The reinforced pedicle technique: a case report of secondary mastopexy following nipple-sparing mastectomy with autologous breast reconstruction.

Background: Immediate autologous reconstruction after nipple-sparing mastectomy (NSM) is challenging in the ptotic breast due to the large skin envelope and reduced vascular supply to the nipple areolar complex (NAC). Patients with significant ptosis who want to preserve their NACs are often advised to undergo a two-stage procedure: first, a mammoplasty is performed to lift the NAC, and second, a delayed NSM with autologous reconstruction is performed. Unfortunately, patients with active cancer cannot delay their mastectomy; as such, they are often treated with skin-sparing mastectomy (SSM) instead. Case Description: The reinforced pedicle is an innovative technique that allows the NAC to be safely raised after NSM with immediate free flap reconstruction. In the first stage, patients with ptotic breasts undergo NSM and immediate autologous reconstruction. The reconstruction itself also appears ptotic, but the dermal blood supply to the NAC is preserved. In the second stage, the ptotic free flap reconstruction is revised using the reinforced pedicle technique, which allows the flap to be reduced and the nipple raised in the manner of a standard superior pedicle breast reduction. Using this technique, we have successfully raised a patient's NAC by 2.5 cm. Conclusions: The reinforced pedicle technique adds to the scant literature on secondary revision techniques after autologous breast reconstruction. While further research on this technique is needed, it has the potential to alter the paradigm of immediate autologous reconstruction in the ptotic breast, allowing such patients to preserve their native NACs.

A Novel Technique of Total Scrotal Resurfacing with NovoSorb Biodegradable Temporizing Matrix for Testicular Preservation.

The reconstruction choice of scrotal defects after Fournier gangrene has been routinely based on the reconstructive ladder. Defects are usually managed with either skin-grafting or regional flaps to achieve testicular coverage. However, skin grafting done directly to testes may lead to chronic pain issues, and skin flaps can potentially be too thick to achieve good temperature control for spermatogenesis. We present the first reported case of total scrotal resurfacing after Fournier gangrene in a 48-year-old patient with NovoSorb Biodegradable Temporizing Matrix. The patient showed a good cosmetic outcome with no residual pain issues. Further research is recommended to further investigate the long-term effects of scrotal reconstruction with Biodegradable Temporizing Matrix.

Activated protein C to heal pressure ulcers.

Pressure ulcers present a major clinical challenge, are physically debilitating and place the patient at risk of serious comorbidities such as septic shock. Recombinant human activated protein C (APC) is an anticoagulant with anti-inflammatory, cytoprotective and angiogenic effects that promote rapid wound healing. Topical negative pressure wound therapy (TNP) has become widely used as a treatment modality in wounds although its efficacy has not been proven through randomised controlled trials. The aim of this study was to determine the preliminary efficacy and safety of treatment with APC for severe chronic pressure sores with and without TNP. This case presentation describes the history, management and outcome of two patients each with a severe chronic non-healing pressure ulcer that had failed to respond to conventional therapy. TNP was added to conservative management of both ulcers with no improvement seen. Then local application of small doses of APC was added to TNP and with conservative management, resulted in significant clinical improvement and rapid healing of both ulcers, displaying rapid growth of vascular granulation tissue with subsequent epithelialisation. Patients tolerated the treatment well and improvements suggested by long-term follow-up were provided. Randomised placebo-controlled double blind trials are needed to quantify the efficacy, safety, cost-effectiveness, optimal dose and quality of life changes seen from treatment with APC.

Combination of activated protein C and topical negative pressure rapidly regenerates granulation tissue over exposed bone to heal recalcitrant orthopedic wounds.

Chronic wounds arising from orthopedic surgery present a major clinical challenge. Osteomyelitis may develop from polymicrobial infection, which can be unresponsive to treatment and lead to amputation. Topical negative pressure (TNP) is an effective treatment in wound management and is now used worldwide. Activated protein C (APC) is an anticoagulant with cytoprotective and healing properties. The aim of this study was to determine whether combined treatment of TNP and APC was tolerated and was efficacious for treatment of difficult-to-treat wounds. Four patients who presented to Royal North Shore Hospital with wounds that were not responsive to conventional therapy were studied. All cases showed a marked reduction in wound size and depth within 1 week of starting treatment and progressively improved over time. There was a remarkable increase in the volume of granulation tissue. After treatment, wounds either completely closed or provided sufficient granulation tissue to allow split-thickness skin grafting. The treatment was well tolerated, and the patients were able to be managed on out-patient basis. Long-term follow-up suggested that this treatment prevented osteomyelitis. This innovative treatment is very promising and may significantly increase quality of care for patients with recalcitrant orthopedic wounds. A randomized, placebo-controlled double blind trial is required to further determine the efficacy of APC plus TNP.