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BACKGROUND: The current study introduces and demonstrates our experience of using a sequential thoracoacromial artery perforator (TAAP) flap to repair the sternocleidomastoid (SCM) flap donor site in this context. The aims of this technique are to optimize both esthetic and functional outcomes and to reduce postoperative complications for patients. METHODS: Between September 2013 and March 2017, the SCM flap combined with sequential TAAP flap was used for reconstruction postradical parotidectomy in 12 patients. Flap characteristics, patient outcomes, and postoperative complications were monitored and objectively measured, with 10 to 24 months of follow-up. RESULTS: There were no incidences of total flap loss. All TAAP flap donor sites were closed directly, and all healed without any complications. The SCM flap and TAAP flap donor areas were esthetically acceptable, with good esthetic and functional outcomes achieved in all 12 patients. CONCLUSIONS: The sequential TAAP flap has a consistent vascular supply and provides a reliable surgical approach to reconstruct the SCM flap donor site with good esthetic and functional outcomes.
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Retalho Miocutâneo , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Artéria Axilar , Humanos , Artérias TorácicasRESUMO
Surgeons performing free flap breast reconstruction need to have a range of techniques in their armamentarium to successfully salvage cases of flap failure. We present a case of 47-year-old patient who suffered near-total right breast deep inferior epigastric perforator (DIEP) flap failure 3 days post-bilateral immediate breast reconstruction with DIEP flaps. At debridement, the DIEP pedicle was noted to be patent with preserved perfusion to a small segment of tissue around the origin of the pedicle. This tissue and the DIEP pedicle itself were therefore preserved to facilitate subsequent breast reconstruction using stacked transverse upper gracilis flaps anastomosed end-to-end to the original DIEP pedicle. Post-operatively, both flaps remained viable with no further complications and symmetrical aesthetic result maintained at 2 months follow-up post-salvage procedure. This case emphasizes the importance of exercising caution during initial debridement for free flap failure to preserve viable tissue in the flap and pedicle, particularly in circumstances where vascular flow in the pedicle is maintained, to facilitate successful salvage reconstruction.
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Anastomose Cirúrgica/métodos , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Desbridamento/métodos , Retalhos de Tecido Biológico/cirurgia , Músculo Grácil/cirurgia , Mamoplastia/métodos , Mastectomia/reabilitação , Retalho Perfurante/efeitos adversos , Retalho Perfurante/irrigação sanguínea , Autoenxertos , Desbridamento/efeitos adversos , Artérias Epigástricas , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Pessoa de Meia-Idade , Aparência Física , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Resultado do TratamentoRESUMO
PURPOSE: Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in 'vessel-depleted neck' and 'frozen neck' respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery. METHODS: The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis. RESULTS: The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm. CONCLUSION: The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable.
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Artéria Carótida Externa/cirurgia , Retalhos de Tecido Biológico/transplante , Neoplasias de Cabeça e Pescoço/cirurgia , Microcirurgia/métodos , Procedimentos de Cirurgia Plástica/métodos , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/métodos , Cadáver , Feminino , Retalhos de Tecido Biológico/irrigação sanguínea , Humanos , Masculino , Pescoço/irrigação sanguínea , Pescoço/cirurgiaRESUMO
INTRODUCTION: Dermoid cysts are common, benign, embryologically derived soft tissue cysts that can arise at a variety of craniofacial sites. It is not known whether specific histological variations exist between the different craniofacial sites. This study aims to establish whether inter-site histologic differences exist between periorbital, nasal, scalp, and postauricular dermoid cysts and analyze these in context of their distinct embryological origin and varied clinical presentation. METHODS: A retrospective review of craniofacial dermoid cysts was performed. Using light microscopy with hematoxylin and eosin staining, histological appearance was directly compared between craniofacial sites. RESULTS: All (n = 16) cysts contained keratinizing, stratified squamous epithelial lining, intraluminal keratin, and hair. Sebaceous glands were commonly present (n = 13). Eccrine (sweat) glands were less common (n = 3). Structures of mesodermal origin were seen in three periorbital cysts. Only the six ruptured cysts showed evidence of inflammation. CONCLUSIONS: Histological properties of dermoid cysts are conserved between craniofacial sites (periorbital, nasal, scalp, and postauricular). This reflects the consistency of ectodermal inclusion during early embryological development, which is independent of specific craniofacial site or surrounding anatomical structures.
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Cisto Dermoide/patologia , Face/patologia , Crânio/patologia , Pré-Escolar , Demografia , Cisto Dermoide/cirurgia , Face/cirurgia , Feminino , Humanos , Lactente , Cuidados Intraoperatórios , Masculino , Crânio/cirurgiaRESUMO
It is widely accepted that during postnatal development trabecular bone adapts to the prevailing loading environment via modelling. However, very little is known about the mechanisms (whether it is predominantly modelling or remodelling) or controls (such as whether loading influences development) of fetal bone growth. In order to make inferences about these factors, we assessed the pattern of fetal trabecular development in the humerus and femur via histomorphometric parameter quantification. Growth and development (between 4 and 9 months prenatal) of trabecular architecture (i.e. thickness, number and bone volume fraction) was compared across upper and lower limb bones, proximal and distal regions, and sexes. The data presented here indicate that during prenatal development trabeculae became thicker and less numerous, whilst bone volume fraction remained constant. This partly mimics the pattern of early postnatal development (0-2 years) described by other researchers. Thickness was reported to increase whilst number reduced, but bone volume fraction decreased. This is perhaps because the balance of bone modelling (deposition vs. resorption) changes post partum. Published histological data suggest that bone deposition slows after birth, while resorption rates remain constant. Hence, fetal development may be characterized by relatively high rates of modelling and, particularly, bone deposition in comparison to postnatal. With respect to measures of thickness, number and bone volume fraction prenatal development was not bone, site, or sex specific, whilst postnatally these measures of architecture diverge. This is despite reported developmental variation in the frequency, speed and amplitude of fetal movements (which begin after 11 weeks and continue until birth), and probably therefore loading induced by muscular contractions. This may be because prenatal limb bone micro-architecture follows a generalised predetermined growth trajectory (or genetic blueprint), as appears to be the case for gross distribution of trabecular tissue.
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Desenvolvimento Ósseo , Fêmur/embriologia , Úmero/embriologia , Análise de Variância , Fêmur/crescimento & desenvolvimento , Humanos , Úmero/crescimento & desenvolvimento , Microtomografia por Raio-XAssuntos
Atitude do Pessoal de Saúde , Técnicas Cosméticas , Publicidade Direta ao Consumidor/métodos , Marketing de Serviços de Saúde/métodos , Procedimentos de Cirurgia Plástica , Mídias Sociais , Cirurgiões/psicologia , Cirurgia Plástica , Atitude Frente aos Computadores , Técnicas Cosméticas/normas , Publicidade Direta ao Consumidor/normas , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Marketing de Serviços de Saúde/normas , Guias de Prática Clínica como Assunto , Procedimentos de Cirurgia Plástica/normas , Mídias Sociais/normas , Cirurgiões/normas , Cirurgia Plástica/normas , Gravação em VídeoRESUMO
There is no international consensus on the use of perioperative thromboprophylaxis in digital replantation. Suboptimal perioperative management may lead to replant failure, which compromises extremity function, worsens psychosocial outcomes for patients, and incurs significant cost. This systematic review evaluates and compares the efficacy and safety of perioperative antithrombotic protocols used in digital replantation. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)--compliant prospectively registered (PROSPERO, CRD42018108695) systematic review was conducted. Cochrane Central Register of Controlled Trials, Medline, EMBASE, and Scopus were searched up until December 2019. Articles were assessed for eligibility in duplicate by 2 independent reviewers. All comparative studies that examined the use of perioperative thromboprophylaxis in digital replantation were eligible for inclusion. RESULTS: Collectively, 1,025 studies were identified of which 7 met full inclusion criteria reporting data from 635 patients (908 digital replants, 86% men, average age 37.3 years). Laceration was the most commonly reported mechanism of injury (68%), with 33% of replantation occurring in Tamai zone III. Fourteen distinct perioperative protocols were identified. One study reported significantly higher digital survival with continuous heparin infusion versus bolus heparin. Five studies demonstrated a significantly higher incidence of complications among patients treated with systemic heparin. CONCLUSIONS: The clinical efficacy and safety of perioperative antithrombotic therapy following digital replantation remains equivocal. The perceived benefits of improved digital survival must be tempered against the adverse systemic side effects of antithrombotic and anticoagulant therapies until further prospectively collected data sets become available.
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This article portrays the authors' clinical experience of a complex case of lower extremity reconstruction using a recycled pedicle from 10 years old free latissimus dorsi musculocutaneous flap to supply a new free anterolateral thigh flap for proximal tibia wound defect reconstruction. It provides clinical evidence that muscle neovascularization occurs and supports the dogma peripheral tissue neovascularization. This case stipulates that recycling of pedicle is feasible, when used with appropriate strategy and safety and also provides evidence for the long-term survival of greater saphenous vein grafts in lower extremity reconstruction.
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BACKGROUND: Selective non-operative management (SNOM) has been proposed as a safe and adequate strategy for penetrating extremity trauma (PET) management. This may reduce unwarranted surgical exploration and enhance cost-effectiveness. Our experience at a UK major trauma centre advocates SNOM-PET as a viable and safe strategy for selected patients. A PET management algorithm is proposed. METHODS: A retrospective review was undertaken for isolated PET from October 2015 to October 2016. Examination findings were recorded as positive if neurovascular or tendon deficits were elicited. Surgical exploration was recorded as positive if neurovascular or tendon injuries were found. Diagnostic statistics were employed for upper limb (UL) and lower limb (LL) examinations. RESULTS: One hundred sixty patients [112 UL and 48 LL PET injuries] were included. Fifty-six out of 112 (50%) patients with UL PET had no examination findings. Twenty-three out of 56 (41%) patients had negative surgical explorations and 33 of 56 (59%) patients had positive surgical explorations. Thirty-four out of 48 patients with LL PET had no examination findings. All 34 patients had negative surgical explorations. The sensitivity (0.61â¯vs 1.00, pâ¯=â¯0.005), specificity (0.82â¯vs 0.97, pâ¯=â¯0.043) and negative predictive value (NPV; 0.41â¯vs 1.00, pâ¯<â¯0.001) were lower for UL PET than for LL PET examinations. There were no statistically significant differences in sensitivity, specificity as well as NPV and positive predictive value between plastic surgery residents and emergency medicine residents for UL and LL examinations. CONCLUSION: This is the first UK evaluation of SNOM-PET. It may be safely utilised for LL PET. UL PET should be surgically explored. SNOM-PET may avoid unwarranted surgical exploration, associated complications and cost.
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Traumatismos do Braço/terapia , Tratamento Conservador/métodos , Gerenciamento Clínico , Traumatismos da Perna/terapia , Ferimentos Penetrantes/terapia , Adulto , Traumatismos do Braço/diagnóstico , Feminino , Humanos , Escala de Gravidade do Ferimento , Traumatismos da Perna/diagnóstico , Masculino , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Ferimentos Penetrantes/diagnóstico , Adulto JovemRESUMO
Deep inferior epigastric artery perforator (DIEP) flap has become the gold standard in autologous breast reconstruction. Attention is now being focused on the impact of DIEP flap harvest technique on abdominal hernia rates. The aim of this study was to evaluate DIEP abdominal wall morbidity in relation to flap harvest and fascial closure technique. A retrospective analysis of patients undergoing DIEP flap breast reconstruction between 2012 and 2016 was performed. Post-operative evaluation of the abdominal wall integrity was performed by an operating consultant. The rectus fascia was closed using one of three techniques. The study included 202 patients, in whom 234 DIEP flaps were performed. Eight patients (3.4%) developed a clinically evident abdominal bulge post-operatively and one (0.5%) had a hernia. Harvesting two or more perforators was more likely to result in post-operative abdominal hernia/bulge than taking a single perforator (p = .032). Using a perforator from the lateral row or both rows was more likely to result in a hernia/bulge than if a single medial perforator was harvested (p = .026). Comparison of the rectus fascia closure technique did not show any statistically significant difference in abdominal wall morbidity. Consideration should be given towards perforator selection when harvesting a DIEP flap. Where appropriate, a suitable single medial row perforator with a favourable suprafascial course should be chosen. This study has not shown mesh-free fascial closure to be inferior to mesh-supported closure. Careful consideration to the role of synthetic mesh within this patient cohort should be given.
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Hérnia Abdominal/etiologia , Mamoplastia , Retalho Perfurante/irrigação sanguínea , Complicações Pós-Operatórias , Sítio Doador de Transplante , Adulto , Idoso , Índice de Massa Corporal , Artérias Epigástricas/transplante , Fasciotomia/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Fatores de RiscoAssuntos
Anestésicos Locais , Extremidades , Bloqueio Nervoso/métodos , Dor Processual/prevenção & controle , Procedimentos de Cirurgia Plástica , Hemorragia Pós-Operatória , Estimulação Elétrica Nervosa Transcutânea/métodos , Anestesia por Condução/efeitos adversos , Anestesia por Condução/métodos , Anestesia Local/efeitos adversos , Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Epinefrina/administração & dosagem , Extremidades/inervação , Extremidades/cirurgia , Humanos , Duração da Cirurgia , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Vasoconstritores/administração & dosagemRESUMO
INTRODUCTION: Articular cartilage is renowned for its poor intrinsic capacity for repair. Current treatments for osteoarthritis are limited in their ability to reliably restore the native articular cartilage structure and function. Mesenchymal stem cells (MSCs) present an attractive treatment option for articular cartilage repair, with a recent expansion of clinical trials investigating their use in patients. AREAS COVERED: This paper provides a current overview of the clinical evidence on the use of MSCs in articular cartilage repair. EXPERT OPINION: The article demonstrates robust clinical evidence that MSCs have significant potential for the regeneration of hyaline articular cartilage in patients. The majority of clinical trials to date have yielded significantly positive results with minimal adverse effects. However the clinical research is still in its infancy. The optimum MSC source, cell concentrations, implantation technique, scaffold, growth factors and rehabilitation protocol for clinical use are yet to be identified. A larger number of randomised control trials are required to objectively compare the clinical efficacy and long-term safety of the various techniques. As the clinical research continues to evolve and address these challenges, it is likely that MSCs may become integrated into routine clinical practice in the near future.