Free-flap breast reconstruction on experimental porcine model.

INTRODUCTION: Free flaps require mastering microsurgical technique. In addition, breast reconstruction implies accuracy not only in flap survival, but also satisfying aesthetic outcome. Thus, such complex abilities can be acquired by creating experimental models for surgical training. MATERIALS AND METHODS: In accordance with relevant anatomy data found in literature, we chose a porcine model and performed a flap similar to the human deep inferior epigastric perforator (DIEP). Furthermore we developed a surgical protocol for a free flap transfer similar to a double-pedicle DIEP flap. The adipo-cutaneous flap was harvested as a free flap based on the superior abdominal vascularization and microsurgical anastomoses were performed to both the internal thoracic and thoracodorsal vessels. RESULTS: We were able to harvest a superior epigastric double-perforator free flap with increased similarity to the human DIEP flap. Microsurgical anastomoses were possible to both to the internal thoracic vessels and thoracodorsal vessels, which both proved to have optimal caliber for termino-terminal anastomosis. CONCLUSION: Although there are several differences when comparing a swine experimental model with human anatomy, our protocol enhances the possibilities for training in breast reconstruction.

Flap surgical techniques for incisional hernia recurrences. A swine experimental model.

BACKGROUND AND AIM: In the age of synthetic prostheses most of hernia studies include a careful examination of the various types of prosthesis, their characteristics and their repair indications. Biological prostheses are also beginning to draw attention. But in terms of recurrence especially for poor or developing countries, the discussion is different, due to their high cost which makes them difficult to afford. In this article we present new flap reconstruction techniques for the reconstruction of the abdominal wall versus mesh repair, applied on swine models, outline the results of each technique, and specify the indications for their use. METHODS: An experimental protocol using four swine models (PIC-FII-337 hybrid breed pigs), five months old, was conducted. All animal care and operative procedures were studied following the protocol approved by the Ethics Committee of the University of Medicine and Pharmacy resolution no. 281/2014 of the Department of Surgery of the University of Agricultural Sciences and Veterinary Medicine); the study was carried out between November 2015 and February 2016. The primary objective was to compare the effect of surgical strategies in the treatment of the abdominal wall defect using variable flaps versus mesh repair in a large-animal models. Physical examination and ultrasound imaging of the abdominal wall repair were done on determined periods, during one month. The complications occurring after the abdominal wall repair were edema, collections, superficial dehiscence an recurrences. RESULTS: No recurrences were reported at one month results, all seromas reported were solved over time by natural drainage. Superficial necrosis appeared in two swine models and superficial dehiscence occurred in one model, the perforator "plus" flap. Mesh infection was detected in the "onlay" swine model. CONCLUSIONS: In terms of recurrences, contaminated abdominal wall defects or other contraindications to the use of prosthetic materials, biological mesh repair or flap surgery are the only surgical options. Based on our findings and considering the high cost reported by the biological meshes use, flap surgery becomes the suitable treatment for such cases, allowing a good reconstruction of the abdominal wall.

Using dynamic infrared thermography to optimize color Doppler ultrasound mapping of cutaneous perforators.

AIMS: The high technical demands associated with perforator flaps demand a precise preoperative identification and evaluation of perforator vessels. Color Doppler Ultrasonography (CDU) and Dynamic Infrared Thermography (DIRT) are currently used for preoperative perforator mapping. Each individual technique has advantages and disadvantages. The purpose of this paper is to analyze the value of combining the two methods in order to optimize the process of preoperative perforator mapping. MATERIAL AND METHODS: CDU and DIRT were used for preoperative perforator mapping in 10 pigs. The results were compared to intraoperative findings. Total number of perforators, localization, and identification of the dominant perforator was analyzed for each method. The examination time was recorded for each procedure. RESULTS: Both methods had a high sensitivity in determining the number and localization of perforators when compared to those identified during surgery. DIRT produced a higher number of false positive results. CDU accurately identified the emergence of the perforators in the fascia in all cases. Both methods correctly identified the dominant perforator. The sensitivity, positive predictive value, and accuracy of CDU were 93.56%, 97%, and 91.30% respectively and for DIRT 95.05%, 80.67%, and 77.41% respectively. The average examination was 39.76 minutes for CDU and 10.24 minutes for DIRT. The average time taken into account for the analysis of a single perforator in order to confirm DIRT findings was 1.83 minutes. CONCLUSIONS: Preoperative perforator mapping has become a compulsory step in nearly all reconstructive procedures. In our study, both CDU and DIRT correctly identified the dominant perforator in all cases. By combining the two examinations overall mapping time can be reduced significantly. A reduced examination time translates into increased patient compliance and a lower procedure cost. The combined mapping technique facilitates the selection of the ideal perforator in all cases. Correctly identifying the dominant perforator preoperatively reduces operative time, lowers complication rates and ensures an overall better result.

Dynamic perfusion assessment during perforator flap surgery: an up-to-date.

Flap monitoring technology has progressed alongside flap design. The highly variable vascular anatomy and the complexity associated with modern perforator flaps demands dynamic, real-time, intraoperative information about the vessel location, perfusion patterns and flap physiology. Although most surgeons still assess flap perfusion and viability based solely on clinical experience, studies have shown that results may be highly variable and often misleading. Poor judgment of intraoperative perfusion leads to major complications. Employing dynamic perfusion imaging during flap reconstruction has led to a reduced complication rate, lower morbidity, shorter hospital stay, and an overall better result. With the emergence of multiple systems capable of intraoperative flap evaluation, the purpose of this article is to review the two systems that have been widely accepted and are currently used by plastic surgeons: Indocyanine green angiography (ICGA) and dynamic infrared thermography (DIRT).

Perforator flaps in hand reconstruction: the effect of blood vessel twisting.

BACKGROUND AND AIMS: Perforator flaps increasingly find acceptance and use in hand reconstructive surgery. A propeller flap is an island flap that moves from one orientation to another by rotating around its vascular pedicle. It is now possible to design propeller flaps based on a single perforator, so-called "perforator-based propeller flaps," but they are more prone to vascular impairment when twisted more than 90°. METHODS: We present a prospective study conducted in the Plastic and Reconstructive Surgery Department of the Rehabilitation Hospital over 17 months. All perforator-based propeller flaps that were used for hand reconstruction were analyzed. The parameters studied included the size and location of the defect, the size and shape of the flap, the perforator (length and location) that was used, the degree of twisting of the perforator, the degree of perforator dissection, the management of the donor site, and flap survival area. RESULTS: In this study we investigated the circulatory impairment induced by twisting of the pedicle on a true perforator flap. All flaps survived completely with the exception of partial skin necrosis in few cases. Some of these cases required debridement and skin grafting. CONCLUSIONS: Perforator-based propeller flaps provide a reliable option for covering small- to medium-size hand complex tissue defects. They have the advantages of using similar tissues in reconstruction, not damaging another area, they do not require main vessels sacrifice, and the donor site can be generally directly closed.

Modified Brunelli pull-out technique in flexor tendon repair for zone II: a study on 58 cases.

BACKGROUND: The reconstruction of the continuity of flexor tendons disruptions in zone II still remains one of the most challenging problems in hand surgery. The ideal repair has to provide sufficient strength and the possibility of early mobilization in the attempt to obtain a functional range of motion. One of the methods which appears to respond to these requests is the pull-out technique described by Brunelli, which moves the tension from the level of the tendon disruption to the finger pulp over the tendon insertion. METHODS: After using this method, but by doing some modifications of the original technique, our aim was to conduct a retrospective study looking at gap formation, suture strength, rupture rate, efficiency of the two-strand suture repair and of the early active mobilization against resistance in obtaining a good range of flexion rate. We reviewed a series of 71 flexor digitorum profundus disruptions in zone II, in 58 patients admitted in our service between 2000 and 2008, and treated with this method. RESULTS: We achieved a complete range of flexion in 41 fingers (57.7%) and a flexion deficit of 5-10° in eight fingers (11.3%) and of 10-20° in 22 fingers (31%). We had no ruptures, major strength deficit, or bowstringing. CONCLUSIONS: Our study demonstrates that, by moving the tension from the level of disruption to the finger pulp, the rehabilitation program can begin very early post surgery. We had 0% ruptures.

Harvesting of forearm perforator flaps based on intraoperative vascular exploration: clinical experiences and literature review.

The use of perforator flaps all over the body, as free microsurgical transfers, as well as pedicled or transposition flaps gained more and more importance in the surgery of tissue defects. When we consider harvesting such flaps at trunk level, in repeatedly traumatized areas, after previous surgery or when we plan to use the perforator flap as a free flap, it is very important to perform preoperative investigations aimed to precisely localize the perforator or perforators able to sustain such a flap. But, at limb level and, especially, at forearm level, the preoperative investigations cannot always have a complete justification. After a short review of the main preoperative investigations used in flap surgery and considering our color Doppler study, we will present in this article our technique of performing such flaps in the forearm, without any preoperative perforator vessel detection.

Microsurgical nonmicrovascular flaps in forearm and hand reconstruction.

Relatively new method in flap's surgery, perforator flaps tends to monopolize nowadays the surgeon's interest. The question is: could these flaps be used not only as free flaps, as were mainly used until now, but also as local or regional flaps? On the basis of our experience with 115 operated cases, we will try to demonstrate that a lot of simple or composite defects in the forearm and hand could be covered, in selected cases, by using local or regional perforator flaps. This may have as result, in the future, a dramatic decrease in the indication for free flap transfers. Because these flaps need a microsurgical dissection, but do not need microvascular sutures, they could be defined as "microsurgical nonmicrovascular flaps." The main advantages of these flaps could be summarized as: no microsurgical sutures, no main vascular pedicles sacrifice, same surgical field, shorter hospitalization time.