PATIENT SATISFACTION AFTER BREAST RECONSTRUCTION: IMPLANTS VS. AUTOLOGOUS TISSUES.

INTRODUCTION: Breast reconstruction is increasingly present in the treatment of breast cancer. It may be accomplished with implants or autologous tissues. This cross-sectional study evaluates patients satisfaction and quality of life in women after successful autologous or implant breast reconstruction. MATERIAL AND METHODS: 109 women who successfully underwent breast reconstruction between 2007 and 2016 were included. The patients completed the BREAST-Q questionnaire at follow-up visits. Additional data were collected retrospectively from the hospital charts regarding complications, smoking, chemotherapy, radiotherapy, unilateral or bilateral reconstruction, BMI and comorbidities. Mann-Whitney U Test was applied to evaluate differences between the autologous breast reconstruction group (n = 50) and the implant breast reconstruction group (n = 59). RESULTS: Women with a successful autologous reconstruction were significantly more satisfied with their reconstructed breasts than women with successful alloplastic breast reconstruction as measured by the BREAST-Q breasts module (p = 0. 00596), psycho-social well-being module (p=0.04) and sexual well-being module (p=0.00068). Furthermore, there is a higher degree of satisfaction in patients who have not undergone radiotherapy, with no complications and with a normal BMI for implant reconstruction group as well as in non-smokers, and bilateral reconstructions for flap reconstruction group. DISCUSSION: The findings of our study are in agreement with the data found in the literature, attributing greater satisfaction with physical, mental and social wellbeing, as well as with elements having repercussion on sexual wellbeing, to autologous breast reconstruction. CONCLUSIONS: Autologous breast reconstruction leads to higher patient satisfaction than implant breast reconstruction. This study may help patients and medical teams in their decision-making process regarding breast reconstruction. This pilot study opens several questions that need further investigations in a larger prospective studyKeywords: Breast reconstruction, breast-Q, satisfaction, implant, autologous tissue.

Compared to coverage by STSG grafts only reconstruction by the dermal substitute Integra® plus STSG increases TcPO2 values in diabetic feet at 3 and 6 months after reconstruction*.

AIM: Purpose of this retrospective comparative study is to evaluate the results of reconstruction of diabetic feet by split thickness skin graft (STSG) and by dermal substitute Integra® covered by STSG in terms of vascularity of the reconstructed wound-bed by measurements of tissue oxygenation (TcPO2). PATIENTS AND METHODS: 23 patients were included into the study (12 were reconstructed by STSG only and 11 with Integra® and STSG three weeks later). In each patient TcPO2 measurements were performed at the same spot of the reconstructed area at 14 days, one month, 3 months, 6 months, 12 months and 24 months after reconstruction. RESULTS: Wound beds reconstructed by Integra® showed on average 10 mmHg higher TcPO2. CONCLUSIONS: Our study estimated in an objective way, by TcPO2 value measurements, the oxygenation of the wound bed in diabetic feet after reconstruction by STSG only and after adding dermal substitute Integra® to the wound bed before final STSG coverage. During first month after reconstruction no statistically significant differences were found. After 3 months TcPO2 studies revealed statistically significant higher oxygen tissue pressure in diabetic feet covered by Integra® plus STSG. These findings endorse in an objective way the clinical findings already reported while using the dermal substitute. It remains to explain the role of this increase of oxygen tissue pressure in redefine the indications for the use of dermal substitutes in reconstruction of poor vascularized regions.

Effect of vascular endothelial growth factor gene therapy on post-traumatic peripheral nerve regeneration and denervation-related muscle atrophy.

Functional recovery after peripheral nerve injury depends on both improvement of nerve regeneration and prevention of denervation-related skeletal muscle atrophy. To reach these goals, in this study we overexpressed vascular endothelial growth factor (VEGF) by means of local gene transfer with adeno-associated virus (AAV). Local gene transfer in the regenerating peripheral nerve was obtained by reconstructing a 1-cm-long rat median nerve defect using a vein segment filled with skeletal muscle fibers that have been previously injected with either AAV2-VEGF or AAV2-LacZ, and the morphofunctional outcome of nerve regeneration was assessed 3 months after surgery. Surprisingly, results showed that overexpression of VEGF in the muscle-vein-combined guide led to a worse nerve regeneration in comparison with AAV-LacZ controls. Local gene transfer in the denervated muscle was obtained by direct injection of either AAV2-VEGF or AAV2-LacZ in the flexor digitorum sublimis muscle after median nerve transection and results showed a significantly lower progression of muscle atrophy in AAV2-VEGF-treated muscles in comparison with muscles treated with AAV2-LacZ. Altogether, our results suggest that local delivery of VEGF by AAV2-VEGF-injected transplanted muscle fibers do not represent a rational approach to promote axonal regeneration along a venous nerve guide. By contrast, AAV2-VEGF direct local injection in denervated skeletal muscle significantly attenuates denervation-related atrophy, thus representing a promising strategy for improving the outcome of post-traumatic neuromuscular recovery after nerve injury and repair.

Classification of soft-tissue degloving in limb trauma.

Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction.

Reconstruction of large upper lip defects by free tissue transfer.

Reconstruction of a large upper lip defect is a demanding procedure and can be performed by a variety of local flaps or by microvascular free tissue transfer. We present our experience in reconstructing near total or total upper lip defects by free tissue transfer. In 11-year period seven patients underwent microvascular reconstruction of upper lip, six with non-innervated radial forearm flap and one with non-innervated anterolateral thigh flap. In all patients good functional and acceptable aesthetic results, with oral competence at rest and during eating and speaking, were achieved. Deglutition and articulation were not affected in any patient. Sensory evaluation of reconstructed upper lips was performed in four patients and in three a reasonable recovery of sensation was recorded. In our opinion subtotal or total upper lip reconstructions with folded thin fascio-cutaneous free flaps produce very good functional and aesthetically acceptable results and avoid additional scars on lower lip and cheek. Further, because the size of the mouth is not altered, microstomia is avoided, which is especially important for patients using dentures. The remaining disadvantage of this method is non-competence of orbicularis oris muscle sphincter.

Arterial anatomy of the lateral orbital and cheek region and arterial supply to the "peri-zygomatic perforator arteries" flap.

Arterial anatomy of the lateral orbital and cheek region and subsequently of the "peri-zygomatic perforator arteries" flap is described, based upon the dissection of the 24 human cadaver head halves. Each specimen was dissected in subdermal, first fascial and deep level. The subdermal vascular network of lateral orbital and cheek region, its orientation and contributing arteries were studied. Origin, perforation sites and diameters of transverse facial, zygomaticoorbital, zygomaticofacial and zygomaticotemporal arteries were also described and measured. Our findings support the view that the cheek island flap used for lower eyelid is a reverse flow axial pattern flap. It includes arterioles of the transverse facial artery, which are part of the subdermal vascular plexus and are uniformly longitudinally oriented. The flap receives its blood supply via perforators of the zygomaticoorbital, zygomaticofacial and zygomaticotemporal arteries, which are connected via their terminal branches with transverse facial artery.

Breast reconstruction following mastectomy for invasive breast cancer by free flaps from the abdomen is oncologically safe.

AIMS: To report the long-term results of oncological safety of breast reconstruction by autologous tissue following mastectomy for invasive breast cancer. METHODS: One-hundred-fifty-six consecutive patients with invasive breast cancer treated with mastectomy and reconstruction by autologous tissue were reviewed throughout (from 1987 to 2003 with median follow up time of 66 months). RESULTS: Median patient age was 45.9 years (range 26-68). The 157 observed tumors had mean diameter of 25+/-19 mm, 70 of them were poorly differentiated, and 137 were invasive ductal carcinoma. Multifocal disease was present in 44 patients. Breast reconstruction was carried out only by autologous tissue (free flaps were used in 95% and free TRAM flap transfer was the most common reconstructive procedure). There was only one local recurrence as first site of recurrence, thus yielding a local recurrence rate of 0.6%. CONCLUSIONS: Breast reconstruction by autologous tissue following mastectomy for invasive breast cancer is an oncologically safe procedure.

Factors predicting free flap complications in head and neck reconstruction.

In this retrospective study, all free flap transfers used for reconstruction following ablation of head and neck tumors in University Medical Centre Ljubljana between the years 1989 and 1999 were analysed. The data taken from the patients' charts covered the demographic profile, the tumor and free flap details (44 variables for each patient). Logistic regression model was used to identify factors associated with free flap failure and complications. One hundred and sixty-two patients with head and neck tumors underwent microsurgical reconstruction. One hundred and ninety-four free flaps were performed with an overall success rate of 85%. Two significant predictors of free flap complication were identified: diabetes and salvage free flap transfer. Patients with diabetes were five times more likely to develop complications associated with free flaps (p = 0.02). Free flap complications were four times more likely to develop after salvage free flap transfer (p = 0.04). In addition, two significant factors predicting free flap failure were identified: salvage free flap transfer (p = 0.019) and use of interposition vein grafts (p = 0.032). After this study we changed our strategy of free flap selection and preoperative evaluation of the patients with head and neck tumors requiring free tissue transfer. Between January 2000 and January 2005 we performed additional 105 free flaps for head and neck reconstruction after tumor resection in 101 patients and our success rate improved to 94.3%.

Breast reconstruction by the free transverse gracilis (TUG) flap.

The transverse upper gracilis (TUG) flap is a free musculocutaneous (type II) flap consisting of a segment of the proximal gracilis muscle and a 25x10 cm skin paddle oriented transversely. The vascular pedicle of the TUG flap is the ascending branch of the medial circumflex femoral artery with two venae comitantes. The pedicle length is 6 cm and the diameter of the artery is 1.6 mm. In the year 2002, seven patients had breast reconstruction by the free TUG flap. There were three primary and four secondary reconstructions. Five flaps totally survived, two flaps were lost (in the same patient).TUG flap is indicated in women who seek primary autologous reconstruction after a skin sparing mastectomy, have small or moderately large breasts, do not accept scars on the abdomen, back or gluteal region, who are large in hips and thighs and want a thigh lift. The vascular pedicle although short, permits easy anastomosis of matching vessel diameters to the internal mammary vessels. The main possible complication, other than thrombosis at the anastomosis, is wound dehiscence on the thigh with secondary wound healing. This can happen when the flap is wider than 10 cm.

Nerve fibre composition of the palmar cutaneous branch of the median nerve and clinical implications.

Fifteen fresh human cadaver hands were dissected, using x2.8 loupe magnification, to study the subcutaneous innervation at the site of the incision (in the line with the radial border of the ring finger) for standard open carpal tunnel decompression. Subcutaneous nerve branches were detected and traced proximally to determine their origin. Morphometric analysis of nerve cross sections from the site of the incision and from the main nerve trunk proximal to cutaneous arborisation was performed using light and transmission electron microscopy and a computer-based image analysis system. At the site of the incision, the ulnar sub-branch (US) of the palmar cutaneous branch of the median nerve (PCBMN), which innervates the skin over the hypothenar eminence, was found in 10 of 15 cases. Branches from the ulnar side were not detected. The main trunk of PCBMN consisted on average of 1000 (SD 229) myelinated axons arranged in 1-4 fascicles. In the US of the PCBMN there were on average 620 (SD 220) myelinated axons, 80% of them smaller than 40 microm(2) i.e. thin myelinated axons, and on average 2037 (SD 1106) unmyelinated axons, arranged in 1-3 fascicles. The ratio of the number of myelinated axons in the US and the main trunk of the PCBMN was on average 63% (SD 19%). Frequency distribution of cross-sectional areas of myelinated axons shows no significant difference between the US and the main nerve trunk of the PCBMN. The importance of incision trauma to subcutaneous innervation of palmar triangle is emphasised and possible mechanisms of scar discomfort are discussed.

External osteotomy in rhinoplasty.

OBJECTIVES: To compare external and internal lateral osteotomy in rhinoplasty. STUDY DESIGN: Retrospective review and study on cadavers. METHODS: One hundred forty-two patients who underwent aesthetic rhinoplasty were examined. The following criteria were taken into consideration: edema and ecchymosis around the eyes, the degree of closure of the roof, symmetry and level of fractures, solidity of the bone pyramid, and any scarring at the access point of the osteotome. In the last 25 patients who had surgery, a nasal endoscopy with optical fibers was carried out to evaluate any damage to the mucosa caused by the 2-mm osteotome. Furthermore, to compare the two routes in vivo, for five of these patients a lateral osteotomy was carried out externally for one side and internally for the other. Lateral osteotomy were performed on five cadavers by an external route on one side and by an internal one on the other. A midface degloving procedure was performed to expose the osteotomy sites. RESULTS: Edema and ecchymosis were always much less severe in patients who were treated with external osteotomy. The control of the fracture line was always excellent. Endoscopic evaluation and study on cadavers revealed damages to the mucosa caused from the internal osteotomy and a better control of fracture line in external osteotomy. CONCLUSIONS: External osteotomy is an easy and precise approach. Because the fracture is of a greenstick type, the bone stumps are stable. The reduced bleeding reduces the formation of edemas and ecchymosis around the eyes. The damage to the nasal mucosa is minimal, and the cutaneous scars are virtually invisible a month after surgery.

Microvascular skin response to local cooling and body tilt early after digital replantation.

To elucidate the alteration in cutaneous microvascular reactivity early after replantation (14-21 days), laser Doppler (LD) flow changes evoked by direct and indirect local cooling and head-up body tilt were studied in the replanted digits (n = 10) and compared with those evoked in the healthy contralateral digits of the same patients (n = 10). During the first 3 minutes of direct cooling of the injured hand, LD flow increased significantly compared with the LD flow before cooling, which confirms that moderate vasodilation is the dominant component of the response to local cooling in skin microcirculation in the early period after replantation. During body tilt, LD flow in the healthy contralateral digit decreased significantly in only the first minute, while LD flow in the replanted digit started to decrease in the second minute after tilting; the decrease was significant from the third to the sixth minute. These results are consistent with the hypothesis that increased human skin alpha-adrenergic receptor sensitivity may be present as early as 2 to 3 weeks after replantation.

Physiological differences for distinct somatic sensory modalities and sweating among the donor sites of cutaneous and fasciocutaneous free flaps.

Differences of sensation and sweating among the typical sites of cutaneous and fasciocutaneous flaps (scapular, lateral arm, radial forearm, groin and dorsalis pedis) were assessed in 30 healthy volunteers (20 males and 10 females) aged 17-62 years (mean 38.2 years). Standard clinical methods were used: Semmes-Weinstein monofilaments for testing light touch threshold, discriminator and blunt caliper for evaluation of static and dynamic two-point discrimination and the Marstock quantitative method for assessing the normative values of warm-cold difference limen and heat and cold pain thresholds. Spontaneous sweat secretion was observed and documented by the ninhydrin test. We established various physiological differences for distinct somatic sensory modalities and sweating among the body regions (donor sites of cutaneous and fasciocutaneous free flaps).

Treatment of extensive bone and soft tissue defects of the lower limb by traction and free-flap transfer.

Twenty patients with extensive bone and soft tissue defects and posttraumatic osteomyelitis were treated between 1983 and 1995. In all cases an external fixator was used for bone fixation. Bone defects were managed with the Ilizarov intercalary bone transport. Two types of traction were used: the Ilizarov type and a 'new' Ljubljana type. The results of treatment were compared between the two types of traction. In all cases delayed bony union was observed. Osteomyelitis never reactivated. All patients were satisfied with treatment. They were all independent except for one amputee. The Ljubljana traction method was found to have the following advantages: no discrepancy in leg length, no orthopaedic support was needed, the aesthetic outcome was better, the traction time was reduced and there was less soft tissue damage during bone traction.

Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap.

The lower abdominal wall has established itself as tissue that can mimic the breast to a high degree. Attention has, therefore, turned to harvesting and transferring this tissue, but with minimal donor site morbidity. We report on our experience with five transfers of this tissue based on the superficial inferior epigastric (SIE) vessels. This technique negates the harvest of any rectus muscle and thus its advantages become immediately obvious. The anatomy is reviewed as well as the techniques used. The limitations of this technique relate to the pedicle. The pedicle is shorter than the deep inferior epigastric (DIE) axis and presents itself on the anterior aspect of the tissue. However, these limitations can be overcome with simple adjustments.

Describing severe limb trauma.

Seventy-nine severe limb injuries were retrospectively reviewed to compare the AO/ASIF and the Gustillo classifications. Specifically, the suitability of these classifications with respect to prognosis and management of these cases was compared. A healed and stable wound was the ultimate outcome measure. Surrogate outcome measures used were: the time to healing; the number of anaesthetics until the wounds were healed; and the number of operations until the wounds were healed. Any change in lifestyle following the injury was also assessed. The primary healing rates of the AO/ASIF groups showed significant (P < 0.001) inter-group differences. However, when the injuries were classified using the Gustillo system, the primary healing rates did not show any differences between the groups. Also, differences in the other outcome measures were most pronounced when using the AO/ASIF system. Importantly, changes in lifestyle correlated with the injury score when using the AO/ASIF system (P < 0.05). Unlike the AO/ASIF system, the Gustillo system was not applicable in 100% of cases. A modified AO/ASIF scoring system is proposed which provides a good predictor of outcome.

Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity.

Reconstruction of the female breast following mastectomy has become commonplace. The number of donor sites have increased as the quest both for improving reconstruction and reducing morbidity continues. There are a number of donor sites which resemble breast tissue in terms of skin texture, suppleness and colour. The 'gold standard' for transfer in breast reconstruction, however, is the lower abdominal skin and fat. The tissue can be moulded into virtually any breast shape desired. The lower abdomen can provide enough material for total autologous reconstruction of small, moderate sized or even large breasts. This tissue can be transferred onto the chest wall for breast reconstruction using four vascular axes. These are the superior epigastric artery (SEA), the deep inferior epigastric artery (DIEA), a perforator of the deep inferior epigastric artery (DIEP) or the superficial inferior epigastric artery (SIEA). The main problem with the majority of these techniques is that they may be associated with significant donor site morbidity due to harvest of some or all of the rectus muscle. An order of decreased muscle harvest is as follows; pedicled TRAM > free TRAM > DIEP > SIEA. It is envisaged that morbidity will be reduced if the aponeurosis and musculature of abdominal wall is kept intact. This can be achieved in selected cases if the 'abdominoplasty' flap is harvested on the SIE vessels. We present a logical approach to harvesting the lower abdominal wall tissue in order to reduce donor site morbidity.