Long-term results of the tuberous breast: What to expect after the primary correction process?

BACKGROUND AND AIMS: Tuberous breast is a rare anomaly affecting the development of mainly the female breast. It presents with varying degrees of hypoplasia in the breast base and skin. In some cases, herniation and widening of the areola is observed. The condition constitutes a great challenge for the reconstructive surgeon. In this study, the surgical cascades of implant and lipofilling corrections were compared with a focus on the need for re-interventions. METHODS: In total, 129 patients whose treatment regimen started between January 2010 and October 2020 were included in this study. Patients were categorized into two groups based on the volume correction method used (lipofilling versus implant). RESULTS: In 35 (27%) patients (41 breasts), breast volume increasement was executed with an implant, while 94 (73%) patients (169 breasts) underwent volume increasement with lipofilling. The mean number of operations during the primary correction process was 1.2 (range 1-5) for the implant group and 2.4 (range 1-5) for the lipofilling group. When assessing the need for re-operations within 5 years after completing the primary correction, 46% of patients in the implant group needed further surgeries, while the corresponding proportion for the lipofilling group was 21% (p = 0.04). There were six major complications, all of them in the implant group. CONCLUSION: Implant-based reconstruction is associated with more revision surgeries and major complications compared to autologous lipofilling corrections. Lipofilling offers a more durable result with less re-operations over time despite initial sequential primary surgeries.

Immediate versus delayed breast reconstruction: Long-term follow-up on health-related quality of life and satisfaction with breasts.

INTRODUCTION: Health-related quality of life (HRQL) can be improved by breast reconstruction following mastectomy. The optimal timing of the reconstruction remains unclear. METHODS: A cross-sectional study on 338 women who had undergone immediate or delayed breast reconstruction between 08/2017 and 07/2019 was performed. The postoperative HRQL was assessed using the BREAST-Q Reconstruction Module and the 36-Item Short Form Survey (SF-36). Regression analysis was performed for group-wise comparison. RESULTS: A total of 146 (43%) patients participated. Seventy-seven patients (53%) had undergone immediate, and 69 patients (47%) had delayed reconstruction. The median age was 55 years (interquartile ratio [IQR] 50-62) for the Immeda group te, and 60 years (IQR 54-65) for the delayed reconstruction group. The median follow-up time was 2.3 years (IQR 1.8-2.9). No difference between the groups was detected in satisfaction with breasts (median 61, IQR 53-71 vs. 62, IQR 46-71, p = 0.62), physical well-being of the chest (median 100, IQR 80-100 vs. 100, IQR 80-100, p = 0.95) or psychosocial well-being (median 69, IQR 54-83 vs. 62, IQR 54-74, p = 0.19). No difference was detected in the SF-36 domains either. CONCLUSIONS: The timing of the breast reconstruction does not affect the postoperative HRQL. Patients with both immediate and delayed breast reconstruction reported high satisfaction with the breast and psychosocial well-being.

Topical tranexamic acid reduces postoperative hematomas in reduction mammaplasties.

BACKGROUND: Postoperative bleeding requiring reoperation is an untoward event in breast surgery. Topical tranexamic acid (TXA) has been routinely used to reduce the risk of postoperative bleeding in some surgical fields. In breast surgery, it is not routinely used owing to scarce information. We investigated whether the intraoperatively applied topical TXA reduces the incidence of postoperative hematoma in reduction mammaplasty surgeries. METHODS: This retrospective, single-center cohort study comprises of 415 consecutive patients who underwent reduction mammaplasty between 2019 and 2021. The prophylactic use of topically applied TXA (20 mg/ml) was implemented as a part of the hospital protocol in November 2020. The patients who were rinsed with TXA before the wound closure were compared with those who were not rinsed. The results were analyzed using statistical tests, two-sided Pearson's Chi-Square and Fisher's exact tests. RESULTS: Topical TXA significantly reduced the number of postoperative hematomas requiring evacuation (p = 0.008). In the non-TXA control group, 12 (5.8%) hematomas were observed out of 208 patients. In the topical TXA group, only one (0.6%) hematoma occurred among the 168 patients. A tendency towards fewer wound infections, seromas, and other minor wound-healing problems can also be seen in the topical TXA group (ns). No adverse events of topical TXA were detected. CONCLUSIONS: The incidence of postoperative hematomas decreased to a tenth after the introduction of topical TXA in reduction mammaplasty surgeries. This simple procedure may save patients from reoperations owing to bleeding. Randomized controlled trials are warranted.

Antibiotic prophylaxis in clean and clean-contaminated plastic surgery: A critical review.

Antibiotic prophylaxis is frequently used in plastic surgery procedures, despite the generally low rates of infection and few guidelines on the practice. The increasing prevalence of bacterial resistance to antibiotics calls for a reduction in unnecessary antibiotic use. The aim of this review was to create an updated summary of the available data on the effectiveness of antibiotic prophylaxis in reducing the postoperative infection in clean and clean-contaminated plastic surgery. A systematic literature search was performed on the databases Medline, Web of Science, and Scopus, limited to articles published January 2000 onward. Randomized controlled trials (RCTs) were included in the primary review, whereas older RCTs and other studies were sought if 2 or fewer relevant RCTs were identified. Overall, 28 relevant RCTs, 2 nonrandomized trials, and 15 cohort studies were identified. Although the number of studies for each type of surgery is limited, the data suggest that prophylactic systemic antibiotic may be unnecessary in noncontaminated facial plastic surgery, reduction mammaplasty, and breast augmentation. In addition, no benefit is apparent from extending the antibiotic prophylaxis over 24 h in rhinoplasty, aerodigestive tract reconstruction, and breast reconstruction. No studies assessing the necessity of antibiotic prophylaxis in abdominoplasty, lipotransfer, soft tissue tumor surgery, or gender affirmation surgery were identified. In conclusion, limited data are available on the effectiveness of antibiotic prophylaxis in clean and clean-contaminated plastic surgery. More studies on this topic are needed before strong recommendations can be made on the use of antibiotics in this setting.

Total Breast Reconstruction with Lipofilling after Traditional Mastectomy without the Use of Tissue Expanders.

BACKGROUND: Lipofilling can be used to reconstruct a breast without additional implants or autologous composite grafts. However, methods to maximize retention of the transferred fat remain under debate. Here, the authors present their experience of breast reconstruction with lipofilling without concomitant use of tissue expanders. METHODS: Patients who had completed breast reconstruction with lipofilling between June of 2010 and June of 2016 were reviewed. Those with obtainable follow-up magnetic resonance imaging scans were included in this cross-sectional study. The hospital records were reviewed for details of the lipofilling operations. Magnetic resonance imaging scans were evaluated for the volume retention and quality of the transferred fat. The patients were asked to assess the appearance and sensitivity of the reconstructed breast, the recovery time, and any adverse effects at the fat donor area. RESULTS: Thirty-eight women with 41 reconstructed breasts were included in the study. The median age at follow-up was 62 years (range, 48 to 78 years). They had undergone a median of four (range, two to six) lipofilling procedures with a median total volume 690 mL (range, 369 to 1350 mL). After a median follow-up of 2.1 years (range, 0.4 to 6.8 years), the median proportion of transferred fat retained was 58% (range, 14% to 119%), representing a reconstructed breast volume of 76% (range, 17% to 100%) of the contralateral breast. Oil cysts larger than 10 mm were detected in 7%. Most patients reported being satisfied with the reconstructed breast and experienced few side effects. CONCLUSIONS: Breast reconstruction with lipofilling can be performed with an acceptable number of procedures and no preoperative skin expansion. It extends the option of autologous breast reconstruction to women unsuited for major reconstructive procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Health-Related Quality of Life After Breast Reconstruction: Comparing Outcomes Between Reconstruction Techniques Using the BREAST-Q.

BACKGROUND: Reconstruction of the breast following mastectomy can improve patients' health-related quality of life (HRQL). We aimed to assess HRQL in women after mastectomy and breast reconstruction and to identify differences in HRQL related to the reconstruction method used. METHODS: A cross-sectional study was performed on patients who had undergone breast reconstruction in Helsinki University Hospital between 08/2017 and 7/2019. The postoperative HRQL was assessed using the BREAST-Q (2.0) Reconstruction Module. The results were compared between patients with different reconstruction methods using the Kruskal-Wallis test. RESULTS: A total of 146 patients were identified. Microvascular flaps (n = 77) were the most common method for primary breast reconstruction, followed by latissimus dorsi (LD) flaps (n = 45), fat grafting (n = 18) and implant reconstruction (n = 6). The satisfaction with breasts was high in all groups (median 61, IQR 49-71). The physical well-being of the chest was high regardless of the reconstructive method (median 100, IQR 80-100). However, women with fat grafting reported more adverse effects of radiation (median 17, IQR 14-17 vs. 18, IQR 17-18 for other groups, p = 0.02). Donor site morbidity was low, and patients reported high satisfaction with the back (median 66/100, IQR57-90) and abdomen (median 9/12, IQR 8-10), and physical well-being of the back (median 61/100, IQR 53-70) and abdomen (median 65/100, IQR 60-86). CONCLUSIONS: The patient-reported HRQL after breast reconstruction is high. Most women report being satisfied with the reconstruction, irrespective of the reconstruction method used. The reconstruction method can thus be chosen individually in cooperation between the patient and the surgeon.

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy.

AIM: Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario. METHODS: A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology. RESULTS: The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR. CONCLUSIONS: The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR.

Beyond the 21-cm Notch-to-nipple Myth: Golden Proportions in Breast Aesthetics.

BACKGROUND: The 21-cm notch-to-nipple distance has been accepted without academic scrutiny as a key measure in breast aesthetics. The Fibonacci sequence and phi ratio occur frequently in nature. They have previously been used to assess aesthetics of the face, but not the breast. This study aims to assess if the static 21-cm measure or the proportional phi ratio is associated with ideal breast aesthetics. METHOD: Subclavicular-breast height and breast width were used to calculate the aesthetic ratio. Subjects were subsequently aesthetically rated. A one-sample t-test was used to determine if the ratio for each breast differed from phi. Breast scores with one, both, or no breasts were compared with an optimal phi ratio. Analysis of variance was performed. Tukey-Kramer adjustment for multiple comparisons was used when pairwise comparisons were conducted. RESULTS: Five subjects (14%) had bilateral optimal phi ratio breasts. Four subjects (11%) had one breast with an optimal phi ratio. Subjects with bilateral optimal phi ratios had significantly higher overall breast scores than those with only one optimal breast (Δ = 0.86, P = 0.025) or no optimal breast (Δ = 0.73, P = 0.008). Distance from optimal Fibonacci nipple position was moderately to strongly correlated with aesthetic score (-0.630, P = 0.016). No correlation was found between 21-cm notch-to-nipple distance and aesthetic score. CONCLUSION: The bilateral optimal phi ratio is correlated with high overall aesthetic scores, as is the optimal Fibonacci nipple position. No correlation was found between 21-cm notch-to-nipple distance and overall aesthetic score.

An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects.

Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson's r, Spearman's ρ, and Kendall's τ. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P < 0.0001). This was also true for upper pole shape (0.826, P < 0.0001) and breast height (0.821, P < 0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P < 0.0001), breast size (0.644, P < 0.0001), and breast width (0.632, P < 0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P < 0.0001), areolar diameter (0.484, P < 0.0001), and areolar shape (0.403, P < 0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027). Conclusions: Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors.

Full breast reconstruction with fat and how to recycle the "dog-ear".

Mastectomy without immediate reconstruction leaves us with a population of women who may need a new breast in a delayed fashion. These women are often elderly, not fit for major flap surgery or reluctant to have long scars or implants. Free fat grafting has mainly been used as an adjunct to other reconstructive methods. We present an option for delayed full breast reconstruction with free fat grafting alone. In some cases, we utilize the lateral excess as a flap in combination with fat grafting. Patient selection is crucial. A lady fitting this reconstruction method should have fat to donate, preferably in several different regions as well as redundant skin on the chest-wall and only minor radiation damage. Also, breast size requirements need to be sensible. The Fat is harvested in a closed system under general or local anesthesia. Following a few minutes decantation, the fat is put into syringes and injected from 4-6 entrance points into 3-4 layers with a blunt cannula. Depending on the width, height and thickness of the receiving chest wall, the transferred volume varies between 150-300 cc/operation. In general, 2-5 operations are needed to reconstruct a breast with fat alone. If the patient presents with lateral excess tissue, this can be utilized as a local, fasciocutaneous flap, de-epithelialized and rotated 180 degrees to support the inferior border of the new breast. This enables inferolateral definition and control of the breast footprint. The secret behind success in free fat grafting for full breast reconstruction lies in the small technical details and works safely and efficiently in a selected group of patients.

Fat Grafting Can Induce Browning of White Adipose Tissue.

BACKGROUND: Fat grafting is commonly used when treating soft-tissue defects. However, much of the basic biology behind fat transfer is still uncovered. Adipocytes can be divided into energy storing white and energy burning brown adipose cells. It is now well known, that also adult humans have metabolically active brown adipose tissue (BAT) within white adipose tissue (WAT). Previously our group showed that transfer of metabolically inactive WAT into a new environment increased the metabolic activity of the fat grafts to resemble the activity in the recipient site and that different WAT depots have variation in the metabolic activity. This led us to speculate, whether the metabolic increase of the graft is a result of "browning" of the transferred WAT toward beige adipose tissue. METHODS: We investigated the metabolic and histological characteristics and BAT marker Ucp1 gene expression in different types of WAT grafts placed either in subcutaneous or muscle tissue in mice. Metabolic activity of the grafts was investigated by FDG-PET/CT at 4- and 12-week time-points. RESULTS: The glucose uptake of all transferred fat types was increased when compared with respective control WAT regardless of transfer location. Ucp1 gene and protein expression was increased in 4 of 15 intramuscularly placed fat graft samples and showed histological resemblance to BAT with multilocular cells. CONCLUSIONS: Grafting of metabolically inactive fat intramuscularly may induce browning of fat grafts toward more active beige adipose tissue. This opens up new research areas in exploiting fat grafting in metabolic diseases.

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions.

INTRODUCTION: Contralateral reduction mammaplasty is regularly included in the treatment of breast cancer patients. We analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens of women with previous breast cancer. We also analyzed if timing of reduction mammaplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. MATERIALS AND METHODS: The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammaplasty between 1/2007 and 12/2011. The data was retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and postoperative follow-up. RESULTS: Reduction mammaplasty specimens revealed abnormal findings in 68 (21.5%) patients. High-risk lesions (ADH, ALH, and LCIS) were revealed in 37 (11.7%), and cancer in six (1.9%) patients. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Abnormal histopathological findings were more frequent in patients with reduction mammaplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). CONCLUSION: The incidences of malignant and high-risk lesions are doubled compared to patients without prior breast cancer. Patients with abnormal histopathology cannot be preoperatively identified based on demographics. If reduction mammaplasty is performed before oncological treatment, the incidence of abnormal findings is higher. In the light of our results, contralateral reduction mammaplasty with histopathological evaluation in breast cancer patients offers a sophisticated tool to catch those patients whose contralateral breast needs increased attention.

Breast Cancer Detection by Preoperative Imaging in Reduction Mammaplasty Patients: A Single Center Study of 918 Patients.

BACKGROUND: The role of preoperative imaging and the usability of different imaging modalities is highly variable and controversial in reduction mammaplasty patients. Our study describes the imaging process in a single center in regard to modality selection, age and timing, and of the association between imaging and histopathological findings in reduction mammaplasty specimens. METHODS: Nine hundred eighteen women, who underwent reduction mammaplasty during 1.1.2007-31.12.2011, were retrospectively reviewed for demographics, preoperative imaging, further preoperative examinations, and pathology reports. RESULTS: Preoperative imaging had been conducted for 89.2% (n = 819) of the patients. In 49 (6.0%) patients, suspicious preoperative imaging led to further examinations revealing 2 high-risk lesions (atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS)), and 2 cancers preoperatively. Postoperatively abnormal histopathology specimens were revealed in 88 (10.4%) patients. The incidence of high-risk lesions was 5.5% (n = 47), and the incidence of cancer was 1.2% (n = 10). Preoperative imaging was normal (BI-RADS 1 and BI-RADS 2) in 80.8% of these patients. The sensitivity of the preoperative imaging for cancer detection was 20.0%, and the specificity was 100.0%. CONCLUSIONS: Preoperative imaging and further examinations do not sufficiently detect malignant or cancer risk-increasing findings. Therefore, histopathological analysis of reduction mammaplasty specimens seems mandatory.

Should we routinely analyze reduction mammaplasty specimens?

BACKGROUND: Reduction mammaplasty is one of the most common plastic surgery procedures. Preoperative imaging and histopathology protocols vary among countries and institutions. We aimed to analyze the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens. We also analyzed whether patients with abnormal histopathology differed from the study population in terms of demographics. PATIENTS AND METHODS: In total, 918 women who underwent reduction mammaplasty from January 2007 to December 2011 were retrospectively reviewed for demographics, preoperative imaging, further preoperative examinations, pathology reports, and postoperative follow-up. RESULTS: Abnormal histopathological findings were revealed in 88 (10%) patients with a mean age of 49.5 ± 10.2 years. The incidence of breast cancer was 1.2%, and the incidence of high-risk lesions (atypical ductal and lobular hyperplasia and lobular carcinoma in situ) was 5.5%. Age and specimen weights were significantly higher in patients with abnormal histopathology. Eighty-one percent of patients with abnormal histopathology had normal preoperative imaging revealing two high-risk and two cancer findings. Two patients developed breast cancer in the same breast in which the high-risk lesion was originally detected. CONCLUSION: Women with abnormal histopathology cannot be sufficiently detected preoperatively. Therefore, histopathological analysis of reduction mammaplasty specimens seems mandatory. Reduction mammaplasty combined with subsequent histopathological examination offers a sufficient chance of detecting cancer and risk-increasing lesions that merits the cost of histopathology.

No need to cut the nerve in LD reconstruction to avoid jumping of the breast: a prospective randomized study.

BACKGROUND AND AIM: It has been shown that the myocutaneous latissimus dorsi flap volume and consistency remain mainly the same regardless the nerve is cut or not in breast reconstruction. It is controversial how big an impact the flap innervation has on the muscle activity of the flap. The aim of the study was to prospectively evaluate the influence of latissimus dorsi flap innervation on the functional and aesthetic outcome of delayed breast reconstruction. METHODS: Between 2007 and 2008, 28 breast reconstructions were performed and randomly divided into denervation group (surgical denervation by excision of 1 cm of proximal thoracodorsal nerve, n=14) and innervation group (thoracodorsal nerve saved intact, n=14). Patients were clinically evaluated and a questionnaire considering functional and aesthetic outcome was filled 1-year after operation. Muscular twitching, pain, tightness, shape and symmetry of the breasts were evaluated. In addition, the mobility of the shoulder joint on the operated side was evaluated and the patients self-estimated the activities of daily living. RESULTS: There was no significant difference in latissimus dorsi flap twitching, pain and tightness of the breast and symmetry and shape of the breasts between denervated and innervated groups. The shoulder joint mobility was not found to be changed significantly in either of the groups and there were no limitations in activities of daily living. CONCLUSIONS: Thoracodorsal nerve division or preservation does not significantly affect muscle contraction activity of the latissimus dorsi flap and distortion of the breast when latissimus dorsi muscle humeral insertion is also detached. Therefore, both cutting and saving the nerve are justified in latissimus dorsi flap breast reconstruction depending on whether the humeral insertion of the muscle is preserved intact or divided and the flap islanded. The study shows that there is no tangible benefit in dividing the nerve when the flap is islanded. Clinical trial has been registered in public trials registry. Trial registry name is 'The significance of latissimus dorsi flap innervation in delayed breast reconstruction'. Registration number is NCT01239524 and URL is https://register.clinicaltrials.gov.

Breast reconstruction de novo by water-jet assisted autologous fat grafting--a retrospective study.

BACKGROUND: Autologous fat grafting has become a frequent, simple, reproducible and low-risk technique for revisional or partial breast reconstruction. The presented European multicenter study describes an optimized treatment and follow-up protocol for the de novo breast reconstruction after total mastectomy by lipotransfer alone. METHODS: A retrospective European multicenter trial included 135 procedures on 28 (35 breasts) postmastectomy patients (mean 52.4 years). All women were treated with the water-jet assisted fat grafting method (BEAULI™) combined with additional procedures (NAC reconstruction, contralateral mastoplasty) and evaluated with at least 6 months follow-up (mean 2.6 years). Sonography or mammography, clinical examination, patient questionnaire (10-point Likert scale) and digital photographs were carried out. RESULTS: On average the patients received 4 to 6 procedures each with a single volume of 159 ml (±61 ml) over 21 months (range 9 months to 2.5 years). In total 1,020 ml (±515 ml) fat were grafted till a complete breast reconstruction was achieved. Irradiated patients needed a significantly higher volume than non-irradiated (p<0.041). Main treatment complications were liponecrosis (2.59%), infection (0.74%) and granuloma (0.74%). Patient satisfaction was overall high to very high (96%) and confirmed the good aesthetic results (68%) and the natural softness, contour and shape of the reconstructed breast. CONCLUSIONS: A complete breast reconstruction with large volume fat grafting is alternatively possible to standard techniques in selected cases. It takes at least 4 to 6 lipotransfers in the course of 2 years. Patients with prior radiotherapy may require even up to 8 sessions over nearly 3 years of treatment.

[Free fat transfer--a versatile tool in reconstructive surgery]. / Rasvansiirto--korjaavan kirurgian yleistyvä työkalu.

Free fat transfer or lipofilling is a procedure quickly increasing in popularity. Free fat transfer offers treatment for soft tissue defects caused by trauma or cancer, congenital anomalies, painful scars, irradiation injuries and aesthetic indications. The advantages compared to, e.g., traditional flap reconstructions includes surgical easiness, minor donor-site morbidity, easy access, hardly no scars, quick recovery and avoidance of foreign bodies such as implants. The regenerative potential of free fat transfer is due to abundant adipose derived mesenchymal stem cells (ADSC). These cells are under extremely active investigation and have rapidly led to clinical trials and treatment modalities in combination with tissue engineering. Free fat transfer nowadays offers hope to patients that formerly could not be helped with surgical intervention.

Skeletal muscle injury and repair: the effect of disuse and denervation on muscle and clinical relevance in pedicled and free muscle flaps.

Skeletal muscle is prone to injury upon trauma or nerve damage. In reconstructive surgery, it is an interesting spare part. Fortunately, skeletal muscle is capable of extensive regeneration. Satellite cells, quiescent myogenic precursor cells, become activated following muscle injury: they divide and form myoblasts, fuse into myotubes, and finally mature to myofibers. Denervation in muscle or muscle flaps leads to myofiber atrophy, fibrosis, and fatty tissue infiltration. Experiments show that muscle flaps that are reinnervated also display a fair amount of atrophy. Muscle mass is better preserved after motor innervation than sensory innervation. Clinical data imply that innervation of the muscle flap does not improve volume preservation significantly compared with denervated flaps. In addition, the softness of the flap remains the same whether the flap is innervated or not. Innervation of the flap seems to be needed only if functional muscle reconstruction is the goal. If reinnervation is successful but the muscle is kept short, disuse atrophy will still proceed. Muscle flaps should therefore be placed into their original length.

The significance of latissimus dorsi flap innervation in delayed breast reconstruction: a prospective randomized study-magnetic resonance imaging and histologic findings.

BACKGROUND: It is controversial whether surgical denervation of the thoracodorsal nerve should be performed in breast reconstruction with a myocutaneous latissimus dorsi flap. Denervation may prevent discomforting symptoms caused by muscle contraction, but the flap may also lose significant volume. The authors prospectively evaluated the influence of latissimus dorsi flap innervation on the latissimus dorsi muscle structure in delayed breast reconstruction. METHODS: Between 2007 and 2008, 28 breast reconstructions were performed and divided randomly into the denervation group (surgical denervation by excision of 1 cm of thoracodorsal nerve, n = 14) and the intact group (thoracodorsal nerve saved intact, n = 14). Muscle biopsy specimens were taken during the operation and 6 months after reconstruction. Histologic (hematoxylin and eosin), immunohistochemical (human developmental, neonatal, slow, and fast myosin heavy chains), and morphometric analyses were performed. Magnetic resonance imaging of the breasts was performed 1 and 12 months after surgery. RESULTS: There was a significant decrease in type I and type II myofiber diameters from 0 to 6 months in both groups. Denervation caused more significant atrophy than disuse alone. However, there was no significant difference in flap thickness between groups that can be explained by more pronounced fatty tissue infiltration in the denervation group. CONCLUSIONS: The authors' data suggest that the volume and consistency of the flap remain more or less the same, regardless of whether the thoracodorsal nerve is cut or not. Thus, in their practice, the authors do not cut the nerve to save surgical time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.