iliac spine was 10.9 cm (range, 4.5 to 16.1 cm), and the diameter was 0.9 mm (range, 0.2 to 2 mm). Four specimens had no musculocutaneous perforator. The average number of septocutaneous perforators was 1.8 (range, 1 to 3), the distance from the anterior superior iliac spine was 10.9 cm (range, 6.2 to 15.7 cm), and the diameter was 1.5 mm (range, 0.5 to 3 mm). Seventy-six percent of the septocutaneous perforators emerged between 8 and 12 cm from the anterior superior iliac spine. The possible pedicle length of a flap based on these vessels is 8.1 cm (range, 6.5 to 10 cm). In the injection study, the average skin area stained with methylene blue was 19.4 x 13.4 cm (range, 10 to 24 cm x 7 to 17 cm) in the ascending branch group. In the perforator group, the average skin area was 19.2 x 13.7 cm (range, 15 to 22 cm x 12 to 16 cm). CONCLUSIONS: The authors could show that the number of septocutaneous perforators for the tensor fasciae latae flap is more constant and that their diameter is greater than that of musculocutaneous perforators. The location of these perforators on a line extending from the ilium to the greater trochanter facilitates planning and dissection of a flap.

Sunburn cell formation, dendritic cell migration, and immunomodulatory factor production after solar-simulated irradiation of sunscreen-treated human skin explants in vitro.

Using human skin explants, we investigated the effects of two different sunscreen preparations containing a chemical UVB filter alone [sun protection factor (SPF) 5.2] or UVA+UVB filter [SPF 6.2] on sunburn cell formation, dendritic cell (DC) migration, CD86- and CD1a-positive cell number, and tumor necrosis factor alpha (TNFalpha) and interleukin (IL)-1, IL-10, and IL-12 production in the skin after irradiation with different doses of solar-simulated UV radiation. Sunscreen- or placebo-treated skin explants were irradiated with solar-simulated UV radiation at 0.5, 1, and 2 minimal erythematous dose equivalents (MEDE) (as determined in an in vivo human study) multiplied by the SPF of the placebo or sunscreens. After irradiation, skin explants were floated on RMPI medium for 48 h. Cells that had emigrated and the skin explants were histologically analyzed, and the soluble mediators were measured in the supernatants by ELISA. Exposure to UV radiation led to concentration-dependent increases in sunburn cell formation and TNFalpha production but a concentration-dependent decrease in DC migration and CD86- and CD1a-positive cell number in the epidermis. Both chemical sunscreens protected against those alterations. The immunoprotective capacity of the sunscreens correlated with their SPF but was independent of the sunscreens' UVA protection capacity, suggesting that UVA is not a major factor for immunosuppression under the conditions used in the model. UV irradiation did not significantly affect the vitality of emigrated DC; the expression of HLA, CD80, and lag on emigrated cells; the number of CD1a-positive cells in the dermis; or the production of IL-1, IL-10, and IL-12. We conclude that our model may be useful in determining the immunoprotective capacity of sunscreens.

The posterior interosseous artery in the distal part of the forearm. Is the term "recurrent branch of the anterior interosseous artery" justified?

In 1993 Angrigiani raised the question as to whether the distal part of the posterior interosseous artery (AIP) is a recurrent branch of the anterior interosseous artery (AIA) and forms a "choke"--anastomosis with the AIP in the middle of the forearm. A dissection study was conducted on 66 upper extremities to evaluate the diameters of the dorsal branch of the anterior interosseous artery, the anastomotic branch, the diameter of the posterior interosseous artery at the point of origin of the septocutaneous perforators in the middle of the forearm and the diameter of the posterior interosseous artery at the point of emergence in the dorsal compartment. We further tried to identify different forms and types of the "distal" anastomosis and the connections to the dorsal carpal arch and the ulnar artery. A distal anastomosis between the AIA and AIP was found in 65 of the 66 upper extremities. Three different types of anastomosis could be identified. The smallest diameter was found at the middle of the forearm (mean diameter AIA 1.28 mm; anastomotic branch 0.6 mm; AIP at the middle of the forearm 0.39 mm; AIP prox. 1.35 mm). A branch through the fifth extensor compartment was present in all of our specimens (mean diameter 0.54 mm). A branch through the forth extensor compartment could be found in 16 specimens. Based on our findings and the embryological development, we conclude that the AIP is only present in the proximal half of the forearm. In the distal part, the dorsal branch of the anterior interosseous artery forms a vascular arcade, which gives off branches to the dorsal carpal arch, the ulnar head and the ulnar artery. This arcade anastomoses with the posterior interosseous artery in the middle of the forearm by means of a choke anastomosis. We also conclude that the term "recurrent branch of the anterior interosseous artery" for the distal part of posterior interosseous artery is correct.

The treatment of painful neuroma on the lower extremity by resection and nerve stump transplantation into a vein.

Lower extremity neuroma resection with nerve stump transposition into a vein was employed in eight patients (five male, three female). The neuromas resulted from amputations (four patients), vein stripping procedures (two patients), tumor resection, and toe-harvest for thumb reconstruction. Follow-up averaged 17 months (range, 8-37). Four of the patients experienced complete and permanent relief of pain; in three patients mild pain recurred within 3 months. All of these patients were satisfied with the result and did not request further treatment. In one case, a painful neuroma recurred. Our results suggest the possibility of inhibiting the formation of painful neuromas by nerve transposition into a vein. Further use of this method is encouraged.

Necrotizing fasciitis after ambulatory phlebectomy performed with use of tumescent anesthesia.

The high cost of treatment of varicose veins has an important role in public health care. The search for a less expensive and office-based procedure led to introduction of tumescent local anesthesia for use in ambulatory phlebectomy. Although the overall infection rate is low, severe infection has been reported after liposuction with tumescent anesthesia. We report necrotizing fasciitis, an infection with a mortality rate of 30% to 50%, after ambulatory phlebectomy and stripping of the long saphenous vein with use of tumescent anesthesia.

Reconstruction of combined defects of the Achilles tendon and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap.

A new approach to reconstruction of the Achilles tendon and overlying soft tissue is presented. A fascia lata graft is used to reconstruct the tendon and is enwrapped by the fascia that is included in a fasciocutaneous lateral arm flap. Five patients were treated with this technique; three of them after surgical Achilles tendon repair, rerupture, and consecutive infection, one after a full-thickness burn with loss of the tendon and one with a history of ochronosis and necrosis of the whole tendon and overlying soft tissue. There were no anastomotic complications and all flaps healed primarily. Functional evaluation with the Cybex II dynamometer was done at least 49 months after reconstruction. A good functional and cosmetic result was obtained in all patients and donor site morbidity was acceptable. These results are well within the results of other surgical treatment options reported in the literature.

Treatment of painful neuroma by resection and nerve stump transplantation into a vein.

Twenty-three patients (14 men, 9 women) with 24 painful neuromas underwent resection of neuroma and transposition of the nerve stump into an adjacent vein. The neuromas resulted from amputations (N = 7), tumor excision (N = 5), laceration injuries (N = 4), different types of wrist surgery (N = 3), vein-stripping procedures (N = 2), open fracture of the radius (N = 1), and toe harvest for thumb reconstruction (N = 1). The duration of painful symptoms averaged 66.7 weeks at the time of operation. Average follow-up was 26.5 months. In 22 patients the symptoms improved permanently. Twelve patients experienced complete and permanent relief of pain; some mild degree of pain returned in 8 patients. Two patients experienced moderate pain, and pain recurred unchanged 2 months postoperatively in 1 patient. The results presented are consistent with results of animal experiments demonstrating that typical neuroma does not develop in nerve stumps transposed into veins. Further clinical use of this approach is encouraged.

Influence of nerve stump transplantation into a vein on neuroma formation.

The objective of this animal study was to investigate the influence of nerve stump transposition into a vein on neuroma formation. In 24 rats the femoral nerve was severed and the proximal nerve stump was transposed into the lumen of the femoral vein on one side. On the other side, the nerve was severed and left in place. The distal nerve stump was shortened to knee level on both sides. In group 1, the bloodstream was released; in group 2, the segment of the femoral vein containing the nerve stump was excluded from circulation. Histological assessment was performed 8 months later. There were significant differences between the treatment and control sides with respect to neuroma size, endoneural architecture, neural-tissue-to-connective-tissue ratio, and myelination of axons. These data suggest that nerve transposition into a vein could inhibit the formation of classic neuroma.