Composite breast reconstruction: Implant-based breast reconstruction with adjunctive lipofilling.

INTRODUCTION: Options for breast reconstructions enclose autologous tissue transfers or implants. Fat grafting is gaining more interest in this specific field of breast surgery. This study concentrates on the technique and aesthetic results of breast reconstruction with fat grafts combined with implants, in women who have undergone total mastectomy. METHODS: Breast reconstructions (n = 23) was performed using a protocol of intratissular expansion with serial deflation-lipofilling. In order to achieve the best aesthetic outcome, an additional small implant was placed. A retrospective data analysis was performed. In all patients a tissue expander was placed at the time of mastectomy or after removal of a previous breast reconstruction. The mean of lipoaspirate material for the reconstruction was 333 mL (range 120-715 mL). To create an adequate volume of the reconstructed breast, a supplementary small implant was placed, with a mean volume of 222 mL (range 125-375 mL). The mean follow-up was 33 months (range 19-50 months). RESULTS: A MRI analysis was performed in eight patients at least 9 months after the last lipofilling procedure, demonstrating a mean of 171 mL (range 64-538 mL) of transferred fat, a mean fat survival of 53% and a volume ratio of fat graft/implant of 0.97 (range 0,3-3,8). CONCLUSION: This composite technique of using autologous fat tissue and implants shows aesthetic pleasant results and must be considered as a valid alternative in a subset of patients. Further investigations to optimize the fat graft take must be encouraged.

Imaging Features of Hypertrophic Olivary Degeneration.

Hypertrophic olivary degeneration (HOD) is a unique form of transneuronal degeneration caused by a disruption of the dentato-rubro-olivary pathway, also known as the triangle of Guillain-Mollaret. The triangle of Guillain-Mollaret is involved in fine voluntary motor control and consists of both the inferior olivary nucleus and the red nucleus on one side and the contralateral dentate nucleus. Clinically, patients classically present with symptomatic palatal myoclonus. Typical magnetic resonance imaging findings include T2-hyperintensity and enlargement of the inferior olivary nucleus evolving over time to atrophy with residual T2-hyperintensity. In this article, we provide a case-based illustration of the anatomy of the Guillain-Mollaret-triangle and the typical imaging findings of hypertrophic olivary degeneration.

[A woman with a swelling in the groin]. / Een vrouw met een zwelling in de lies.

A 75-years-old woman presented to the Emergency Department with a painfull swelling in the right groin. Clinical examination was suggestive of an incarcerated hernia. Echography and examination during surgery revealed an Amyand's hernia. Amyand's hernia is a rare type of a sliding hernia that is characterized bij protrusion of the appendix in the hernial sac. Surgical reduction of the hernial sac was followed by appendectomy because the appendix was inflamed: a rare complication of Amyand's hernia.

The use of platelet-rich plasma in plastic surgery: a systematic review.

OBJECTIVE: The study's aim was to evaluate the available evidence regarding the use of platelet-rich plasma in plastic and reconstructive surgery, through implementation of a systematic review of the literature. DATA SOURCES: PubMed and The Cochrane Library were searched using MeSH terms: 'platelet rich plasma' and 'plastic surgery' for all publications up to July 2011. All English, German, French and Dutch papers were included. In addition, the reference lists of relevant articles were searched for potentially appropriate publications. STUDY SELECTION: Included studies needed to report on topics related to plastic and reconstructive surgery, mentioning at least one clinical end point. Both in vivo and in vitro comparative studies, performed in humans or animals, were included. A total of 82 publications were found, of which 40 studies met the inclusion criteria and were relevant to be used in this systematic review. DATA EXTRACTION: Data from retrieved studies were reviewed and tabulated according to year of publication, study design, human or animal studies, characteristics of the population, mode of application, outcomes and preparation method. DATA SYNTHESIS: A total of 15 randomised controlled trials and 25 case-control studies were found. Thirty-six publications demonstrated favourable outcomes with the use of platelet-rich plasma. The included articles were divided into three topics related to plastic surgery: wound healing, fat grafting and bone grafting. CONCLUSIONS: This systematic review describes a substantially beneficial effect of platelet-rich plasma for several indications, including a better wound healing rate, an increased survival rate of fat grafts and an enhancement of bone graft regeneration.

Classification of primary and incisional abdominal wall hernias.

PURPOSE: A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. METHODS: Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. RESULTS: To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. CONCLUSIONS: A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study.

PURPOSE: To evaluate the feasibility, the reproducibility, the safety and the efficacy of a recently introduced preperitoneal memory-ring patch (Polysoft, Davol Inc., C.R. Bard Inc., Crawley, UK) by a prospective multicentric observational study. METHODS: We performed 235 unilateral groin hernia repairs in 200 consecutive patients during a 12-month period. Patients were operated by three different surgeons in two different centres. Pre- and intraoperative data, as well as postoperative complications, were prospectively recorded. RESULTS: Two hundred patients, with a mean age of 55.4 years, were operated for primary or recurrent unilateral groin hernias. The mean operation time for unilateral hernia repair was 22 min (range 14-37 min). Seventy-one patients (35.5%) were operated in an ambulatory setting. Considering pain scores, we observed a preoperative visual analogue scale (VAS) score of 1.4 (range 0-3.7). After 24 h, 3 weeks and 6 months, VAS was 4.2 (0.5-6.9), 1.7 (0-2.0) and 0.1 (0-1.5), respectively. The follow-up was more than 18 months in all patients (range 19-31 months). In total, three patients were diagnosed with a recurrence and were reoperated by an anterior Lichtenstein repair with large-pore mesh. CONCLUSION: This transinguinal minimally invasive preperitoneal mesh repair is reproducible, easy to perform and safe with acceptable mid-term results. These elements, together with a minimal superficial dissection in the inguinal canal, preperitoneal mesh placement and the absence of fixation, are possible elements to reduce acute and chronic postoperative pain compared to other open and also laparoscopic techniques that have to be proven in larger (randomised) trials.

Tailgut cysts: rare retrorectal tumours.

Two patients presented with tailgut cysts. The first patient complained of pain and pressure in the sacrococcygeal region. The second patient had developed a cystic mass superficial to the coccyx. Pelvic CT scans of both patients demonstrated a retrorectal mass. Both tumours were excised through a posterior para-sacrococcygeal approach with resection of the coccyx.

Caecostomy in the management of acute left colonic obstruction.

In the management of acute left colonic obstruction there is a tendency to perform immediate resection with anastomosis. We evaluated 27 consecutive patients (mean age 73.8 years) with acute left colonic obstruction and gross dilatation of the proximal colon treated by the "traditional" staged procedure. After caecostomy, no further resection was performed in two patients. In 25 patients, the obstructing tumour was resected after a median period of 14 days. In 17 (68%) patients the caecostomy was closed simultaneously. In 8 patients this was done at a third stage. Histologic examination revealed diverticular disease in 6 and adenocarcinoma in 19 patients. No deaths occurred after caecostomy nor was there major morbidity. After colonic resection, one in-hospital, nonprocedure related, death occurred (mortality rate 4%). In 21 patients with an anastomosis no dehiscence occurred. Other postoperative complications occurred in 5 patients (morbidity rate 20%). The median hospital stay for patients with a two-stage procedure was 32 days and with a three-stage procedure 39.5 days. The staged procedure in the management of acute colonic obstruction is still a safe and acceptable procedure in elderly patients with acute large bowel obstruction. To shorten the hospital stay the period between caecostomy and colonic resection should be reduced and it is best to close the caecostomy simultaneously.

Stenosis development at the distal anastomosis of prosthetic bypasses for aortoiliac occlusive disease. Incidence and accuracy of colour flow duplex in the diagnosis.

When bypasses for aortoiliac occlusive disease fail they often do so because of a stenosis at the distal anastomosis. To assess the incidence of stenotic lesions and to establish the diagnostic reliability of colour-flow Duplex scanning, we investigated 103 aortoiliac and aortofemoral bypasses using intravenous (i.v.) digital subtraction angiography (DSA) as the reference method. Stenotic lesions at or just beyond the distal anastomosis were identified by i.v. DSA in 30 patients. The stenosis had a 30-49% diameter reduction (DR) in 10, 50-79% DR in 17 and 80-99% DR in three patients. The incidence of stenoses identified within the first 3 years following the operation was 33%, in the period of 3-6 years 20%, in the period of 6-9 years 32% and for bypasses longer than 9 years after the operation 50%. Colour-flow imaging had a 89% sensitivity in identifying the presence and location of distal anastomotic stenosis and a 95% specificity of ruling out significant lesions. A threshold value of 0.65 of the index between the peak systolic velocity (PSV) at a normal vascular segment and the maximum PSV at the side of stenosis demonstrated lesions with a sensitivity of 86% and a specificity of 90%. Prophylactic repair of a high grade stenosis (> 70% DR) was performed in only two patients. Colour-flow Duplex is accurate in identifying distal anastomotic stenoses. Although the precise incidence of these lesions can be determined only by a prospective surveillance study, available data suggests a low yield of cases requiring prophylactic repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Color-flow duplex criteria for grading stenosis in infrainguinal vein grafts.

Color-flow duplex scanning of infrainguinal vein bypasses was used to identify failing grafts. Several duplex parameters were compared to determine their value in identifying and quantifying the degree of stenosis. Intraarterial digital subtraction angiography was used as the "gold standard" to determine the severity of the stenosis. The goal of this study was to identify specific color-flow duplex criteria for grading stenotic lesions. After a retrospective analysis some of these parameters were prospectively validated. The surveillance protocol required a color-flow duplex scan every 3 months for the first year and every 6 months during the second year. One hundred sixteen vein grafts in 112 patients were studied. Forty-three stenoses were identified and classified into categories from 30% to 49%, 50% to 69%, and 70% to 99% diameter reduction. These stenoses were identified in either the bypass graft or adjacent inflow or outflow arteries. Failing grafts were evaluated further by intraarterial digital subtraction angiography. Patients with normal appearing bypasses (without suspected stenotic lesions) had intravenous digital subtraction angiography. The five duplex parameters that were studied included the following: (1) graft peak systolic velocity (PSV-graft), (2) the maximum peak systolic velocity (at the site of a stenosis or in normal grafts at the narrowest segment of the bypass) (PSV-max), (3) the ratio between PSV-graft and PSV-max, (PSV-index), (4) end-diastolic velocity (EDV) at a stenosis or from narrowest graft segment, (5) color-flow image diameter measurements. For discrimination of different degrees of stenosis, threshold values of these parameters were calculated by receiver operating characteristic analysis. Diameter reduction measured by color-flow imaging was best to identify all stenotic lesions greater than 29% (sensitivity 88%, specificity 99%). Peak systolic velocity-index proved optimal identification of stenoses greater than 49% (sensitivity 89%, specificity 92%), and 70% to 99% stenoses were associated with increased EDV (sensitivity 91%, specificity 100%). The PSV-index criteria were then validated prospectively in a separate group of vein grafts. The data support the value of surveillance of femorodistal vein grafts and demonstrate that calculation of the degree of graft stenosis is feasible.

[Results of bypass surgery for imperiled leg]. / Resultaten van bypass-operaties wegens bedreigd been.

Femoropopliteal and crural bypass operations are performed frequently, but the results of operations for intermittent claudication and severe ischaemia are often reported jointly. However, the importance of the latter category for the quality of life is of a different order, so that its results should be studied separately. In a period of over eight years 199 bypass operation were performed. The cumulative proportion of preserved legs after three years was 82% for femoropopliteal and 68% for femorocrural transplantations. Factors such as presence of gangrene, diabetes mellitus and a systolic ankle blood pressure below 40 mm Hg were associated with a significantly smaller proportion of saved legs. The five-year survival rate for the group of patients as a whole was 42%, far lower than the 79% that applies to a comparable group of healthy persons. Cardiopathy was the main cause of death. Even if the number of remaining years of life is less, saving the leg by a bypass operation performed in time should be considered of major importance.

Long-term behaviour of modified human umbilical vein grafts; late aneurysmal degeneration established by colour-duplex scanning.

To define long-term results of modified human umbilical vein (MHUV) grafts a retrospective study was undertaken, and in addition the incidence of aneurysmal degeneration was investigated by Colour-Duplex scanning. From July 1979 until December 1986, 227 MHUV grafts were implanted in 181 patients (204 limbs). The operative indication was claudication in 110 limbs and ischaemic rest pain or gangrene in 94 limbs. The distal anastomosis was at the level of the popliteal artery in 167 limbs and at one of the crural arteries in 37 limbs. During the first month mortality was 3%. Primary and secondary patency rates were calculated for different subgroups. At 5 years the cumulative primary and secondary patency rates for femoro-popliteal grafts were 56 and 64% and for femoro-crural bypasses 19 and 21%. In the retrospective part of this analysis non-occlusive graft-failure occurred in 14 limbs (7%). This was due to infection (7 limbs), aneurysm-formation (4 limbs) or progressive footgangrene (3 limbs). Six of these limbs came to an amputation, however, no amputation was related to aneurysmal degeneration. The amputation-rate was significantly higher in the group with femoro-crural reconstructions as compared to the group with femoro-popliteal reconstructions (32 and 13% respectively; P less than 0.001). From these observations it becomes apparent that the use of MHUV-grafts as femoro-crural bypass is rarely justified. Aneurysmal changes as found by colour-Duplex scanning of 63 limbs with patent grafts at the time of this investigation were present in 23 grafts (37%). The mean internal diameter of the aneurysms was 12.6 mm (range 9.1 to 43.0 mm).(ABSTRACT TRUNCATED AT 250 WORDS)