Surgeon-conducted color Doppler ultrasound deep inferior epigastric artery perforator mapping: A cohort study and learning curve assessment.

BACKGROUND: Perforator mapping using diagnostic methods facilitates deep inferior epigastric perforator (DIEP) flap planning. Computed tomographic angiography (CTA) is a well-proven tool for perforator mapping. However, the benefits of color Doppler ultrasonography (CDU) are as follows: 1) CDU involves dynamic real-time examination and 2) does not use radiation. Comparing the accuracies of both methods in a cohort of patients, this study aimed to evaluate the learning curve of surgeon-conducted CDU perforator mapping. METHODS: Twenty patients undergoing DIEP flap breast reconstruction were enrolled in a cohort study. All patients underwent CTA perforator mapping preoperatively. XY coordinates of significant perforators were subtracted by a radiologist. A single surgeon (sonographer) with minimal experience with CDU performed CDU perforator mapping, including XY coordinates subtraction. The sonographer was blinded to the CTA data. The reference coordinates of dissected perforators were measured during surgery. Deviations from reference coordinates for both methods were compared, and CDU mapping learning curve was assessed using Joinpoint Regression. RESULTS: We included 20 women (32 DIEP flaps and 59 dissected perforators). The mean deviation between mapped and reference coordinates was 1.00 (0.50-1.12) cm for CDU and 0.71 (0.50-1.12) cm for CTA. The learning curve of CDU mapping showed the breaking point after the seventh patient (≈ 21 localized perforators). After the breaking point, no significant differences between the deviations of both methods were found (p = 0.980). CONCLUSION: A limited number of examinations were needed for the surgeon to learn CDU DIEA perforator mapping with accuracy similar to that of CTA mapping.

A Comprehensive In Vitro Comparison of Preparation Techniques for Fat Grafting.

BACKGROUND: Lipomodeling is a technique that uses the patient's own fat for tissue regeneration and augmentation. The extent of regenerative effect is reported to be determined by the numbers of adipose-derived stem cells and the viability of cells in processed adipose tissue which, together with other factors, influence the degree of graft retention. This study addresses whether differences exist in properties of fat graft obtained by three commonly used techniques. METHODS: Adipose tissue harvested from the hypogastric regions of 14 patients was processed by decantation, centrifugation, and membrane-based tissue filtration. The morphology of each preparation was assessed by electron microscopy and overall cell viability was assessed by live/dead assay. The number of adipose-derived stem cells was determined and their stem cell character was assessed by the presence of cell surface molecules (i.e., CD105, CD90, CD31, and CD45) and by their capacity to differentiate into adipogenic and osteogenic lineages. RESULTS: First, morphologies of processed fat samples obtained by individual procedures differed, but no preparation caused obvious damage to cellular or acellular components. Second, although the highest numbers of adipose-derived stem cells were contained in the upper fraction of centrifuged lipoaspirates, the difference between preparations was marginal. Third, the maximal concentration of adipose fraction (removal of watery component) of lipoaspirate was achieved by membrane-based tissue filtration. Finally, no significant differences in overall viability were detected. CONCLUSIONS: Properties of processed lipoaspirate were influenced by the preparation procedure. However, the differences were not dramatic; both centrifugation and membrane-based filtration are methods of choice whose selection depends on other criteria (e.g., practicality) for individual surgical settings.

Reconstruction of a Nose Bitten and Eaten by a Dog: A Ten-Year Follow-up of a Bitten-Off Nose Replantation Performed on an Eleven-Year-Old Boy.

The nose is one of the most important aesthetic units of the face. After a traumatic amputation, replantation is undoubtedly the procedure of choice, although, technically, very challenging. We report the 10-year follow-up of a partially digested nose replantation after a dog-bite in an 11-year-old boy using supermicrosurgery technique. Our report confirms that the microsurgical replantation of the nose can lead to an acceptable aesthetic result, with the sufficient growth of the replanted part in the following years. Besides the patient did not report sensibility disorders. The nose replantation in our opinion is the best reconstructive option to achieve an optimal aesthetic and functional outcome.

New technique of immediate nipple reconstruction during immediate autologous DIEP or MS-TRAM breast reconstruction.

BACKGROUND: Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Usually considered a secondary complement to breast reconstruction, nipple-areola creation is ordinarily done after an interval of several months using different techniques involving local flaps or composite graft from the opposite nipple. METHODS: Because the position of the nipple-areola complex is well defined from the outset in skin-sparing mastectomy, the authors propose a new technique of immediate nipple reconstruction using the skin envelope after skin-sparing mastectomy. A modified wise pattern design of skin-sparing mastectomy with 3 local flaps is used. The dermal-fat flaps are lifted and sutured together to form the new nipple. RESULTS: Seventeen patients (average age, 47 years; range, 33-58 years) underwent immediate nipple reconstruction between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). Average follow-up was 13 months (range, 2-25 months). Aesthetic results were evaluated retrospectively from photographic documentation. A minimum average score of 7.2 points was achieved in all evaluated criteria using a 10-point scale. Patient satisfaction with nipple reconstruction was studied by means of a questionnaire. The shape of the nipple received an average of 9.7 points and the position of the nipple 9.9 points on the 10-point scale; 77% of patients were also very satisfied with nipple sensitivity. CONCLUSIONS: One-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local flaps on skin envelope flap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction using deep inferior epigastric perforator or muscle-sparing transverse rectus abdominis myocutaneous flap. Our technique is suitable for patients with ptotic or hypertrophic breasts.

Vasospasm of the flap pedicle: the effect of 11 of the most often used vasodilating drugs. Comparative study in a rat model.

BACKGROUND: There has been no review study published yet comparing the effects of the vasodilating drugs that are most often used in clinical practice empirically. The aim of the authors' study was to perform this comparison and to select the drugs that are able to release vasospasm and the drugs that reduce vasospasm duration most effectively in an experimental model in vivo. METHODS: Pedicled groin flaps were dissected in 300 male Wistar rats. Vasospasm was induced by tension applied on the pedicle in the axial direction using a 15-g weight. The blood perfusion of the flap was monitored using a laser Doppler device. The duration of vasospasm was defined as the time from the release of tension until blood flow began to rise. These times were detected using automated computerized detection. The effects of 11 different drugs were studied in 14 groups. The drugs were applied locally; some of them were tested in different concentrations or applied parenterally. RESULTS: Ten percent magnesium sulfate reduced the duration of vasospasm most effectively (p < 0.01). Verapamil applied locally and also pentoxifylline applied parenterally were also very effective. In contrast, the duration of vasospasm was extended after local application of 2% lidocaine (p < 0.01). CONCLUSIONS: The authors concluded that 10% magnesium sulfate applied locally has the best ability to relieve surgically induced vasospasm because of the highest level of significance and reliability. The finding that local application of 2% lidocaine prolongs vasospasm may be surprising.

Pectoral muscle flap with V-Y skin paddle for covering sternal defects.

Deep sternal wound infection (DSWI) after a cardiac operation is a rare but serious complication associated with significant morbidity and mortality. It can lead to wound dehiscence with sternal osteomyelitis and both bony and soft tissue residual defects. When the infection is eradicated, reconstruction of the thoracic wall remains the main challenge. Tissue used for covering the defect must be well nourished and sutures must be tension free. We present our unique modification of the method using the pectoral muscle axial flap with a V-Y skin paddle.

Bilateral breast reconstruction with DIEP flaps: 4 years' experience.

UNLABELLED: Bilateral prophylactic mastectomy without reconstruction is not accepted by the majority of patients. Successful reconstruction is therefore a mandatory condition for prophylactic mastectomy. Of the many options for autologous breast reconstruction, the deep inferior epigastric perforator (DIEP) flap best meets requirements for bilateral reconstruction in selected patients. The goal of this study is to verify the feasibility of the procedure in our conditions and to find out how it is accepted by patients. We present 55 consecutive patients who were scheduled for bilateral DIEP flap reconstruction during a 4-year period. We reviewed medical charts, performed clinical assessments and processed anonymous questionnaires. There were 77 immediate and 33 delayed breast reconstructions. There was 100% flap survival and no microanastomoses revisions. In 11 patients (10%) the surgeon preferred to convert the DIEP into a mini transverse rectus abdominis muscle (miniTRAM) flap in order to provide adequate blood supply. COMPLICATIONS: revision for haematoma under the flap in four patients (7.2%), excessive blood loss in four patients (7.2%) and partial mastectomy skin flap necrosis in 10 immediate breast reconstructions (12.9%). Patients' evaluation of the aesthetic result was good or excellent in 96.2% of cases. In 33.9% of patients the postoperative quality of life was considered unchanged and 50.9% of them it even improved. The DIEP flap is recommended for bilateral breast reconstruction. Occasional conversion into a miniTRAM flap can increase the total flap survival rate. Bilateral prophylactic mastectomy and DIEP flap reconstruction are very well accepted by patients.

Primary vein grafting in treatment of ring avulsion injuries: a 5-year prospective study.

Out of 262 hands with total finger amputations treated by replantation of finger/fingers from January 2001 until January 2006, there were only 6 cases of type III ring avulsion injuries, all of which were replanted. Radical resection of the damaged part of the artery with primary vein grafting was used in each case; only 1 artery and 2 veins were anastomosed for each finger. The survival rate was 100%. Mean total active motion was 195 degrees (ranging from 175 degrees to 220 degrees ). Mean 2-point discrimination was 8.6 mm static (ranging from 4 to 11 mm) and 6.2 mm moving (ranging from 3 to 9 mm), and mean grip strength was 37.4 kg. We believe that liberal resection of the "zone of contusion" of vessels and primary vein grafting for arterial repair can improve the overall survival rate of replantation in type III ring avulsion injuries, and replantation can be attempted in majority of the cases; good hand function can be expected.

New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals.

From December 2001 to September 2005, the technique of total penile reconstruction with a reinnervated free latissimus dorsi myocutaneous flap was used in 22 patients (24-38 years old) with gender dysphoria. These patients were followed up for at least 11 months (range, 11-44 months). All flaps survived. Complications include hematoma (7 cases), vascular thrombosis (2 cases), partial necrosis (1 case), excessive swelling of the neophallus (3 cases), and skin graft loss at the donor site (1 case). Of the 19 patients included in the final evaluation, the transplanted muscle was able to obtain contraction in 18 (95%) cases and 8 patients (42%) had sexual intercourse by contracting the muscle to stiffen and move the neopenis. The described technique of neophalloplasty proved to be a reliable technique and the muscle movement in the neophallus can be expected in almost all cases. The muscle contraction in the neophallus leads to "paradox" erection-stiffening, widening, and shortening of the neopenis, which allows for sexual intercourse in some patients. Subsequent reconstruction of the urethra is possible.

The bilobed arterialized venous free flap for simultaneous coverage of 2 separate defects of a digit.

We report a case of a 17-year-old patient who sustained multiple finger contusions on the left hand. After thorough debridement, the volar and dorsal defects of the middle finger were covered simultaneously with bilobed arterialized venous free flap from the left forearm. The flap was composed of 2 paddles, which were connected by a subcutaneous bridge containing a subcutaneous venous network. The subdermal plexus in the bridge was interrupted with no impairment of blood supply to the second cutaneous paddle. The flap survived completely with only temporary mild venous congestion. Excellent functional and cosmetic result was reached. We consider bilobed arterialized venous free flap as a useful option for coverage of concomitant volar and dorsal digital defects.