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.

Clinical Validation of Superficial Lip Injections Utilizing Cohesive Polydensified Matrix Hyaluronic Acid-Based Soft Tissue Fillers.

BACKGROUND: A combination of optimal injection technique and dermal filler choice is key for improving lip architecture with natural and long-lasting results. OBJECTIVE: To investigate the positioning of Cohesive Polydensified Matrix™ (CPM) hyaluronic acid (HA) fillers after superficial lip injections and document their tissue integration and effects on lip architecture and shape. METHODS: Eligible patients underwent lip contouring and volumization using a superficial direct tissue action technique. All injections were performed with CPM-HA lip fillers using a 30G needle and retrograde microthreading. Total injected volume was 0.8-1.2 mL. High-resolution ultrasound (US) imaging, 3D surface scanning, and Global Aesthetic Improvement Scale (GAIS) assessments were performed before, and 1, 3 and 6 months post-injection to define the anatomy, positioning, longevity and patient satisfaction. RESULTS: Sixteen patients were injected (mean age, 33.2 years). US measurements revealed an increased skin–orbicularis oris muscle distance up to 1 month post-injection after which measurements returned to baseline values. This observation correlated with complete product integration into the surrounding tissue visualized by US at 3 months. An increased dry mucosa thickness (vermilion body) remained at 6 months, and GAIS scores revealed 70% of patients continued to experience visible lip improvements. 3D analyses revealed significantly increased total lip surface area at 3 months with increased Cupid’s bow distance, philtral height, and anterior upper lip projection. CONCLUSION: Superficial injection of CPM-HA fillers offers an effective and safe tool for improving lip architecture and volume. Results showed homogeneous dermal integration of the product and aesthetic outcomes maintained up to 6 months. J Drugs Dermatol. 2021;20(9):940-945. doi:10.36849/JDD.6011.

The Iliac Crest Osteomuscular Flap for Bony Reconstruction: Beast or Beauty? A Reassessment of the Value and Donor Site Morbidity in the CAD/CAM Era.

BACKGROUND: The iliac crest bone flap (ICBF), based on the deep circumflex iliac artery, has a bad reputation regarding donor site morbidity. However, the ICBF has an ideal curvature and shape for occlusion-based hemimandibular reconstructions with rapid dental rehabilitation and for vertical class III maxillary reconstructions that require bony support and muscular bulk to fill cavities and to provide intraoral lining. Is this notorious donor site reputation still valid with modern flap procurement using computer aided design/computer aided manufacturing (CAD/CAM) and recipient-site closure techniques? METHODS: We performed a literature search of the public databases PubMed, Cochrane, Google Scholar, and Web of Science for papers using mesh keywords related to donor site morbidity of the ICBF. We report three illustrative case reports using our current protocols for oncologic bony resection and reconstruction, using in-house CAD/CAM and three-dimensional printing to procure a tight-fit ICBF and minimizing donor site morbidity. RESULTS: We found 191 articles in the PubMed database of which we considered 176 nonrelevant. Cochrane Library and Google Scholar database searches resulted in the inclusion of 11 additional papers. The second search resulted in 172 articles of which we used five after excluding nonrelevant papers. Accurate preoperative (CAD/CAM) planning, preservation of the anterior superior iliac spine (ASIS), and paying attention to thoroughly donor site closure make the ICBF a very valuable option for accurate maxillofacial reconstructions with very acceptable comorbidities. This corresponds with our clinical findings. CONCLUSION: Dogma never is a good teacher; it remains elementary that routine "knowledge" is (re)questioned. Donor site morbidity of the ICBF is comparable to other bone flaps. The shape and bone stock of the ICBF is ideal and often may be first choice. In combination with CAD/CAM planning, the ICBF is an excellent option for specific maxillofacial reconstructions.

Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders.

BACKGROUND: For patients with psychiatric illnesses remaining refractory to 'standard' therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups. METHODS: To expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments. FINDINGS: The proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered 'established' in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients. INTERPRETATION: This consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.