Nipple-Areola Complex Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand how to determine nipple-areola complex positioning on the reconstructed breast. 2. Understand the multitude of local flap and distant graft options for nipple-areola complex reconstruction. 3. Draw at least three fundamental nipple-areola complex reconstruction patterns. 4. Understand the forces that are responsible for flattening of the reconstructed papule. 5. Understand the current techniques used in secondary nipple-areola complex reconstructions. SUMMARY: Nipple-areola complex reconstruction and tattooing represent the final two stages of breast reconstruction. Nipple-areola complex reconstruction is typically accomplished with the use of local flaps, local flaps with augmentation grafts, or a combination thereof. Regardless of the technique used, however, all nipple-areola complex reconstructions lose a degree of projection over time. Options for secondary reconstruction include the use of local tissue flaps alone or in combination with acellular biological matrices.

Comparison of Synthetic and Biologic Mesh in Ventral Hernia Repair Using Components Separation Technique.

Ventral hernia repair (VHR) for large abdominal wall defects is challenging. Prior research established that the use of mesh is superior to suture closure alone and that component separation is an effective technique to combat loss of abdominal domain. Studies comparing component separation technique (CST) outcomes utilizing synthetic versus biologic mesh are limited. A retrospective review was conducted of 72 consecutive patients who underwent VHR with CST between 2006 and 2010 at our institution. Surgeon preference and the presence of contamination guided whether synthetic mesh (27 patients) or biologic mesh (45 patients) was used. Mean follow-up interval for all comers was 13.9 months and similar in both groups (P > 0.05). Degree of contamination and severity of premorbid medical conditions were significantly higher in the biologic mesh group, as reflected in the higher Ventral Hernia Working Group (VHWG) score (2.04 versus 2.86). Clinical outcomes, as measured by both minor and major complication rates and recurrence rates, were not significantly different. Minor complication rates were 26% in the synthetic group and 37% in the biologic group and major complication rates 15% in the synthetic group and 22% in the biologic group. There was 1 recurrence (4%) in the synthetic mesh group versus 5 (11%) in the biologic mesh group. Multivariable analysis for major complications revealed no significant difference for either synthetic or biologic mesh while controlling for other variables. Subset analysis of uncontaminated cases revealed recurrence rates of 4% in the synthetic mesh group and 6% in the biologic mesh group. VHR using CST and either synthetic mesh or biologic mesh resulted in low recurrence rates with similar overall complication profiles, despite the higher average VHWG grading score in the biologic mesh group. Our results support the VHWG recommendation for biologic mesh utilization in higher VHWG grade patients. In VHWG grade 2 patients, our clinical outcomes were similar, supporting the use of either type of mesh.

Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and groin reconstruction.

BACKGROUND: Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications. METHODS: All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables. RESULTS: There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups. CONCLUSIONS: Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Implantable Cook-Swartz Doppler probe versus Synovis Flow Coupler for the post-operative monitoring of free flap breast reconstruction.

BACKGROUND: The Cook-Swartz Doppler has long been a trusted tool for close monitoring of blood flow after microvascular reconstruction; however, device implantation requires additional operating time. Synovis Life Technologies, Inc. received FDA approval in 2010 for the Flow Coupler, which combines an end-to-end anastomotic coupler with a removable 20 MHz Doppler, allowing both procedures to be performed simultaneously. However, its short history of widespread use necessitates further evaluation in the clinical setting. The authors studied the Synovis Flow Coupler in comparison to the more well-established Cook-Swartz Doppler for effectiveness and reliability in detection of vascular compromise. METHODS: The authors reviewed 220 free flap breast reconstructions in 150 patients over a three-year period in which either the Cook-Swartz Doppler or the Synovis Flow Coupler was implanted to monitor blood flow. Outcomes measured include false-positive or false-negative rates (FPR, FNR); rates of OR take-back and salvage; and flap survival. RESULTS: FPR was 1.0% for the Cook-Swartz Doppler and 1.9% for the Synovis Flow Coupler (p>0.05). FNR was 0.0% for both groups. Take-back rates were 10.1% for the Cook-Swartz, and 4.5% for Synovis (p>0.05). Flap failure rates were 1.8% and 0.9% for the Cook-Swartz and Synovis devices, respectively (p>0.05). CONCLUSIONS: Our study reveals no statistically significant differences in outcomes for free flap breast reconstruction where either the Cook-Swartz Doppler or the Synovis Flow Coupler was used to monitor blood flow to the perforator flap. LEVEL OF EVIDENCE: III.

[Heart and combined heart-lung transplantation. Indications, chances and risks]. / Herz- und Herz-Lungen-Transplantation. Indikationen, Chancen, Risiken.

Orthotopic heart transplantation (HTX) is nowadays the worldwide accepted gold standard for the treatment of terminal heart failure. The main indications for HTX are non-ischemic dilatative (54%) and ischemic (37%) heart failure. In the acute phase after HTX the survival rate is approximately 90%. Good short and long-term results with survival rates ranging from 81% after 1 year to more than 50% after 11 years demonstrate that there is currently no real treatment alternative to HTX for treatment of end-stage heart failure. In the case of irreversible pulmonary hypertension in combination with end-stage heart failure or complex congenital heart syndromes, a combined heart and lung transplantation (HLTX) is necessary. Compared with HTX the short-term survival of HLTX is reduced, mostly for technical reasons. Improved long-term results after HTX and HLTX are a result of highly specialized transplantation units and effective immunosuppression. However, a major problem is the shortage of organ donors in Germany and the resulting long waiting times for patients with frequently occurring blood groups of up to 10 months for transplantation. The consequence of the latter is the ever increasing number of implanted cardiac assist devices in patients not only as a bridge to transplant but also as destination therapy.

[Interruption of the aortic arch with no patent ductus arteriosus: is survival possible?]. / Interruption de l'arche sans canal artériel : la survie est-elle possible ?

Interruption of the aortic arch is a rare congenital disease. It is defined by the complete interruption between the ascending and descending aorta. A patent ductus arteriosus is necessary to maintain flow from the pulmonary to the descending aorta. Its closure leads to a cardiovascular collapse and this malformation is therefore duct-dependent. However, in rare cases, survival remains possible even after ductus arteriosus closure. We report such a case.

Comparison of outcomes using AlloDerm versus FlexHD for implant-based breast reconstruction.

BACKGROUND: Prosthetic reconstruction using human acellular dermis (ADM) is a common practice in breast reconstruction. AlloDerm and FlexHD are two different forms of ADM, each with unique characteristics. No studies have directly compared the postoperative complications of these 2 products. METHODS: The outcomes of 547 consecutive implant-based breast reconstructions were reviewed. RESULTS: Reconstruction was performed in 382 consecutive women (547 total breasts), employing mostly immediate reconstruction (81%). Mean follow-up was 6.4 months. Among immediate reconstructions, 165 used AlloDerm and 97 used FlexHD. Complications were similar by univariate analysis. In multivariate analysis, smoking and higher initial implant fill were risk factors for delayed healing. The use of FlexHD, single-stage reconstruction, and smoking were independent risk factors for implant loss. CONCLUSIONS: There is no significant difference in the complication rates between AlloDerm and FlexHD in immediate breast reconstruction. Multivariate analysis suggests that FlexHD may be a risk factor for implant loss.

Successful pregnancy and delivery in a woman with a single ventricle and Eisenmenger syndrome.

BACKGROUND: Patients with a single ventricle represent a rare abnormality found in 1% of patients with congenital heart disease, often discovered during childhood. Without pulmonary stenosis, the disease can progress to fixed pulmonary hypertension. Both pregnancy and delivery are risky events capable of increasing the right-to-left shunt. Pregnancy is contraindicated. CASE: We report the case of a 27-year-old woman with a single ventricle without pulmonary protection and fixed pulmonary hypertension at 60 mmHg, discovered during a pregnancy. The delivery was obtained by cesarean section with epidural anesthesia and the patient was perioperatively treated with nitric oxide. Though contraindicated, pregnancy and delivery were successfully achieved in this patient. COMMENT: Patients with single ventricle and Eisenmenger syndrome rarely reach adult life. Pregnancy with this condition is exceptional and fundamentally perturbs hemodynamic stability. In spite of the development of anesthesia and resuscitation and the description of some cases in literature, pregnancy with Eisenmenger syndrome is contraindicated.

[Striatopallidodentate calcinosis, hypoparathyroidism and neurological features: a case series study]. / Calcinose striatopallidodentelée, hypoparathyroïdie et atteinte neurologique: étude de série.

INTRODUCTION: The respective roles of hypocalcemia and intracerebral calcifications in the occurrence of various neurological manifestations in hypoparathyroidism is not entirely clear. Nevertheless, therapeutic and prognostic implications are important. OBJECTIVES: We analyze the neurological clinical aspects observed in hypoparathyroidism and correlate them to the biological calcium abnormality and radiological CT scan findings. We also compare these results with data reported in the idiopathic form of striatopallidodentate calcinosis. PATIENTS: The neurological clinical, CT scan findings and outcome have been retrospectively studied in patients recruited during 13 years (2000-2012) for neurological features associated with hypoparathyroidism or pseudohypoparathyroidism. RESULTS: Twelve patients with primary hypoparathyroidism (n=5), secondary to thyroidectomy (n=4) and pseudohypoparathyroidism (n=3) were studied. The sex-ratio was 1 and mean age was 39 years. All patients had a tetany, 60% had epilepsy, associated in one patient with "benign" intracranial hypertension; 50% had behavioral changes. Response to calcium therapy was excellent for all these events. Moderate cognitive deficit was noted in three patients (25%), parkinsonism in two patients and hyperkinetic movement disorders in one other. These events were not responsive to calcium therapy and were more common in cases of extensive brain calcifications and in patients who had pseudohypoparathroidism. COMMENTS: This study suggests that, in patients with hypoparathyroidism, epilepsy and psychiatric disorders are induced by hypocalcemia and reversible after its correction. Cognitive and extrapyramidal impairment seem to be related to the progressive extension of intracerebral calcification, particularly in patients with a late diagnosis. In patients with pseudohypoparathyroidism, this finding is different because of the contribution of other factors, specific to this disease.

Clinical utility of CT angiography in DIEP breast reconstruction.

BACKGROUND: CT angiography has become the gold-standard imaging modality prior to DIEP flap breast reconstructions. Recent studies show excellent correlation between CTA and operative perforator location, but not their clinical significance. This study seeks to specifically evaluate the clinical utility of CTA in DIEP free flaps. METHODS: Preoperative CT angiography of the deep inferior epigastric system was obtained in 52 sequential DIEP free flaps involving 37 patients with dominant perforators marked by radiologist. Planned and used perforators were documented by the surgeon before and after the operation. RESULTS: A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT. CONCLUSION: CTA mapping of perforators prior to DIEP flap surgery increases surgeon confidence and reduces operative time; however, there are still a significant number of changes made based on clinical judgment. This study highlights the importance of surgeon review of CTA images. Caution is warranted in reliance on CTA mapping, and significant perforators should not be sacrificed until the anticipated perforator(s) have been exposed and evaluated. LEVEL OF EVIDENCE: Level 3.

Duration of antibiotics after microsurgical breast reconstruction does not change surgical infection rate.

BACKGROUND: Infection rates for breast surgery are 3 to 15 percent, higher than average for a clean surgical procedure. Preoperative and postoperative antibiotics have lowered infection rates in other surgical groups, yet there is no consensus on postoperative prophylactic antibiotic use in microsurgical breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent autologous breast reconstruction between 2006 and 2009 was performed. Specific risk factors for autologous reconstruction were reviewed, including medical comorbidities, irradiation, and chemotherapy history. Data were collected on type and duration of prophylactic antibiotics. A prospective cohort of patients who received only 24 hours of postoperative antibiotics was identified. The incidence of surgical-site infections was measured using Centers for Disease Control and Prevention criteria. RESULTS: A total of 256 patients with 360 microvascular breast reconstructions who received both preoperative and postoperative prophylactic antibiotics were analyzed. The overall surgical-site infection rate was 17.2 percent (44 of 256 patients). Surgical-site infection was correlated with increased age, tobacco use, and prior radiation. Duration of postoperative antibiotic use did not differ in those patients who developed surgical-site infections (6.2 versus 7.7 days; p = 0.19). Eighty-two patients (32 percent) received only 24 hours of postoperative antibiotics, while 174 (68 percent) received more than 24 hours of antibiotics for a median duration of 10 days. There was no difference in the overall surgical-site infection rate in those who received more than 24 hours of antibiotics (19.5 versus 15.5 percent; p = 0.47). CONCLUSION: There was no reduction in the overall surgical-site infection rate among autologous breast reconstruction patients who received postoperative antibiotic prophylaxis for more than 24 hours. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quantifying tissue level ischemia: hypoxia response element-luciferase transfection in a rabbit ear model.

Ischemia is a common underlying factor in a number of pathologic conditions ranging from cardiac dysfunction to delayed wound healing. Previous efforts have shown the resulting hypoxia activates the hypoxia inducible factor, a transcription factor with signaling effects through an intranuclear hypoxia response element (HRE). We hypothesized that ischemic conditions should activate these hypoxic signaling pathways in a measurable manner. We tested our hypothesis using variations of an established rabbit ear ischemic wound model and an HRE-luciferase-reporter gene construct. This plasmid construct was transfected into the ears of young, female New Zealand White rabbits, harvested at day 7 and processed to yield a reactive solution. Luminometry was used to quantify luciferase expression in each solution as a marker for HRE activation in each wound. Quantitative readings of hypoxic signaling as measured by luminescence yielded profound and statistically significant differences between the various ischemic models. Our results suggest that the biologic systems for hypoxic signaling can be used to detect local ischemia. HRE-luciferase transfection is an effective tool for quantifying the degree of tissue hypoxia. The caudal ischemic rabbit ear model showed significantly higher levels of hypoxia. Use of a validated model that produces sufficient tissue levels of hypoxia is recommended for meaningful study of ischemic wound healing.

[Cobalamin deficiency: neurological aspects in 27 cases]. / Carences en cobalamine: aspects neurologiques chez 27 patients.

INTRODUCTION: Combined medullar sclerosis, together with peripheral sensory neuropathies, is the most common neurological manifestation observed in cobalamin deficiency. Biermer's disease is the predominant cause. Other clinical and etiological aspects are nevertheless frequent, although underestimated. METHODS: This retrospective study included patients with neurological symptoms and cobalamin (B12 vitamin) deficiency confirmed by laboratory tests collected over a period of 11 years. RESULTS: Twenty-seven cases were analyzed. Mean age was 47 years and there were 11 women and 16 men. Distribution of the neurological syndromes was: combined medullar sclerosis in 18 patients (67%), sensory neuropathies in 30% of cases and sensory-motor neuropathies in 15%. One patient had fronto-subcortical dementia with good improvement after vitamin replacement. In addition, autonomic dysfunction was noted in six patients (orthostatic symptomatic hypotension and/or urinary dysfunction and/or erectile failure). Dysautonomia revealed cobalamin deficiency in three patients with a good and fast response to the cobalamin therapy in all cases. Biermer's disease was diagnosed in 17 patients (63%) and a likely syndrome of nondissociation of cobalamin in two patients. One patient had Crohn's disease and no etiology was found in seven patients. In five patients (19%), nitrous oxide undoubtedly induced decompensation of latent cobalamin deficiency; four after a general anesthesia and one by chronic professional exposure. Outcome was very good in 46% of patients after vitamin replacement, particularly if treatment was started rapidly. DISCUSSION: The findings in this series highlight the frequency of autonomic dysfunction sometimes revealing cobalamin deficiency with a fast and good response to vitamin replacement and the frequency of neurological disorders following decompensation triggered by general anesthesia using nitrous oxide in patients with latent cobalamin deficiency.

[Subacute myelopathy revealing systemic sarcoidosis]. / Myélopathies subaiguës révélatrices de sarcoïdose systémique.

INTRODUCTION: The spinal localization is rare for neurosarcoidosis (0.43 percent of cases) but can be the inaugural manifestation of the disease. We report two cases of spinal neurosarcoidosis in a 57-year-old man and a 43-year*old woman with uneventful past medical histories. Both presented progressive myelopathic features. METHODS: Magnetic resonance imaging (MRI) of the spine demonstrated intramedullary lesions, dorsal in the first case, and cervical in the second case. Serum angiotensin converting enzyme was elevated. Radiographs of the chest revealed bilateral symmetric hilar mediastinal lymphadenopathy in the first patient, and bronchial biopsy demonstrated non caseating granulomas. In the second patient the diagnosis was made on pathological examination of a minor salivary gland biopsy. RESULTS: The patients received corticosteroid therapy with good response in the second patient. CONCLUSION: The diagnosis of intramedullary sarcoidosis is difficult without a previous diagnosis of systemic sarcoidosis or other apparent symptom(s). Extraneurologic biopsies may be suggestive. We reviewed the literature on the diagnosis and treatment of intramedullary sarcoidosis.

Reconstruction of the pelvic floor and perineum with human acellular dermal matrix and thigh flaps following pelvic exenteration.

BACKGROUND: Patients who undergo pelvic floor resection as treatment for recurrent cancer following radiation therapy have increased rates of complications, particularly if permanent prosthetic mesh is used for reconstruction. Human acellular dermal matrix (HADM), commonly used for reconstruction in other torso locations, is associated with lower rates of complications (including infection, adhesions and cutaneous exposure) than synthetic mesh. We describe an effective technique to reconstruct the pelvic floor and perineum with HADM and thigh-based flaps following pelvic exenteration and radical vulvectomy. CASE: A 75-year-old woman underwent radical resection of the pelvic floor and perineum to treat recurrent vulvar squamous cell carcinoma and osteoradionecrosis. The pelvic floor and perineal soft tissue defect were reconstructed with HADM (AlloDerm; LifeCell Corporation, Branchburg, NJ) and bilateral, thigh-based tissue flaps, respectively. Despite a large resection, previous irradiation therapy and bacterial contamination the wounds healed without complications. CONCLUSION: Reconstruction of pelvic floor defects using HADM is an option when wound conditions are unfavorable for the use of permanent prosthetic meshes.

[Peripheral neuropathy in systemic lupus erythematosus with epineural vasculitis and antiphospholipid antibodies]. / Neuropathie périphérique au cours du lupus érythémateux disséminé avec vascularite épineurale et anticorps antiphospholipides.

Neurological manifestations of systemic lupus erythematosus are frequent and polymorphic. Their frequency varies according to authors (24-75p.cent). Central nervous system complications predominate; peripheral features are rare, classically symmetrical polyneuropathy, multiple mononeuropathies or cranial nerve involvement. We report a case of a 48-year-old woman presenting a histologically documented sensitivo-motor polyneuropathy with severe motor involvement complicating lupus associated with antiphospholipides antibodies. Outcome was good after cyclophosphamid pulse. We discuss the frequency of peripheral involvement in systemic lupus erythematosus, pathogenic mechanisms, therapeutic possibilities and outcome of this complication.