Tumescent local anaesthesia for the surgical therapy of congenital nevi in the first year of life.

BACKGROUND: The indication for surgical treatment of congenital nevi must be made after individual consideration of the expected benefit and risk and requires careful information of the parents as well as interdisciplinary psychological support. In addition to suspected malignancy, a relevant indication is the risk of stigmatization depending on the size and localization of the nevus. Objective was to show which size reduction of the congenital nevus can be achieved by surgical therapy under tumescent local anaesthesia (TLA) in infancy and how often complications of anaesthesia or surgery occur. METHODS: All infants up to 12 months of age who underwent surgery for a congenital nevus under TLA at the University Dermatological Clinic Tuebingen between January 2015 and December 2021 were included; surgeries were performed using serial excisions (powerstretching technique), whereby the incisions were made inside the nevus and mobilization was strictly limited to the skin side without nevus. RESULTS: Overall, a cumulative total area of 38.65 cm2 could be removed on average within the first year of life (trunk: 67 cm2 , head: 21.2 cm2 , legs: 21.6 cm2 , arms: 13.2 cm2 ). A cumulative maximum area reduction of 406.9 cm2 could be achieved. We evaluated 363 surgical sites (123 children) on all body regions. The median age of the children at the first surgery was 3.5 months (0.46-10.7 months). Complications occurred in 2.3% (seven procedures). All these complications were reversible in the course of the operation and did not lead to a prolonged hospital stay. No anaesthesia-related complications occurred. CONCLUSION: We were able to show that a reduction of large areas of congenital nevi is possible in the first year of life with the combination of serial excisions using powerstretching technique, TLA, and intracutaneous butterfly sutures.

Immediate Two-Stage Prosthetic Breast Reconstruction Failure: Radiation Is Not the Only Culprit.

BACKGROUND: Immediate prosthetic breast reconstruction produces a satisfactory aesthetic result with high levels of patient satisfaction. However, with the broader indication for postmastectomy adjuvant radiation therapy, many patients are advised against immediate breast reconstruction because of concerns of implant loss and infection, particularly as most patients also require chemotherapy. This retrospective cohort study examines outcomes for patients who underwent immediate two-stage prosthetic breast reconstruction after mastectomy with or without adjuvant chemotherapy or radiotherapy. METHODS: Between 1998 and 2010, 452 patients undergoing immediate two-stage prosthetic breast reconstruction involving a total of 562 breasts were included in this study. Stage 1 was defined as insertion of the temporary expander, and stage 2 was defined as insertion of the final silicone implant. Postoperative adjuvant radiotherapy was recommended with a tissue expander in situ for 114 patients. Complications, including loss of prosthesis, seroma, and infection, were recorded and analyzed. Cosmetic result was assessed using a four-point scale. RESULTS: Postoperative prosthesis loss was 2.7 percent, 5.3 percent for patients undergoing adjuvant chemotherapy and increasing to 11.3 percent for patients receiving chemotherapy plus radiotherapy. Chemotherapy and radiotherapy independently were the main, statistically significant risk factors for expander or implant loss [incidence rate ratio, 13.85 (p = 0.012) and 2.23 (p = 0.027), respectively]. Prosthesis loss for patients undergoing combination chemotherapy plus radiotherapy was also significant [incidence rate ratio, 4.791 (p < 0.001)]. CONCLUSIONS: These findings serve to better inform patients on risk in weighing treatment options. Postmastectomy radiation therapy doubles the risk of prosthesis loss over and above adjuvant chemotherapy but is an acceptable option following immediate two-stage prosthetic breast reconstruction in a multidisciplinary setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Effective treatment of ketamine-associated cystitis with botulinum toxin type a injection combined with bladder hydrodistention.

Objective Ketamine-associated cystitis (KAC) has been described in a few case reports, but its treatment in a relatively large number of patients has not been documented. This study aimed to describe our experience of treatment of 36 patients with KAC. Methods Thirty-six patients (30 males and 6 females, aged 19-38 years) with KAC, who had previously taken a muscarinic receptor blocker and/or antibiotics, but without symptomatic relief, were treated with botulinum toxin A injection combined with bladder hydrodistention. Urodynamic testing, and the O'Leary-Sant interstitial cystitis symptom index (ICSI) and problem index (ICPI) were used to evaluate baseline values and improvement before and after the treatment. Results One month post-treatment, all patients achieved marked relief of symptoms. The nocturia time was markedly reduced, while bladder capacity, the interval between micturition, the void volume, and the maximum flow rate were remarkably increased at 1 month. Additionally, the ICSI and ICPI were significantly improved. Conclusion Botulinum toxin A injection along with bladder hydrodistention is effective for managing KAC.

Double-Chamber Tissue Expanders Optimize Lower Pole Expansion in Immediate Breast Reconstruction Requiring Adjuvant Radiation Therapy.

INTRODUCTION: Tissue expander-based reconstruction in the irradiated breast has been associated with significant complications, including infection, skin breakdown and implant extrusion, and poor aesthetic outcome. These complications may be attributed to inadequate lower pole expansion causing increased pressure on the suture line. Achieving and maintaining adequate lower pole expansion in the reconstructed breast requiring adjuvant radiation therapy may reduce the pressure/strain on the suture line and preserve the natural appearance of the breast. We describe the effective use of a double-chamber tissue expander to control lower pole expansion in immediate breast reconstruction requiring adjuvant radiation therapy. METHODS: We performed a retrospective chart review of patients who underwent postoperative radiation therapy after immediate breast reconstruction using Sientra's double-chamber tissue expander, performed by a single plastic surgeon from 2012 to 2014. RESULTS: A total of 22 patients met our inclusion criteria. Seventeen patients had bilateral, and 5 patients had unilateral reconstruction (n = 39 total breasts). All patients were over expanded by 20% on the side affected by cancer before the start of radiation, which started by the sixth postoperative week. There was no expansion during radiation therapy. Two patients had further expansion after radiation therapy was completed. The tissue expanders were exchanged for shaped silicone gel implants 3 to 4 months after completion of radiation. A total of 2 complications occurred in 2 patients (9.0%) and 2 breasts (5.1%). These included an infection in one patient and a tissue expander leak in another. No patient developed Baker grade 3 or 4 capsular contracture, seroma, or device malposition. Good lower pole contour and projection was maintained in all breasts at 9 to 12 months of follow-up. CONCLUSIONS: The double-chamber tissue expander is effective in controlling shape, contour, and position of the breast following immediate tissue expander reconstruction requiring adjuvant radiation therapy, with decreased complication rates compared to standard expanders. These results suggest that double-chamber tissue expanders may be the preferred expander option in patients requiring adjuvant radiation therapy. Prospective clinical studies are needed to better evaluate the advantages of this reconstructive approach.

Using an external soft tissue expander before autologous fat grafting for non-irradiated breast reconstruction.

Autologous fat grafting is a method that has been used for breast augmentation since last century. This case report presents a woman with non-irradiated breast requested autologous fat grafting after modified radical mastectomy for breast cancer. An external soft tissue expander was used before fat grafting. This innovative technique showed benefits for the patient, with tight skin after the operation.

Effects of hyperbaric oxygen therapy on rapid tissue expansion in rabbits.

BACKGROUND: Tissue expansion has been widely used to provide additional soft tissue for clinical reconstruction. Rapid expansion requires a much shorter clinical period than conventional expansion; however, less natural skin growth occurs resulting in a larger stretch-back ratio and insufficient extra soft tissue for clinical use. In this study, hyperbaric oxygen therapy (HBOT) was used in the inflation phase of rapid expansion to increase natural skin growth. METHODS: Twelve rabbits were divided into two groups. Each group received rapid expander inflation every day. One group received HBOT and the other did not. Blood flow in the expanded skin of each rabbit was assayed in the 10-day inflation phase. After the inflation phase, a rectangular expanded flap of each rabbit was harvested. The instant stretch-back ratio, tension, weight and histological characteristics of the flaps were evaluated. RESULTS: (1) After the second inflation day, the mean blood flow of the HBOT group became significantly higher than that of the control with each day (P < 0.05). At the last day, the blood flow of the HBOT group increased to 131 ± 17 pu, while the control group decreased to 35 ± 5 pu. (2) The mean instant stretch-back ratio of the HBOT group under no-tension conditions was 29 ± 4%, which was significantly less than that of the control group, 46 ± 3% (P < 0.01). (3) The mean flap tension of the HBOT group was 15.3000 ± 1.47648 g and 12.9833 ± 0.73598 g in the transverse and longitudinal axis, respectively, both significantly smaller than that of the control group (33.9167 ± 4.78390 g and 26.5000 ± 2.45031 g, respectively) (P < 0.01). (4) Mean per unit flap weight of the HBOT group was 0.221 ± 0.005 g cm(-2), significantly heavier (P < 0.01) than that of the control group (0.143 ± 0.010 g cm(-2)). (5) Histologically, the epidermal layer and thickness of the expanded skin of the HBOT group were much thicker than those of the control group, and more vessels were visible in the subcutaneous tissue. CONCLUSIONS: The use of HBOT in the inflation phase of rapid expansion can effectively promote blood flow in the expanded skin, increase its natural skin growth and reduce the instant stretch-back ratio and tension of expanded skin.

Early excision of congenital melanocytic nevi under tumescent anesthesia and skin expansion by intracutaneous double butterfly sutures.

BACKGROUND: Excision of large congenital melanocytic nevi is recommended because of the risk of malignant transformation and for aesthetic reasons. Our treatment concept includes 1) excision in one or more steps preferably before the age of one year, 2) skin expansion through high-tension wound closure with intracutaneous double butterfly sutures and 3) performing surgery with tumescent or general anesthesia. PATIENTS AND METHODS: A retrospective survey was conducted among all parents with children treated for congenital melanocytic nevi in 2004 or 2005 with a maximum age of 6.0 years. The parents were asked to evaluate the trauma associated with their child's surgery and the aesthetic result. RESULTS: Fifty-nine families were contacted, of whom 51 replied. Forty-two parents assessed surgery-associated trauma as light or very light. Thirty-nine parents rated the aesthetic results as good to very good. Severe complications did not occur. CONCLUSION: The proposed surgical concept is a safe procedure with good aesthetic results and low surgery-associated trauma for the child.

Facilitated tissue expansion with topical estriol.

Tissue expansion is a helpful technique in reconstructive plastic surgery. Unfortunately, tissue expansion still needs to be improved. Twenty-four male Wistar rats were used to evaluate the effect of estriol on tissue expansion. The agents hyaluronidase, estriol, and base cream (as a control) were applied topically to separate animal groups for 5 weeks, and their effects were studied on tissue expansion. Both hyaluronidase (p < 0.05) and estriol (p < 0.001) enhanced the rate of expansion when compared with control animals. Estriol was more effective than hyaluronidase (p < 0.05). Breaking strengths were measured in the estriol and the control groups. Breaking strength was not evaluated in the hyaluronidase group because of the necrotic changes seen at the end of the fifth week. The breaking strength was higher in the control group than in the estriol group (p < 0.05). The authors suggest that topical estriol be used as an adjunctive agent to facilitate tissue expansion.

Association of latissimus dorsi muscle expansion with electrostimulation before cardiomyoplasty.

BACKGROUND: The principle of cardiomyoplasty is chronic electrostimulation of the latissimus dorsi muscle (LDM) flap wrapped around the heart to obtain a phasic activity that can be integrated to ventricular kinetics. In clinical cardiomyoplasty procedures, a complete wrap of both ventricles by the LDM cannot always be obtained in cases of extremely dilated hearts. This is due to the limited LDM length available for wrapping. In most of these cases, benefits of cardiomyoplasty are very limited. We have investigated the feasibility of progressive LDM expansion associated with electrostimulation. The aim was to increase the muscle area before cardiomyoplasty, while preserving the electrophysiologic characteristics of muscle fibers. METHODS: In 5 goats, a silicone LDM expander with two incorporated muscular pacing electrodes was inserted deep into the LDM through a paravertebral incision along the posterior edge of the muscle. The pacing leads were connected to a myostimulator implanted in a subcutaneous pocket. The expander was progressively inflated over 8 weeks, up to 500 mL. Simultaneously the LDM was electrostimulated. RESULTS: At 2 months planimetric studies demonstrated an increase of the LDM surface from 175 +/- 12 to 229 +/- 17 cm2 (+31% +/- 4%; p < 0.05). The expanded LDM showed preserved electrophysiologic characteristics. The analysis of biopsy samples revealed histologic integrity of muscle fibers and preservation of their mean diameter. CONCLUSIONS: Potential benefits of this procedure are (1) increase of muscle surface, (2) training of muscular fibers and preservation of muscular tone, and (3) division of the distal vascular supply at implantation, which may potentiate vascularization from the LDM main pedicle. An LDM expansion could be considered before cardiomyoplasty in cases of significant heart dilatation. This device was successfully implanted in 2 patients, 2 months before cardiomyoplasty. Cardiomyoplasties were performed without difficulty, and a complete biventricular wrap was obtained in both patients in spite of massive cardiomegaly.

A study of the delayed linear expansion of a dental stone type IV

Na presente pesquisa, foi verificada a expansäo do gesso tipo IV quando da adiçäo de água, de gesso tipo II, de gesso tipo III e de tipo IV. Os incrementos, tanto de água quanto de gessos, foram feitos nos tempos de 10, 30 e 90 minutos após a espatulaçäo do gesso de base (tipo IV). Todos os incrementos causaram aumento na expansäo normal de presa (ENP), alcançando valores como 300 por cento e 400 por cento, sendo que esses valores eram independentes do tempo para o incremento

Adjuncts to scalp reduction surgery. Intraoperative tissue expanders and hyaluronidase.

Scalp reduction has become an important part of the cosmetic surgeon's armamentarium in the treatment of male pattern alopecia. Recently, the use of two-stage tissue expansion has been advocated for scalp reduction. Intraoperative tissue expansion obviates many of the disadvantages of delayed expansion and increases the yield of excised scalp by 20-30% over standard reduction techniques in the 20 patients studied. The addition of hyaluronidase to the local anesthetic facilitates its diffusion, enhancing anesthesia and the ease of dissection. Therefore, the use of intraoperative tissue expansion and the addition of hyaluronidase to the local anesthetic are two separate adjuncts to scalp reduction surgery.