Posterior Circumflex Humeral Artery Perforator Flap: A Cadaveric Study and Case Series.

BACKGROUND: Reconstruction of soft tissue defects of the acromioclavicular region represents a relatively uncommon but challenging event. Many muscular, fasciocutaneous, and perforator flaps have been described, including the posterior circumflex humeral artery perforator (PCHAP) flap based on the direct cutaneous perforator of the PCHA. This study aims to describe a variant of the PCHAP flap, based on a constant musculocutaneous perforator, by means of a cadaveric study and a case series. METHODS: A cadaveric study was conducted using 11 upper limbs. The perforator vessels originating from the PCHA were dissected and the musculocutaneous ones were identified and measured in their length and distance from the deltoid tuberosity. Besides, we retrospectively analyzed the posterior shoulder reconstruction conducted among 2 plastic surgery department (San Gerardo Hospital, Monza and Hospital Papa Giovanni XXIII, Bergamo) using the musculocutaneous perforators of the PCHA. RESULTS: The cadaver dissection showed the presence of a constant musculocutaneous perforator arising from the PCHA. The mean pedicle length is 6.10 ± 1.18 cm, and the musculocutaneous perforator pierces the fascia at a mean distance of 10.4 ± 2.06 cm from the deltoid tuberosity. In all the cadaver dissected, the perforator of interest divided into 2 terminal branches, anterior and posterior, nourishing the skin paddle.In our case series, the mean age of the patients was 66.7 years, the mean size of the defect was 46 cm 2 , the mean operating time was 79.3 minutes, the mean length of hospital stay was 2.7 days, and the complication rate was 28.6%. CONCLUSIONS: According to this preliminary data, the PCHAP flap based on the musculocutaneous perforator seems to be a reliable alternative in posterior shoulder region reconstruction.

Thoracodorsal artery perforator flap, muscle-sparing latissimus dorsi, and descending branch latissimus dorsi: A multicenter retrospective study on early complications and meta-analysis of the literature.

The thoracodorsal (TD) vessels represent a complex vascular system that offers a variety of pedicled and free flaps. Variations of the classical latissimus dorsi (LD) flap have been developed to overcome its major drawbacks. The thoracodorsal artery perforator (TDAP) flap described by Angrigiani represents one of these options. Other techniques have been defined as "muscle-sparing" latissimus dorsi (MSLD) due to the preservation of the LD muscle and the TD nerve, in whole or in part. Nevertheless, the term "muscle sparing" has also been applied to the descending branch LD (DB-LD) flap which requires the denervation of the LD muscle. According to our knowledge, there are no articles in the literature reviewing and comparing the reconstructive options based on the TD vessels. We performed a systematic search in PubMed, Web of Science, and Cochrane databases to perform a literature review and meta-analysis about the reconstructive options based on the TD vessels. The primary outcome of interest was the percentage of flaps developing a specific early complication, i.e., hematoma of the donor site, seroma of the donor site, partial flap loss, total flap loss, wound dehiscence, and wound infection. Moreover, we analyzed the outcomes and complications of our cases, comparing the MSLD flaps, the DB-LD flaps, and the TDAP flaps. According to both our casuistry and the literature, the three techniques can be considered safe in terms of early donor site complications. According to the literature, MSLD has been shown to develop partial flap necrosis more frequently than the TDAP flap.

A Retrospective Comparative Analysis of Latissimus Dorsi (LD) Flap Versus Thoracodorsal Artery Perforator (TDAP) Flap in Total Breast Reconstruction with Implants: A Pilot Study.

BACKGROUND: In breast surgery, an autologous flap combined with implant may reduce the risk or repair the soft-tissue defects in several cases. Traditionally, the preferred flap is the myocutaneous latissimus dorsi (LD) flap. In the perforator flap era, the evolution of LD flap is the thoracodorsal artery perforator (TDAP) flap. The aim of this study is the comparison between LD flap and TDAP flap with implants in terms of early complications and shoulder function. METHODS: We performed a retrospective cohort study in accordance with the STROBE guidelines. Between January 1 2015 and January 1 2020, 27 women underwent a unilateral total breast reconstruction with LD or TDAP flap combined with an implant at our institution. 15 women were operated with LD flap and 12 with TDAP flap. The most frequent indications for intervention were results of mastectomy and radiation-induced contracture. We evaluated several data in terms of clinical and demographical characteristics, operative and perioperative factors, and follow-up variables. We assessed shoulder function through the Disability of the Arm, Shoulder and Hand Questionnaire (DASH). RESULTS: The rate of complications was significantly lower in the TDAP group compared with the LD group (16.7% vs 60.0%, p = 0.047. Table 3). Although the small sample size limited further detailed statistical analyses, we particularly noticed no cases of donor site seroma in the TDAP group, as compared with four in the LD group. Patients in the TDAP group had an ∼11-point lower mean DASH score compared with the LD group (9.8 vs 20.5). This difference was statistically significant (p = 0.049). CONCLUSIONS: TDAP flap seems to be a reliable technique for soft-tissue coverage in total breast reconstruction with implants. In comparison with the traditional LD flap, it could be a more favorable option in terms of less complications and better quality of life.

Capsulectomy vs capsulotomy in total hip arthroplasty. Clinical outcomes and proprioception evaluation: Study protocol for a randomized, controlled, double blinded trial.

BACKGROUND: Patients affected by coxarthrosis may be treated surgically with total hip arthroplasty (THA). During the surgical intervention, the hip joint capsule can be completely removed, performing a capsulectomy. Otherwise it's possible to perform a capsulotomy, which allows for capsular conservation. Since there is no scientific evidence demonstrating the superiority of one method over the other, the choice whether to remove or conserve the capsule is at the surgeon's discretion and both procedures are actually accepted.The purpose of our study is to evaluate the differences in functional activities and proprioception in patients who underwent THA and capsulotomy with capsular conservation versus patients who underwent THA with capsulectomy. METHODS: In order to compare the two surgical techniques of capsulotomy with capsular conservation and capsulectomy, we created a randomized, controlled, double-blind, single-centre, non-pharmacological, interventional, superiority, parallel-group trial. The primary outcome of our study is evaluated using the HOOS scale (Hip disability and Osteoarthritis Outcome Score). Secondary outcomes are: the proprioceptive sensitivity, the postoperative bleeding, the surgical time, the active range of motion, and the ability to walk, sit and stand. The proprioception study is carried out through active and passive repositioning tests. THA is performed through the minimally invasive direct anterior approach. The evaluation tests are carried out in the 15 days preceding the intervention (T0), at 50-day post-operative (T1), and finally at three months after surgery (T2). DISCUSSION: Considering that the hip joint capsule is innervated by proprioceptive nerve endings, while the psuedocapsule that replaces the native capsule following a THA with capsulectomy doesn't have any active neurophysiological role, we hypothesize that capsulotomy with capsular conservation at the time of primary THA may lead to better proprioception and therefore better functional recovery. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02749058. Date of registration: 04/21/2016.