Total breast reconstruction with the fat-augmented latissimus dorsi (FALD) flap: High safety in a single-center uncontrolled case series.

According to ASPS, 107,238 breast reconstructions (BR) have been performed in the United States this year. The latissimus dorsi (LD) flap is used for breast reconstruction (BR), either with an implant or an extended flap harvest. Implant-enhanced LD is associated with 50% reoperation rates. To avoid implant-related complications, we introduced the Fat-Augmented LD (FALD) flap. Several authors report 92% patient satisfaction and 36% complication rates (CR). The aim of our study is to present a single-center uncontrolled case series with long follow-up assessing CR and esthetic results. Women with small-to-moderate breasts requiring immediate or delayed BR were included, whereas athletic and paraplegic women or patients with contraindication for free flap BR were excluded. Clinical and surgical data were analyzed. Esthetic analysis was performed using a panel of independent observers. Between December 2010 and November 2019, 100 patients underwent 148 FALD-based BR. Average operative time was 193.5 min for unilateral procedure and 290.6 min for bilateral procedure. Mean immediate AFT volume was 105.3 cc (range 60-170) per breast. Major complication (total or partial flap necrosis > 30%) rate was 0%, and minor complication (partial flap necrosis < 30%, fat necrosis hematoma, seroma, donor site dehiscence, and chronic pain) rate was 6.76%. Esthetic analysis garnered satisfactory results for all types of mastectomies. For variables regarding skin texture (p = 0.001), scar location (p = 0.005), and total score (p = 0.001), patients undergoing Modified Radical Mastectomy scored lower than Skin-Sparing Mastectomy and Nipple-Sparing Mastectomy. We were able to confirm that the FALD flap is a safe with a low complication rate and high patient satisfaction. Level of Evidence IV.

Facial Transplantation: Nonimmune-Related Hyperacute Graft Failure-The Role of Perfusion Injury: A Case Report.

BACKGROUND: The aim of this study was to report the first case of acute facial allograft transplantation (facial allograft transplantation) failure with allograft removal and autologous free-flap reconstruction. METHODS: A 49-year-old female patient affected by neurofibromatosis type 1 with a massive neurofibroma infiltrating the whole left hemiface was planned for FAT for the left hemiface including the auricle, all skin and soft tissues from the temporal region, periorbital and nasal region, and up to the perioral area. The maxillary process of the zygomatic bone, left hemimaxilla, and hemimandible from contralateral parasyphysis to the incisura mandibulae were also included. RESULTS: Total surgical time was 26 hours. There were 2 intraoperative arterial thromboses that were solved with new anastomoses and sufficient flap perfusion. On postoperative day 2, the allograft became pale with suspected arterial occlusion and the patient returned to the operative room for exploration no flow into the FAT was found. The allograft was removed and the recipient site reconstructed with a skin-grafted composite left latissimus dorsi-serratus anterior flap. CONCLUSIONS: Hyperacute loss of FAT is a very dramatic event, and the activation of a backup surgical plan is crucial to save patient's life, give a reasonable temporary reconstruction, and return on the waiting-list for a second face transplantation.

Safe Reentry for False Aneurysm Operations in High-Risk Patients.

BACKGROUND: In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. METHODS: We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. RESULTS: We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. CONCLUSIONS: The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Late unilateral hematoma after breast reconstruction with implants: case report and literature review.

UNLABELLED: Although reports of late hematoma after placement of breast implants are rare, there has been a noticeable increase in these reports in recent years. Various etiologies have been proposed, usually relating to history of trauma, anticoagulant use, or physical strain. In this case report, we describe a 61-year-old patient who slowly developed a unilateral intracapsular hematoma 2 years after breast reconstruction with Biocell (Natrelle; Allergan, Inc, Irvine, California) textured implants. This case is unique because of the intraoperative finding of 2 capsules surrounding the implant, with the hematoma between the 2 layers. We also discuss the possible pathophysiological mechanisms of this phenomenon. LEVEL OF EVIDENCE: 5.

Correction of myopathic blepharoptosis by check ligament suspension: clinical evaluation of 89 eyelids.

Myopathic blepharoptosis is a congenital anomaly of the eyelid. The levator muscle does not function because of primary myogenic atrophy. Different procedures based on eyelid suspension, or the simple or combined resection of the eyelid have been described. A simple dynamic suspension of the tarsus to the check ligament of the superior fornix, neither sacrificing nor adding any tissue was used for 89 procedures on 71 consecutive patients with primary myopathic blepharoptosis. Their mean age at operation was 16 years (range 2-58) and the follow up ranged from 2 months to 12 years. Ptosis was unilateral in 53 patients (33 left, 20 right) and bilateral in 18. Preoperatively 27 had mild ptosis (1-2 mm), 33 moderate (3-4 mm), and 29 severe (>4 mm). The patients were divided into two groups: not previously operated on (50 patients/63 eyelids) and previously operated on by other techniques (21 patients/26 eyelids); both groups were compared for duration of procedure, normalisation rate, and number of revisions. In the unoperated group the normalisation rate was 81% (51 eyelids), and to achieve a good final result nine eyelids were revised once, while just three were reoperated on twice (19%). In the group previously operated on the normalisation rate was 69% (18 eyelids), while 3 eyelids needed one revision (12%). In unilateral cases the normalisation rate was 79% (42 eyelids) and in bilateral 75% (27 eyelids). In unilateral blepharoptosis there were 13% of revisions (7 eyelids) while bilaterally there were 22% (8 eyelids). Despite a previous operation, the operating time of a unilateral correction was similar in both groups, while the number of revisions needed to achieve the final result was low for unilateral ptosis, but higher for bilateral ones. This simple atraumatic suspension technique produced an improvement in all cases and it seemed useful in both primary and secondary cases.

The efficacy and safety of extending the ischemic time with a modified cardioplegic technique for coronary artery surgery.

BACKGROUND AND AIM: The need to intermittently discontinue the administration of cardioplegia in order to complete the surgical procedure is a major drawback of antegrade warm blood cardioplegia. An ischemic time of 15 minutes is generally considered safe based on empirical observation. The aim of this study was the evaluation of the efficacy and safety of an intermittent warm blood cardioplegia with intervals between administrations prolonged to 25 minutes. METHODS: Ninety-seven patients undergoing primary elective coronary artery revascularization were prospectively randomized into two groups. The first, Intermittent Antegrade Warm Blood Cardioplegia (IAWBC) group, comprising 49 patients, received standard intermittent antegrade warm blood cardioplegia repeated every 15 minutes. The second, Modified Intermittent Antegrade Warm Blood Cardioplegia (M-IAWBC) group, comprising 48 patients, received intermittent antegrade warm blood cardioplegia supplemented with magnesium sulfate (MgSO(4)), delivered in volumes proportional to the ventricular mass and repeated every 25 minutes. The clinical outcomes were evaluated. The levels of creatine kinase-MB (CK-MB) isoenzyme, in addition to the echocardiographic assessment of septal dyskinesia and tricuspid annulus plane systolic excursion (TAPSE), have been used as markers of myocardial damage. RESULTS: There were no statistically significant differences in clinical outcomes, need for inotropes and vasodilators, length of stay in the intensive care unit, and postoperative levels of CK-MB between the two groups. Likewise, postoperative echocardiographic assessment showed no relevant differences. CONCLUSIONS: Administration of warm antegrade cardioplegic solution supplemented with MgSO(4), delivered in volumes proportional to ventricular mass every 25 minutes, provides adequate myocardial protection for coronary artery surgery.

Preliminary experience in breast reconstruction with the free vertical deep inferior epigastric perforator flap.

The transverse abdominoplasty flap based on the perforators of the deep inferior epigastric pedicle (DIEP) is not indicated in patients with longitudinal midline abdominal scars because of the poor midline crossover of blood and the high risk of necrosis of the distal flap. Four patients who required breast reconstruction and presented with a mid-abdominal scar and an incongrous half abdomen, had a flap outlined vertically over the rectus abdominis muscle (VDIEP). The flaps were transferred to the thorax and reperfused to the thoracodorsal vessels. All flaps healed uneventfully which showed that the VDIEP is a reliable option for breast reconstruction, with the abdominoplasty flap, in patients with a vertical mid-abdominal scar. This flap seems to be perfused more robustly than the transverse DIEP; it has a better arterial inflow because of the inclusion of zone I and II alone according to Scheflan's model, and an easier longitudinal venous outflow.

Surgical treatment of ulcers caused by extravasation of cytotoxic drugs.

Despite preventive measures, the extravasation of cytotoxic drugs still occurs in 0.6% to 6% of cases. The aetiology is thought to be that tissue necrosis develops into a chronic ulcer, which causes problems if the harmful action of the drug is not blocked. From 1988-2002 at the Department of Plastic Surgery of Rome University "La Sapienza", 240 patients presented with extravasation of cytotoxic drugs; all had been treated with an original conservative protocol first described in 1994, based on the repeated local infiltration of a large quantity of saline solution (90-540 ml) into the area of extravasation. We considered only cases with actively necrotic lesions. Eleven of the 240 patients (5%) had ulcers ranging from small ulcers to extensive areas of tissue necrosis. Of the 11 patients, eight had already had ulcers, while the remaining three were those in whom our conservative protocol had not prevented necrosis. They were all operated on and given grafts, local flaps, reverse radial flaps, and free flaps.

Reconstruction of a natural-looking umbilicus.

Based on the assumption that the umbilicus is a wound that has healed by second intention, we describe a method of reconstruction. The procedure consists of complete resection of the umbilical scar and its reconstruction by a linear incision at the site of the new umbilicus and inversion of the skin hedges, which are sutured to the linea alba leaving a 1 cm space between the skin borders to cause secondary wound healing. This procedure provides a natural-looking umbilicus. It is easy and quick to do, and can be used for reconstruction after abdominoplasty, excision of a naevus, or when the umbilicus has been removed during a previous xiphopubic incision.