Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

BACKGROUND: Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. METHODS: Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. RESULTS: Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. CONCLUSION: In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Impact of COVID-19 pandemic on hand injuries.

BACKGROUND: The aim of the study was to evaluate etiologies of hand injuries in emergency department (ED), to compare the etiologies of hand injuries at the time of this study with the previous year, to assess whether novel coronavirus-2019 (COVID-19) pandemic affected the treatment decisions, and to investigate the COVID-19 infection rate within the first 14 days after admission. METHODS: A total of 229 patients admitted to ED with hand injury between March 15 and April 30, 2020, were included in the study. The control group consisted of 439 ED admissions with hand injury in the previous year (March 15-April 30, 2019). Data including age, sex, cause of trauma, treatment, and COVID-19 infection status within 14 days after ED admission were compared between groups. RESULTS: The mean age was 32.30±15.63 years in the study group and 30.85±18.54 years in the control group. The number of patients consulted to the surgery department decreased by 52.6% and the number of patients admitted to ED with hand injuries de-creased by 47.6% during the pandemic, compared to the previous year (p=0.0001). The incidence of home accidents increased and the glass cuts and penetrating/perforating injuries were the most common causes during the pandemic most of which occurred at home. CONCLUSION: The COVID-19 pandemic-mandated social restrictions led to a significant decrease in the number of ED admissions with hand injuries and the type of injuries. The incidence of home accidents increased with more time spent indoors. This study may be a useful guide for ED admissions of hand injury cases and management planning in the current and future pandemics.

The Efficacy of Hydrodilatation for the Prevention of Vasospasm following Microsurgical Anastomosis.

BACKGROUND: Vasospasm is a major problem following microsurgical reconstruction which can result in the partial or complete loss of the flap tissue. The aim of this study was to investigate the efficiency of hydrodilatation for the prevention of vasospasm. METHODS: Thirty male Wistar rats were used for this experimental study. Femoral arteries of were exposed, photographed, and transected. In group 1, group 2, and group 3 papaverine solution, hydrodilatation, and minimal mechanical dilatation (control group) was performed, respectively. The anastomosis was completed and the arteries were photographed again 10 minutes after completion of the anastomosis. Following 7-day period samples for transmission electron microscopy (TEM) and light microscopy were obtained. RESULTS: The mean vessel diameters prior to transection were 0.43, 0.45, and 0.52 mm in the papaverine, hydrodilatation, and control groups, respectively. The mean vessel diameter 10 minutes following the completion of anastomosis was 0.76, 0.75, and 0.51 mm in the papaverine, hydrodilatation, and control groups, respectively. Median score for papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 2, 3, 2, and 3 positive, respectively. Median score for the papaverine group regarding histological parameters of regular endothelial lining and lumen, neutrophil infiltration, vascular congestion, and edema in tunica adventitia was 3, 3, 3, and 3 positive, respectively. All the histological scores were negative in the control group. The difference between the control group and the experiment groups 1 and 2 was significant regarding all four histological parameters (p < 0.05). CONCLUSION: Hydrodilatation and papaverine application were both effective in preventing vasospasm following microsurgical intervention but papaverine caused slightly less damage to the endothelial lining and less edema in the tunica adventitia when compared with the hydrodilatation. Hydrodilatation group showed a vasodilatory effect that was statistically similar to that of papaverine, which has a proven efficacy.

The Role of Extracellular Vesicles Secreted From Thermal Stress-Induced Adipose-Derived Stem Cells on Bone Regeneration.

PURPOSE: Extracellular vesicles (EVs) are responsible for intercellular communication. Mesenchymal stem cell-derived vesicles have been shown to have similar properties as functional mesenchymal stem cells. The aim of this study was to compare the therapeutic benefit of EVs obtained from adipose tissue-derived stem cells (ADSC) on bone repair whereas using ß-tricalcium phosphate (ß-TCP) biomaterial as a carrier. MATERIALS AND METHOD: A single critical size bone defect of 8 mm in diameter was created on the right side of rat calvarium using a custom-made punch needle. Animals were randomly divided into 5 groups: group 1 (no treatment), group 2 (bone graft), group 3 (ß-TCP + ADSC), group 4 (ß-TCP + EV), group 5 (ß-TCP). Eight weeks later, animals were sacrificed and histologic and radiologic evaluation was performed. RESULTS: Semiquantitative histologic scoring demonstrated significantly higher bone regeneration scores for groups 2, 3, and 4 compared to group 1. Radiologic imaging showed significantly higher bone mineral density for groups 2, 3, and 5 compared to group 1. There were no significant differences between treatment groups in either histologic or radiologic scoring. CONCLUSIONS: Our data showed that EVs provided from thermally induced ADSCs did not show any significant difference in bone regeneration when compared to ADSCs themselves. Future studies should focus on determining the optimum amount and content of EV application since these vary significantly depending on the microenvironment.

Long-term BTX-A effects on bi-articular muscle: Higher passive force, limited length range of active force production and unchanged intermuscular interactions.

Botulinum toxin type-A (BTX-A) is commonly used for spasticity management aiming at reducing joint stiffness and increasing joint range of motion in CP patients. However, previous animal studies showed acutely increased passive forces and a narrowerlength range of active force exertion (lrange) for muscles exposed. BTX-A can spread affecting mechanics of several muscles in a compartment, but it was shown acutely to diminishepimuscular myofascial force transmission (EMFT). Yet, our understanding of these effects in the long-term is limited and they need to be tested in a bi-articular muscle. The goal was to test the following hypotheses in a long-term rat model: exposure to BTX-A (i) has no effects onlrangeand passive forces of bi-articular extensor digitorum longus (EDL) muscle and (ii) diminishes EMFT. Male Wistar rats were divided into two groups: BTX-A and control (0.1 units of BTX-A or only saline was injected into the tibialis anterior). Isometric proximal and distal EDL forces were measured simultaneously, one-month post-injection. Proximally and distally lengthening the muscle showed that BTX-A causes a significantly narrowerlrange(by 14.7% distally and 32.2% proximally) and significantly increased passive muscle forces (over 2-fold both distally and proximally). Altering muscle position at constant length showed that BTX-A does not change EMFT. The findings reject both hypotheses showing that long-term exposure to BTX-A compromises bi-articular muscle's contribution to motion for both joints and the muscle's mechanical interaction with the surroundings remains unaffected. These effects which may compromise long-term spasticity management should be studied in CP patients.

Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review.

BACKGROUND: The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario. METHODS: A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019. RESULTS: The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting. CONCLUSIONS: In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Long-Term Effects With Potential Clinical Importance of Botulinum Toxin Type-A on Mechanics of Muscles Exposed.

Botulinum toxin type-A (BTX-A) is widely used for spasticity management and mechanically aims at reducing passive resistance at the joint and widening joint range of movement. However, recent experiments on acute BTX-A effects showed that the injected rat tibialis anterior (TA) muscle's passive forces increased, and the length range of active force exertion (l range) did not change. Additionally, BTX-A was shown to spread into non-injected muscles in the compartment and affect their mechanics. Whether those effects persist in the long term is highly important, but unknown. The aim was to test the following hypotheses with experiments conducted in the anterior crural compartment of the rat: In the long term, BTX-A (1) maintains l range, (2) increases passive forces of the injected TA muscle, and (3) spreads into non-injected extensor digitorum longus (EDL) and the extensor hallucis longus (EHL) muscles, also affecting their active and passive forces. Male Wistar rats were divided into two groups: BTX-A and Control (0.1 units of BTX-A or only saline was injected into the TA). Isometric forces of the muscles were measured simultaneously 1-month post-injection. The targeted TA was lengthened, whereas the non-targeted EDL and EHL were kept at constant length. Hydroxyproline analysis was done to quantify changes in the collagen content of studied muscles. Two-way ANOVA test (for muscle forces, factors: TA length and animal group) and unpaired t or Mann-Whitney U test (for l range and collagen content, where appropriate) were used for statistical analyses (P < 0.05). BTX-A caused significant effects. TA: active forces decreased (maximally by 75.2% at short and minimally by 48.3%, at long muscle lengths), l range decreased (by 22.9%), passive forces increased (by 12.3%), and collagen content increased (approximately threefold). EDL and EHL: active forces decreased (up to 66.8%), passive force increased (minimally by 62.5%), and collagen content increased (approximately twofold). Therefore, hypothesis 1 was rejected and 2 and 3 were confirmed indicating that previously reported acute BTX-A effects persist and advance in the long term. A narrower l range and an elevated passive resistance of the targeted muscle are unintended mechanical effects, whereas spread of BTX-A into other compartmental muscles indicates the presence of uncontrolled mechanical effects.

Evaluation of Sensation on Mastectomy Skin Flaps following Immediate Breast Reconstruction.

BACKGROUND: During a subcutaneous mastectomy, nerves are severed and patients lose sensation on the breast skin. The aim of this study is to investigate factors that have impact on the sensation of the mastectomy flaps and patients' own perception regarding overall breast skin sensation. PATIENTS AND METHODS: Patients who have undergone skin sparing or nipple sparing mastectomy with immediate reconstruction with either an implant or autologous tissue were included. Sensory assessment was performed at least 12 months after surgery using Semmes-Weinstein monofilaments (Aesthesio, San Jose, CA). The breast envelope was divided into four quadrants, and one measurement from each quadrant was recorded. Patients were also asked to fill out a questionnaire before the examination. RESULTS: A total of 59 breasts in 40 women were examined. In lower medial quadrant, significantly more patients reported "no sensation" in the radiated group than the nonradiated group. In upper medial quadrant and lower lateral quadrant, patients with NSM reported better sensation than patients with skin sparing mastectomy (SSM). CONCLUSION: Vascularized tissue did not improve sensory recovery. There was no relationship between sensation and the preoperative cup size and the number of revision surgeries. Irradiation was associated with higher sensory thresholds in lower medial quadrant. Nipple sparing mastectomy was associated with lower sensory thresholds in two quadrants compared to SSM. Independent of all variables none of the patients reported normal sensation.

Anaplastic Large Cell Lymphoma of the Breast Arising in a Burn Cicatrix.

Anaplastic large cell lymphoma (ALCL) is a T cell lymphoma characterized by large anaplastic cells with diffuse and uniform CD30 reactivity. Here, we report a patient with no prior implant history who developed anaplastic lymphoma kinase-1-negative ALCL within a burn cicatrix on a breast. We hypothesize that the chronic inflammation caused by burn injury and the patient's history of immunosuppression secondary to organ transplantation may have contributed to development of ALCL in this patient. This report supports the essential role of chronic inflammation in the development of ALCL in the breast. Level of Evidence: 5.

A Comparative Clinical Study of Flap Thickness: Medial Sural Artery Perforator Flap Versus Anterolateral Thigh Flap.

INTRODUCTION: The purpose of this study is to measure flap thicknesses of anterolateral thigh (ALT) and medial sural artery perforator (MSAP) flaps in healthy subjects by Doppler ultrasonography and compare the results in relation to sex and body mass index (BMI). METHOD: The perforators of ALT and MSAP flaps were marked on 30 healthy subjects. The thickness of skin and subcutaneous tissue was measured in millimeters at the site of the perforator using Doppler ultrasonography. RESULTS: The mean ± SD age of the participants was 36.4 ± 10.5, the mean ± SD BMI was 25.2 ± 3.9 (19.4-32.5). The mean ± SD flap thickness was 11.55 ± 4.38 mm for ALT and 8.31 ± 3.6 mm mm for MSAP (P < 0.01). Anterolateral thigh flap was significantly thicker than MSAP in both males (9.02 vs 6.11 mm) and females (14.07 vs 10.52 mm) (P < 0.05). The thickness of both MSAP and ALT flap had a positive correlation with BMI. The relationship was stronger for ALT in males (r = 0.66 for ALT, r = 0.59 for MSAP) and for MSAP in females (r = 0.70 for ALT, r = 0.83 for MSAP). DISCUSSION: This study confirms that MSAP flap is thinner than ALT and the results correlate with BMI. Therefore, MSAP flap can be considered a good alternative to ALT, to avoid bulk, in reconstruction of shallower soft tissue defects.

Assessment of Tissue Perfusion Following Conventional Liposuction of Perforator-Based Abdominal Flaps.

BACKGROUND: The effect of liposuction on the perforators of the lower abdominal wall has been investigated in several studies. There are controversial results in the literature that have primarily demonstrated the number and patency of the perforators. The aim of this study was to determine the effect of liposuction on the perfusion of perforator-based abdominal flaps using a combined laser-Doppler spectrophotometer (O2C, Oxygen to See, LEA Medizintechnik). METHODS: Nine female patients undergoing classical abdominoplasty were included in the study. Perforators and the perfusion zones of the deep inferior epigastric artery flap were marked on the patient's abdominal wall. Flap perfusion was quantitatively assessed by measuring blood flow, velocity, capillary oxygen saturation, and relative amount of hemoglobin for each zone preoperatively, after tumescent solution infiltration, following elevation of the flap on a single perforator, and after deep and superficial liposuction, respectively. RESULTS: The measurements taken after elevation of the flap were not significantly different than measurements taken after the liposuction procedures. CONCLUSIONS: The liposuction procedure does not significantly alter the perfusion of perforator-based abdominal flaps in the early period. The abdominal tissue discarded in a classic abdominoplasty operation can be raised as a perforator flap and has been demonstrated to be a unique model for clinical research.