Facial Allograft Donation: An Interpretative Phenomenological Analysis of the Experiences of Family Members.

Facial allograft transplantation can be regarded as a particular and complex type of donation because of its perceptibility and the importance of the face as an identity characteristic. As research on this topic is currently lacking, the objective of this study is to explore the experiences of the family members of the donor in facial allograft donation. In-depth, semi-structured interviews were conducted separately with the donor's family members and analyzed using interpretative phenomenological analysis. Six themes were identified: (1) Contrasting facial donation to that of more commonly donated organs; (2) Consenting to facial donation; (3) Expectations towards the recipient of the facial graft; (4) Expectations and consequences of restoration of the donor's face; (5) Relationship with the medical team during the process; and (6) Media attention. The findings of our study help to better support donor families through the facial donation process and to improve facial transplantation procedures.

The Lumbar Artery Perforator Flap in Breast Reconstruction.

SUMMARY: The lumbar artery perforator flap is a valuable alternative in breast reconstruction whenever the deep inferior epigastric perforator flap is not feasible because of insufficient or unavailable abdominal tissue. The advantage is the ideal shape and consistency of the flap, in addition to the option to perform a nerve anastomosis with the cluneal nerve. The anatomy is consistent, but there are some technical issues related to the short perforator and difficult surgical exposure in the lower back region. The inclusion of a vascular interposition graft improved the authors' results and facilitated their technical challenges and final inset of the flap. These videos guide the surgeon through the different steps involved in a breast reconstruction with the lumbar artery perforator flap.

The Prepectoral, Hybrid Breast Reconstruction: The Synergy of Lipofilling and Breast Implants.

Breast reconstruction modalities are based on autologous tissue transfer, implants, or a combination of both. The aim of an allogeneic breast reconstruction is to minimize the impact of the implant on surrounding tissues to achieve an aesthetically pleasing result. Accurate tissue coverage, proper implant selection, and implant location are the absolute concerns in planning an implant-based reconstruction. METHODS: A single surgeon's experience with the ergonomic, hybrid approach in primary and secondary breast reconstructions is presented. The hybrid approach is based on tissue expansion followed by serial sessions of fat grafting to augment the residual autologous (subcutaneous) compartment. The last step included the insertion of a prepectoral, ergonomic implant to obtain central core projection and additional volume. RESULTS: Fifty-six hybrid breast reconstructions were performed with a mean follow-up of 24.1 months. Aesthetic outcomes and patient satisfaction have been good with pleasing breast projection, natural breast motion, and optimal coverage of the prepectoral implants. CONCLUSIONS: The hybrid reconstructive approach is a reliable technique to improve the outcomes in implant-based breast reconstructions. The 2-step, prepectoral approach with expander-to-implant exchange allows better control of the final breast shape, and complications related to submuscular approaches are avoided. Fat grafting adds an autologous benefit to obtain natural results.

Breast levonorgestrel concentrations in women using a levonorgestrel-releasing intrauterine system.

OBJECTIVE: To measure breast tissue and serum LNG concentrations in women using a LNG-IUS. STUDY DESIGN: This pilot study was performed in 25 healthy women undergoing breast surgery at the Ghent University hospital. LNG concentrations were measured in serum and microdissected breast tissue samples using a validated ultra-performance liquid chromatography/tandem mass spectrometry assay. RESULT(S): The mean LNG concentration in the 18 LNG-IUS users was 0.18±0.16 ng/mL in serum and 0.26±0.28 ng/g in breast tissue. For four women without any form of hormonal contraceptive (the negative controls), the mean concentrations were below the limit of quantification, i.e., 0.15 ng/mL and 0.20 ng/g, for serum and breast tissue, respectively. For the three positive controls the concentrations in the serum (20.5 and 3.4 ng/ml) and the breast (3.74 and 1.24 ng/g) were respectively for the 20 µg EE/100 µg users and 315 pg/ml in the serum and 1.17 ng/g in the breast for the minipill user. The intracellular free fraction of LNG may be as low as 0.008 ng/g. CONCLUSION(S): The concentration of LNG in breast epithelium cells in women using the LNG-IUS is very low. IMPLICATIONS: The relationship between the serum and breast tissue levels of LNG was studied in women using a LNG-IUS or oral LNG-containing contraception. Compared to oral contraception, the tissue levels of LNG in LNG-IUS users are much lower in the breast. It is not known what level of LNG exposure in the breast would stimulate RANKL and WNT4 expression; such information is needed.

Aging of the Upper Lip: Part II. Evidence-Based Rejuvenation of the Upper Lip-A Review of 500 Consecutive Cases.

BACKGROUND: Findings from photometric analysis of soft tissue on cranial magnetic resonance imaging demonstrate that the aging upper lip shows significant lengthening, thinning, volume loss, and deepening of the nasolabial folds. In this study, these findings are implemented in a review of 500 cases of upper lip rejuvenation to propose an evidence-based strategy for surgical rejuvenation of the upper lip. METHODS: The charts of 500 consecutive surgical perioral rejuvenation patients treated by the senior authors (P.L.T. and A.M.V.) from 2014 until 2018 were reviewed. The surgical methods of lip lift and fat grafting were described in relation to the cases and the metric data. RESULTS: Of the 500 patients, 51 had an isolated procedure such as a lip lift (3 percent), lip augmentation (3 percent), augmentation of the nasolabial folds (2 percent), or skin resurfacing (2 percent). The remaining 449 patients underwent combinations of lip lift, augmentation of the lip and nasolabial fold (32 percent), lip lift with augmentation of the lip and nasolabial fold with resurfacing (30 percent), lip augmentation and resurfacing (14 percent), or lip lift and resurfacing (14 percent). CONCLUSIONS: Rejuvenating the upper lip needs to address both lengthening and volume loss. This requires a combination of surgical shortening of the upper lip by a precisely designed lip lift and a differential filling of certain upper lip regions by microfat grafting. The combination of these two modalities works synergistically. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facing a New Face: An Interpretative Phenomenological Analysis of the Experiences of a Blind Face Transplant Patient and His Partner.

Increasing evidence points to good functional, aesthetic, and psychosocial outcomes after face transplantation. However, research investigating how patients and their families subjectively experience the transplantation process is lacking thus far. This study aims to investigate the personal experiences of a blind face transplant patient and his partner. In-depth interviews exploring different experiences were conducted with both partners separately 20 months after face transplantation. The interviews were analyzed using interpretative phenomenological analysis. Seven themes were identified in both interviews: coping with the facial trauma, motivation for the face transplantation, outcomes of the face transplantation, acceptance of the new face, gratitude toward the donor family, relation to the medical team, and dealing with the media. Two further themes were only mentioned by the patient (coping with complications and coping with blindness) and one theme only by the partner (loss of choices). The results of this study increase our understanding of the transplantation process as experienced by a face transplant recipient and his partner. They may help to better inform professionals to optimize transplantation procedures or supportive interventions.

Lumbar artery perforators: an anatomical study based on computed tomographic angiography imaging.

BACKGROUND: The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted. METHODS: An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid. RESULTS: Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7-10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm). CONCLUSION: This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

Intratissular expansion-mediated, serial fat grafting: A step-by-step working algorithm to achieve 3D biological harmony in autologous breast reconstruction.

BACKGROUND: Breast reconstruction involves the use of autologous tissues or implants. Occasionally, microsurgical reconstruction is not an option because of insufficient donor tissues. Fat grafting has become increasingly popular in breast surgery. The challenge with this technique is how to reconstruct a stable and living "scaffold" that resembles a breast. METHODS: Breast reconstruction (n = 7) was performed using intratissular expansion with serial deflation-lipofilling sessions. Mean age of the patients was 41 years (22-53). The expander generated a vascularized capsule at 8 weeks, which demarcated a recipient site between the skin and the capsule itself, and functioned as a vascular source for angiogenesis. Serial sessions of deflation and lipofilling were initiated at 8 weeks with removal of the expander at the completion of the treatment. An average of 644 ml (range, 415 ml-950 ml) of lipoaspirate material was injected to reconstruct the breast mound. An average of 4 (range, 3 to 5) fat-grafting sessions with a 3-month interval was needed to achieve symmetry with the contralateral breast. The average follow-up was 14 months (range, 9-29 months). MRI examination was performed at 8 months to analyze tissue survival and the residual volume. RESULTS: MRI examination retained tissue survival and the mean reconstructed breast volume was 386 ml (range, 231 ml-557 ml). An aesthetically pleasant breast mound was created, with a high satisfaction rate. CONCLUSION: We could reconstruct an aesthetically pleasant and stable breast mound in a selected group of patients by using intratissular expansion and fat grafting.

Bipedicled DIEAP flaps for reconstruction of limb soft tissue defects in male patients.

BACKGROUND: Extensive soft tissue deficiencies involving the limbs can be difficult to reconstruct and may require more than one microsurgical flap transfer to cover the defect. This can be particularly challenging in male patients, where the sacrifice of a donor muscle could result in considerable comorbidity. This paper describes the use of the bipedicled deep inferior epigastric artery perforator (DIEAP) flap to perform a one-stage reconstruction of extensive soft tissue defects in male patients. METHODS: By using preoperative multidetector computed tomographic (MDCT) angiography, the dominant perforators of the abdominal wall were identified and the bipedicled DIEAP flap was used for a one-stage reconstruction of complicated tissue loss in 12 male patients. In seven of these flaps, a microsurgical anastomosis between the two epigastric pedicles of the DIEAP flap was carried out. The feasibility of the procedure, clinical outcome, and possible associated comorbidities were evaluated. RESULTS: Successful large tissue reconstructions were performed using all four traditional zones of the DIEAP flap, with dimensions of flaps ranging from 20 × 8 to 50 × 17 cm. Venous congestion was seen to develop in two flaps, one of which was salvaged by performing an additional venous anastomosis, but the other flap failed to survive. Apart from this, complications were minimal. CONCLUSIONS: Soft tissue coverage of extensive wounds in male patients without sacrificing muscle flaps can be challenging. This extended utilization of the entire DIEAP flap has helped us to address this issue.

DIEAP flap for safe definitive autologous breast reconstruction.

BACKGROUND: Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. METHODS: 1036 DIEAP flap breast reconstructions carried out at the University Hospital, Gent (five year period) and at the Sana Kliniken, Düsseldorf (three year period) were included prospectively. Comorbid factors like chemotherapy, radiotherapy, patient age >65 years, BMI >30 and smoking were recorded. Outcomes were evaluated over a mean follow up of 2 years. RESULTS: Overall complication rate related to the reconstructed breast and donor abdominal area was 6.8 percent. Total flap loss was seen in only 0.8 percent. The mean operating time was less than five hours. Older age, higher BMI, chemotherapy and radiotherapy did not have a significant influence on complication rates, however smoking resulted in significant delay in wound healing in the breast (p = 0.025) and abdominal wounds (p = 0.019). CONCLUSION: The DIEAP flap is an excellent option for breast reconstruction, with a low level of donor site morbidity and complications. It is an autologous reconstruction that provides a stable long term result.

Long-Term Multifunctional Outcome and Risks of Face Vascularized Composite Allotransplantation.

Vascularized composite allotransplantation (VCA) to reconstruct complex centrally located facial defects and to restore vital functions in a 1-staged procedure has worldwide gained acceptance. Continuous long-term multidisciplinary follow-up of face transplant patients is mandatory for surveillance of the complications associated with the immunosuppressive regime and for functional assessment of the graft. In December 2011, our multidisciplinary team performed a digitally planned face transplant at the Ghent University Hospital, Belgium on a 55-year-old man with a large central facial defect after a high-energy ballistic injury. The patient was closely followed to assess functional recovery, immunosuppressive complications, overall well-being, and quality of life. Three years postoperatively, the patient and his family are very satisfied with the overall outcome, and social reintegration in the community is successful. Motor and sensory functions have recovered near normal. Infectious and medical complications have been serious but successfully managed. Immunosuppressive maintenance therapy consists of corticoids, tacrolimus, and mycophenolate mofetil in minimal doses. Epithetic reconstruction of both eyes gave a tremendous improvement on the overall aesthetic outcome. Despite serious complications during the first 12 months, multifunctional outcome in the first face transplant in Belgium (#19 worldwide) is successful. This should be attributed to the continuous and long-term multidisciplinary team approach. As only few reports of other face transplant patients on long-term follow-up are available, more data need to be collected and reported to further outweigh the risk benefit ratio of this life changing surgery.

Facial transplantation in a blind patient: psychologic, marital, and family outcomes at 15 months follow-up.

BACKGROUND: Quality of life has frequently been reported to improve after vascularized composite allotransplantation of the face. However, psychosocial functioning of the partner or of particular patient groups such as blind patients are until now less well investigated. OBJECTIVE: The aim of this study is to investigate psychologic, marital, and family functioning of a blind 54-year-old patient, Mr. A, and his partner after facial transplantation. METHODS: Depressive and anxiety symptoms, hopelessness, personality, coping, resilience, illness cognitions, marital support, dyadic adjustment, family functioning, and quality of life of Mr. A and his partner were assessed before and after facial transplantation and at 15 months follow-up. Reliable change index (RCI) was further calculated to evaluate the magnitude of change. RESULTS: Most psychologic, marital, and family scores of both Mr. A and his partner were within a normative and healthy range before and after transplant and at 15 months follow-up. Resilience (RCI: 3.6), affective responsiveness (RCI: -3.6), and disease benefits (RCI: 2.6) of Mr. A further improved at 15 months follow-up whereas the physical quality of life (RCI: -14.8) strongly decreased. Only marital support (RCI: -2.1) and depth (RCI: -2.0) of the partner decreased at 15 months. CONCLUSIONS: The results of this study point to positive psychosocial outcomes in a blind patient after facial transplantation. Further, they may underscore the importance of good psychosocial functioning before transplantation of both partners and of their involvement in psychologic and psychiatric treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Early experience with the free lumbar artery perforator flap for breast reconstruction.

BACKGROUND: Autologous breast reconstruction has become a progressively more popular method of breast reconstruction. A wide variety of perforator flaps have been described and subsequently refined to decrease donor-site morbidity. Recently, the lumbar artery perforator (LAP) flap has been reported as an option for autologous breast reconstruction. METHODS: This study summarises the prospectively gathered data of 35 free LAP flaps for breast reconstruction in 28 patients. The mean follow-up was 18 months. RESULTS: The internal mammary artery and the venae comitantes were used as recipient vessels in all reconstructions. In 80% of the reconstructions (28 flaps), an interposition graft was used. Six flaps (17%) had to be revised for venous thrombosis. Two of the revised flaps (5.7%) could not be salvaged, and total flap necrosis occurred. The mean operating time was 6 h and 15 min, 6 h and 39 min when an interposition graft was used and 5 h and 23 min when no interposition graft was necessary. CONCLUSION: The LAP flap should be considered as a further alternative for breast reconstruction in patients in whom a deep inferior epigastric artery perforator (DIEAP) flap is not possible or not desirable. Shaping of this flap is easier compared to any other flaps due to the quality of the lumbar fat and the gluteal extension. An interposition graft is frequently used to facilitate anastomosis, either to lengthen the pedicle or to resolve size mismatch. This is a disadvantage of the LAP flap.

Complex facial reconstruction by vascularized composite allotransplantation: the first Belgian case.

INTRODUCTION: Complex injuries to the central part of the face are difficult to reconstruct with the current plastic surgery methods. The ultimate one-staged approach to restore anatomy and vital facial functions is to perform a vascularized composite allotransplantation (VCA). METHODS: A 54-year-old man suffered from a high-energy ballistic injury, resulting in a large central facial defect. A temporary reconstruction was performed with a free plicated anterolateral thigh (ALT) flap. Considering the goal to optimally restore facial function and aesthetics, VCA was considered as an option for facial reconstruction. A multidisciplinary team approach, digital planning, and cadaver sessions preceded the transplantation. RESULTS: A digitally planned facial VCA was performed involving the bilateral maxillae, the hard palate, a part of the left mandible, and the soft tissues of the lower two-thirds of the face. Due to meticulous preparations, minimal adjustments were necessary to achieve good fitting in the recipient. At week 17, a grade 4 rejection was successfully treated; sensory and motor recovery was noted to occur from the fourth postoperative month. Several serious infectious and medical problems have occurred until 15-months postoperatively; following that, the clinical situation has remained stable. Two years postoperatively, the patient and his family are very satisfied with the overall outcome and social reintegration in the community is successful. CONCLUSION: The first face transplant in Belgium (#19 worldwide) was successful because of a meticulous 3-year preparation by a large multidisciplinary team. In our experience, preparatory cadaver dissections and three-dimensional (3D) computed tomographic (CT) modeling were valuable tools for an optimal intraoperative course and good alignment of the bony structures. Continuous long-term multidisciplinary follow-up is mandatory for surveillance of the complications associated with the immunosuppressive regime and for functional assessment of the graft.

Evaluation of a new skin closure device in surgical incisions associated with breast procedures.

BACKGROUND: A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner. To determine its clinical utility in breast procedures, a prospective clinical investigation was undertaken to demonstrate equivalence of a new adhesive (PRINEO™ Skin Closure System) to intradermal sutures in wound closure. METHODS: The investigation comprised 79 patients who underwent elective surgery for bilateral breast procedures. Each breast incision was randomized to wound closure with the PRINEO™ Skin Closure System or intradermal sutures (used in accordance with standard local practice). Postoperative evaluations took place at 24 hours, 7 days, 12-25 days, 90 days, 6 months, and 12 months. Data were collected on the continuous approximation of the skin edges, the time required to close the include final skin layer, the evaluation of incision healing, and cosmesis outcomes. Safety evaluations were related to the incidence and extent of local acute inflammatory reactions, clinical infection, skin blistering, and adverse events. RESULTS: PRINEO™ Skin Closure System was found to be equivalent to intradermal sutures for the continuous approximation of wounds associated with breast procedures. The upper limit of the one-sided 95% confidence interval for difference in proportions was less than the predetermined 12%, at 5.9%. The mean time to closure for the PRINEO™ Skin Closure System was 2.56 minutes, which was 13.66 minutes faster than that for intradermal sutures (16.22 minutes, P < 0.0001). Time savings may be less if 2 operators close simultaneously. On the other hand, because the device can be applied by 1 operator, the assistant's time may be freed up to attend to other tasks. Both treatments had similar incision healing and cosmetic outcomes. No quantitative or qualitative differences of clinical significance were evident between the treatment groups for local acute inflammatory reactions, clinical infection, or skin blistering. The number of serious adverse events was low, although the number of adverse events was higher, with 54/79 patients experiencing at least 1 adverse event. CONCLUSION: PRINEO™ Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions associated with breast procedures, with regard to safety and effectiveness. It was also 6.3 times faster than intradermal sutures for wound closure.

A comparison of a new skin closure device and intradermal sutures in the closure of full-thickness surgical incisions.

BACKGROUND: A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner. To determine its clinical utility, a clinical investigation was undertaken to demonstrate equivalence of a new adhesive skin closure system (Prineo Skin Closure System) to intradermal sutures in wound closure. METHODS: The investigation included 83 patients who underwent elective abdominoplasty, circumferential body lift procedures, and breast reconstruction with deep inferior epigastric perforator flaps. Incisions were divided in half, and each half was randomized to wound closure with the new skin closure system, including a pressure-sensitive adhesive mesh tape for wound edge approximation and next-generation cyanoacrylate or intradermal sutures. Postoperative evaluations took place at 24 hours, 7 days, 12 to 25 days, 90 days, 6 months, and 12 months. RESULTS: The new skin closure system was found to be equivalent to intradermal sutures for the continuous approximation of wounds. The upper limit of the two-sided 90 percent confidence interval for difference in proportions was 10.9 percent. The mean time to closure for the new skin closure system was 1.46 minutes, approximately 5 minutes faster than that for intradermal sutures (p < 0.0001). Both treatments had similar incision healing and cosmetic outcomes. No quantitative or qualitative differences of clinical significance were evident between the treatment groups. CONCLUSIONS: The Prineo Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions with regard to safety and effectiveness. The ease and speed of application contribute to shortened operative times (4.5 times faster than intradermal sutures).

Technical recommendations for penile replantation based on lessons learned from penile reconstruction.

Penile amputation is an exceptional surgical emergency. Immediate replantation yields a high success and low complication rate. We report a case of a self-inflicted penile amputation treated with successful microsurgical replantation. Postoperative edema caused minor skin slough and temporary venous congestion was treated with medicinal leech therapy. Follow-up at 18 months showed normal subjective sensation; voiding and erectile function were present. Surgical management and technique refinements are discussed, based on a review of the literature and on our experience in penile reconstruction.