Polyurethane Implants in Revisional Breast Augmentation: A Prospective 5-Year Study.

BACKGROUND: Revisional surgery for aesthetic breast augmentation remains a challenging procedure. Polyurethane (PU) implants have been found to avoid capsular contracture recurrence as well as to prevent implant displacement by bio-integrating with the pocket. OBJECTIVES: Our study aimed to assess the use of PU implants in breast revisional surgery and to provide an algorithm. METHODS: Over a 5-year period, a prospective study was conducted involving consecutive patients undergoing implant revision. Patient demographics, previous breast procedures, and specific surgical details were documented. Postoperative outcomes were followed up. RESULTS: Out of 92 patients (184 breasts), 78 (156 breasts) were included in the analysis. The average age was 47.5, with a BMI of 22.3 and a mean follow-up of 5 years. A majority (63%) represented secondary revisional cases, while 37% were tertiary cases. Implant size averaged 296 cc, with 53% placed in retropectoral position and 47% prepectoral. Significantly more implants in secondary cases were changed from prepectoral to retropectoral (P = .005), and in tertiary changed from retropectoral to prepectoral (P = .002). Complete capsulectomy was performed in 61.5% and partial in 25.6%. Additional lipofilling was performed in 32%, and concurrent mastopexy in 40%. Revisional surgery in our series had a 1.9% acute complication rate, 4.5% longer-term reoperation rate for corrections, 0.6% implant exchange rate, and no recurrent capsular contracture. CONCLUSIONS: This is the first study to provide data on outcomes of revisional breast augmentation surgery with PU implants. It shows that polyurethane implants offer consistent stability and have low rates of recurrent capsular contracture in revisional surgery.

Using an Elastomeric Skin Protectant to Manage Donor Site Wounds of Split-thickness Skin Grafts: A Case Series.

ABSTRACT: Split-thickness skin grafting (STSG) is a common surgical procedure to manage acute and chronic wounds. A plethora of dressings exists to treat STSG donor site wounds (DSWs). Recently, a new elastomeric skin protectant was adopted (Cavilon Advanced Skin Protectant; 3M) in the treatment of incontinence-associated dermatitis. In this report, the authors assess the effects of this elastomeric skin protectant as an alternative wound dressing for STSG donor sites.The authors report a single-center prospective case series that was performed to establish a treatment protocol. Nine consecutive patients with different indications for treatment with an STSG from May to September 2018 were included. Collected data included general patient information, comorbidities, complications, blood loss, pain during dressing change, and the duration of DSW healing.This case series showed promising results in terms of duration of DSW healing when applying the elastomeric skin protectant. The authors also observed less blood loss and less pain during dressing changes. No infections were seen during the trial.

Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study.

BACKGROUND: The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA). METHODS: A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin. RESULTS: A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%). CONCLUSIONS: This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.

The monsplasty: Surgical and functional outcomes using an effective and reproducible surgical technique.

BACKGROUND: The available literature on monsplasty remains sparse and most of the reports are limited to the description of one surgical technique, with limited to no post-operative data. This study aims to describe a reproducible monsplasty surgical technique and to analyze the post-operative functional and esthetic outcomes. METHODS: Patients with at least grade 2 mons pubis ptosis were included in the study and observed for 3 months. Pre- versus post-operative analysis included body image, psychological function, sexual function, urinary function, hygiene maintenance of the pubic area, and post-operative complications. An additional retrospective analysis of a larger group of patients was also performed. RESULTS: Between April 2021 and January 2022, a total of 25 patients were included in the prospective study. They reported a significant improvement in body image (p < 0.001), satisfaction with the abdomen (p < 0.001), and sexual functioning (p = 0.009). Functionally, improvements were recorded with regard to visualization of the genitalia (36%), hygiene maintenance of the pubic area (32%), sex life (48%), genital sensitivity (24%), and urinary continence (4%). Patient satisfaction was very high. There were no major complications. The retrospective study included 80 patients between 2010 and 2021, with a mean follow-up time of 18 months. No major complications were noted. CONCLUSION: Monsplasty is a simple and fast procedure that can truly bring an added value to the patient's satisfaction and functional outcomes. It can be incorporated in both esthetic and reconstructive abdominoplasties and should be a standard component of the procedure for cases with mons ptosis grade 2 or higher. EVIDENCE BASED MEDICINE LEVEL: Level II.

A new oncoplastic technique with immediate nipple reconstruction for central breast tumors using Würinger's septum-based flap.

INTRODUCTION: Centrally located breast tumors represent a challenge for both oncological and reconstructive surgeons, mainly due to the necessity of nipple-areola complex (NAC) removal. We describe an original oncoplastic solution utilizing a displacement flap technique with immediate nipple reconstruction. METHODS: Since 2008, we developed an oncoplastic technique using a septum-based island flap for the reconstruction of central breast defects, including the NAC. This technique is based on the Würinger's septum which is centered around the intercostal perforators. A retrospective study was performed collecting data on patient characteristics, oncological features, and outcomes. Patient satisfaction was reported using a Likert scale. RESULTS: Reconstruction was successfully realized in 15 patients (14 immediate and one delayed post-lumpectomy correction). In immediate surgery, the excision margins were all free of tumor. Minor complications occurred in three patients; one small area of skin necrosis was managed by secondary intention, and two cases of partial nipple necrosis were treated by debridement under local anesthesia. Contralateral symmetrization surgery was performed on nine patients. Patient satisfaction scored high. CONCLUSION: In comparison with the previous oncoplastic techniques used for reconstructing central defects, the septum-based island flap has increased flexibility, provides better projection, and can be combined with immediate NAC reconstruction.

Schwannoma Arising from the Deep Motor Branch of the Ulnar Nerve - A Case Report and Review of Literature.

Schwannomas of the ulnar nerve in the hand are uncommon and those arising from the deep motor branch of the ulnar nerve (DMBUN) are rare. We were able to find only five reports of a schwannoma of the DMBUN. We report a schwannoma arising from DMBUN beyond the Guyon canal and summarise the literature on schwannomas involving the DMBUN. Level of Evidence: Level V (Therapeutic).

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction.

BACKGROUND: The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed. METHODS: The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed. RESULTS: A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen. CONCLUSION: The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Limiting the fascia incision length in a DIEP flap: Repercussion on abdominal wall morbidity.

BACKGROUND: The evolution from free muscle-sparing transverse rectus abdominis myocutaneous flap to deep inferior epigastric perforator (DIEP) flap leads to less donor-site morbidity. However, rectus fascia is usually incised longitudinally from perforator(s) to iliac vessels, often exceeding 15 cm when including longitudinal muscle spreading. By using a limited fascia incisional (LFI-) technique, we try to diminish abdominal wall functional decrease. METHODS: Twenty-seven patients who underwent unilateral breast reconstructions using free DIEP-flap with limited fascia incision between December 2014 and October 2017 were included in the study. Each patient received a periumbilical electromyogram (EMG) preoperatively, at 6 and 14 weeks postoperatively. They were compared with 27 patients having unilateral breast reconstructions using classic free DIEP-flap, performed at the same department between November 2009 and May 2011. RESULTS: In our LFI-technique, one vertical (4 cm) incision is made where the pedicle exits the muscle. A second, oblique (3 cm) incision is made more distally where the pedicle runs into the iliac vessels. After release, the pedicle is tunneled through the incisions, leaving all fascia, and therefore muscle, intact. In the LFI-group small neurogenic changes were noticed in only 26% and 11% of the patients at, respectively, 6 and 14 weeks postoperatively. By contrast, in the control group, postoperative neurogenic deviations remained in 37% of the patients at 14 weeks postoperatively; significant different compared to the LFI-group. CONCLUSION: This study shows the importance of preserving anterior rectus fascia. Nerve supply and abdominal rectus muscle function are less endangered using small segmental fascia incisions. We believe that our technique diminishes donor-site morbidity significantly and improves the postoperative recovery.

The 10-Year Experience with Volume Distribution Mastopexy: A Novel, Safe, and Efficient Method for Breast Rejuvenation.

BACKGROUND: Recurrent ptosis may occur after mastopexy procedures over time. The volume distribution mastopexy technique provides breast lifting with projection enhancement and maintains breast suspension. METHOD: Since 2010, 50 patients underwent volume distribution mastopexy procedures. The technique consists of a superior or superomedial pedicle, dissection of a Würinger-septum-based chest wall flap, suspension of the flap to the pectoralis major muscle using a prosthetic mesh, gland suture to the mesh, and fat grafting if required. A prospective study was conducted. Nipple position and length of the lower pole distance of the breast were noted. Patient satisfaction and results evaluation were reported using a Likert scale. RESULTS: A Vicryl mesh was used in the first 23 patients and a mixed polyester/Vicryl mesh was used in the following 27 patients. Wound dehiscence occurred in one patient. At an average follow-up of 3 years, nipple position remained stable in position, but lower pole distance elongation was observed in five patients (20 percent) and in one patient (3 percent) who had Vicryl mesh and mixed mesh respectively (p < 0.05). Only four breasts (4.7 percent) demonstrated significant lower pole elongation over time (>15 percent), all in the Vicryl mesh group. Worth noting, both the patients and the independent evaluators provided high ratings of the result of 4.7 and 4.6, respectively, on a Likert scale. CONCLUSIONS: The volume distribution mastopexy technique repositions the ptotic gland with a mesh to suspend the breast gland and to maintain the lifting effect. However, the synthetic mixed mesh proved to be significantly more effective in achieving this goal. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Case Report of Two Patients With COVID-19 and Sacral Pressure Injuries Associated with Pyoderma Gangrenosum.

ABSTRACT: During the COVID-19 pandemic, an increasing number of patients have been admitted to the ICU with severe respiratory complications requiring prolonged supine positioning. Recently, many case reports have been published regarding dermatologic manifestations associated with COVID-19. However, there is little information about the clinical features of these manifestations. Pyoderma gangrenosum (PG) is an ulcerative noninfectious inflammatory disease of the skin. In at least 50% of the cases, the etiology is unknown. Nevertheless, PG is associated with many systemic diseases. In this article, the authors report two critically ill patients with COVID-19 who developed sacral ulcers during their recovery in the ICU. These ulcers had an atypical course and were exacerbated by surgical debridements. Accordingly, providers suspected PG, which was confirmed by the clinical evolution of the ulcers and biopsies taken from the wounds. To the best of the authors' knowledge, no previous articles have reported sacral pressure injuries associated with PG in patients with COVID-19. Providers should suspect PG in patients with COVID-19 who develop nonhealing pressure injuries.

The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction.

BACKGROUND: Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction. OBJECTIVES: The authors sought to describe a new and efficient technique that enhances breast projection in delayed breast reconstruction employing abdominal free flaps and compare it with the current standard methods utilized. METHODS: The charts of 490 consecutive patients who underwent delayed breast reconstruction employing free abdominal perforator flaps were reviewed between 2007 and 2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization, and the "hug flap" (HF). In the newly described technique, the caudal mastectomy skin was de-epithelialized, and then the medial and lateral thirds were undermined and folded over to cover the central part. The rates of complications and secondary corrections were analyzed between the 3 groups. RESULTS: There were 570 free abdominal flaps performed. The de-epithelization technique was the most commonly utilized (328 cases) followed by the undermining technique (153 cases). The HF technique was employed in 89 cases. The majority of HFs were performed in unilateral breast reconstruction. Bilateral cases were conducted in only 12 patients. The need for additional fat grafting was significantly (P = 0.003) less required in the HF group compared with the undermining and de-epithelializing groups (12% vs 28% and 21%, respectively). CONCLUSIONS: Although all breast-enhancing options can be mixed and matched based on the surgeon's preference and experience as well as each patient's needs, the HF can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry.

Decreasing donor site morbidity after groin vascularized lymph node transfer with lessons learned from a 12-year experience and review of the literature.

INTRODUCTION: Donor site morbidity related to vascularized lymph node transfer (VLNT) remains a cause of worry among surgeons. As such, our study explores donor site morbidity after VLNT with or without concomitant deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Furthermore, we evaluate our surgical approach to ascertain whether it reduces the morbidity rate. MATERIALS AND METHODS: A retrospective chart review of donor site complications and surgical techniques was performed from 2006 to 2018. The patients' medical histories and demographic data were analyzed for risk factors. Patients were contacted by telephone for a long-term follow-up questionnaire. A literature review was implemented to evaluate the reported donor site complications and surgical strategies in literature. Complications were evaluated with and without concomitant autologous breast reconstruction (DIEP flap). RESULTS: Eighty-nine patients were included in our case series. Sixty-five cases (73%) were combined with DIEP flap breast reconstruction. Seroma rate diminished from 60% in the first 39 cases to 18% in the last five years (50 cases) (p < 0,001). Lymphedema of the afferent lower limb is described in the literature but did not occur in our series. CONCLUSIONS: Seroma formation is the most common donor site morbidity after groin VLNT flap harvest, particularly when combined with DIEP flap breast reconstruction. This paper contains the largest reported series of combined VLNT + DIEP flaps and describes surgical strategies on how to decrease seroma formation and avoid iatrogenic lymphedema of the lower limb.

The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications.

BACKGROUND: Hyaluronic acid (HA) fillers are frequently used for cosmetic purposes as volumizers or as wrinkle fillers. One of the major advantages of hyaluronic acid use is the possibility to neutralize it by using hyaluronidase should complications occur. PATIENT: A case of a 21-year-old female patient is presented, in whom a hyaluronic acid injection-induced vascular occlusion was seen four days after the initial injection, with increasing pain and severe signs of ischemia. METHOD: Treatment consisted of an immediate hyaluronidase injection, supplemented with administration of acetylsalicylic acid, piracetam, low molecular weight heparin (LMWH), corticosteroids, analgesics, prophylactic antibiotics, application of topical nitroglycerin and warmth, smoking cessation, and hyperbaric oxygen therapy. RESULTS: The initial progress and evolution of the deformity with possible therapeutic options are being discussed. CONCLUSION: The "ART" (avoid, recognize, and treat) in handling filler complications is presented, as a new universal guideline for clinical aesthetic practitioners and injectors.

A Rare Case of KID Syndrome: The Use of Hydrosurgery and Strategies for Antiseptic Wound Care.

A 14-year-old girl with a history of keratitis-ichthyosis-deafness (KID) syndrome, a rare autosomal dominant condition, was referred to the Department of Plastic Surgery at Brussels University Hospital in June 2016 for progressively worsening inguinoperineal ulceration exacerbated by overapplication of combination drug treclinax (tretinoin and erythromycin). On assessment, a large area of purulent papillomatous hyperkeratosis with follicular plugging, likely superimposed bacterial colonization, and deep ulceration were noted requiring thorough debridement.A first procedure was performed in June 2016 with hydrosurgical debridement (Versajet IITM; Smith & Nephew, Forth Worth, Texas). During the procedure, significant blood loss was noted, and topical adrenaline, blood transfusion, and a short ICU stay were required for monitoring during which the patient remained hemodynamically stable. The wound was primarily dressed with an antimicrobial barrier silver dressing; meropenem, ceftazidime, and fluconazole were started to treat for Gram-negative, Gram-positive, and anaerobic bacilli, as well as Pseudomonas aeruginosa and fungal infections in situ. A further three debridements were required 6, 12, and 26 days after the initial procedure. The patient was discharged 36 days after admission without any antibiotics and with an outpatient wound care plan.Not only was this case rare, but it also reflected the importance of a careful approach when tackling KID syndrome's cutaneous manifestations. Multiple debridements, thorough wound care, and appropriate antibiotic therapy may be required to achieve local healing and a satisfactory result. Hydrosurgical debridement offered a precise and well-controlled method for treating a large ulcerating hyperkeratotic urogenital lesion in this pediatric patient.

Deep inferior epigastric artery perforator flap harvest after full abdominoplasty.

Abdominal scars are no longer a contra-indication for abdominal perforator flap harvesting. Few research data exists about the regeneration potential of the abdominal wall's perforator system. Therefore, previous abdominoplasty with umbilical transposition is an absolute contra-indication for a DIEaP-flap (deep inferior epigastric artery perforator flap). A 50-year-old patient required a breast reconstruction of the right breast, 10 years after an abdominoplasty with undermining of the superior abdomen and umbilical transposition. The patient was scheduled for a free lumbar artery perforator (LaP) flap. The preoperative computed tomography-angiography mapping showed nice lumbar perforators and to our surprise a good-sized DIEa perforator in the peri-umbilical region. The DIEa perforator on the right hemi-abdomen, consisting of two veins and one artery, was pulsatile and found suitable in size. A classical flap harvest and transfer was further performed. This case report is the first in which a dominant perforator is found in the area of undermining after a full abdominoplasty with umbilical repositioning. Further investigations regarding the nature and timing of re-permeation or regeneration of perforators after abdominoplasty are to be done. Nevertheless, we are convinced that with appropriate perforator mapping and a suitable plan B, previous abdominoplasty is no longer an absolute but a relative contra-indication for performing DIEaP-flap.

MR lymphography in patients with upper limb lymphedema: The GPS for feasibility and surgical planning for lympho-venous bypass.

BACKGROUND AND OBJECTIVES: Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery. METHODS: A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed. RESULTS: Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully. CONCLUSIONS: MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb.

Débridement and Autologous Lipotransfer for Chronic Ulceration of the Diabetic Foot and Lower Limb Improves Wound Healing.

BACKGROUND: The application of autologous lipotransfer (fat grafting, lipofilling) in reconstructive surgery is steadily becoming more popular as evidence of the regenerative and reparative effects of fat becomes better known. The authors investigated the use of autologous lipotransfer for treatment of chronic diabetic and other foot and lower limb ulcers. METHODS: Twenty-six patients with nonhealing wounds were treated with surgical débridement and autologous lipotransfer (using the débridement and autologous lipotransfer method). The mean age of the wounds before intervention was 16.7 months. Wound size after débridement averaged 5.1 ± 2.6 cm2. On average, 7.1 ± 3.3 cc of lipoaspirate was transferred into the wound area. RESULTS: Twenty-two of 25 wounds (88 percent) healed completely within a mean of 68.0 ± 33.0 days. A reduction of wound size by 50 percent was achieved after an average of 4 weeks. In one patient with an ulcer within particularly scarred tissues on the lower limb, a repeated session of lipotransfer led to complete wound healing after another 4 weeks. CONCLUSION: The authors describe a simple and useful technique to improve wound healing in diabetic feet and chronic lower limb ulcers with a background of peripheral vascular disease, where other interventional options to achieve wound healing have failed.