Cook-Swartz Doppler Probe Surveillance for Free Flaps-Defining Pros and Cons.

Introduction The main postoperative complication of free flaps is perfusion compromise. Urgent intervention is critical to increase the chances of flap survival. Invasive flap perfusion monitoring with direct blood flow feedback through the Cook-Swartz Doppler probe could enable earlier detection of perfusion complications. Materials and Methods Between 2012 and 2016, 35 patients underwent breast reconstruction or defect coverage after trauma with a deep inferior epigastric perforator, anterolateral thigh, transverse musculocutaneous gracilis, gracilis, or latissimus dorsi flap in our department. All flaps were monitored with a Cook-Swartz probe for 10 days postoperatively. The 20 MHz probe was placed around the arterial-venous anastomosis. A flap monitoring protocol was established for standardized surveillance of postoperative perfusion. In the event of probe signal loss, immediate surgical revision was initiated. Results Signal loss was detected in 8 of the 35 cases. On return to the operating room, six were found to be true positives (relevant disruption of flap perfusion) and two were false positives (due to Doppler probe displacement). There were also two false negatives, resulting in a slowly progressive partial flap loss. Flap perfusion was restored in three of the six cases (50%) identified by the probe. Following surgical intervention, three of the six cases had persistent problems with perfusion, resulting in two total flap losses and one partial flap necrosis leading to an overall 5.7% total flap loss. Conclusion Postoperative flap perfusion surveillance is a complex matter. Surgical experience is often helpful but not always reliable. The costs, false-positive, and false-negative rates associated with invasive perfusion monitoring with Cook-Swartz probe make it most appropriate for buried flaps. Level of Evidence This is an original work.

Risk Factors for Complications after Skin-Sparing and Nipple-Sparing Mastectomy.

INTRODUCTION: In order to achieve a complication-free breast reconstruction, it is fundamental for each individual patient case to determine preoperatively certain risk factors that might have a negative impact on the postoperative result after skin-sparing (SSM) or nipple-sparing mastectomy (NSM). METHODS: A retrospective study of 39 female breast cancer patients who received SSM or NSM breast reconstruction in our department (time interval: 2010-2015), was performed. The study focus is on determining patient characteristics (e.g., demographics, history of radiotherapy/chemotherapy, menopausal status, amount of resected breast tissue) leading to higher complication rates. RESULTS: Overall, 50 mastectomies (27 SSM and 23 NSM) with 6 immediate and 35 immediate 2-stage tissue expander breast reconstructions amounting to a total of 41 surgical interventions (n = 41) were carried out. Median follow-up time was 2 years and 5 months (range 121-1,863 days). Increased complication rates were associated with the following patient characteristics: age >50 years (p < 0.05) and personal history of cardiovascular disease (p < 0.05). Increased but not significant risk factors included postmenopausal status (p = 0.07), radiotherapy prior to SSM/NSM (p = 0.06), and weight of resected breast tissue >438 g (p = 0.09). CONCLUSION: This work identified age >50 years and personal history of cardiovascular disease to be risk factors for increased complication rates following SSM and NSM. Therefore, the given findings should be taken into account when selecting patients for these 2 procedures.

[Plastic-reconstructive treatment options for burns caused by concrete exposure]. / Plastisch-rekonstruktive Therapieoptionen bei Verätzung nach Betonexposition.

BACKGROUND: In industry as well as in the private sector, cement is often used as building material. Although severe skin injuries are known to be caused due to improper handling of cement, the incidence and severity of these cutaneous injuries are often underestimated. Heavy cement burns are rare but in our centers the authors treat affected patients on a regular basis. The aim of this study is to analyze the given patient data in order to give treatment suggestions. PATIENTS AND METHODS: During 2013 to 2017, a total of 7 patients (median age: 39 years), which had suffered chemical burns after concrete, cement or screed exposure, were treated in two German plastic-surgical clinics. The authors performed a retrospective data analysis by using the hospital information systems (HIS). RESULTS: All patients were treated with surgical interventions. Median inpatient treatment period was 9.8 days (n = 6). The average time for surgery was 1:04 hours (n = 5). During surgical treatment an average of 1.4 operations were performed (n = 7). In all cases a sustained wound healing could be achieved. CONCLUSIONS: If a patient suffers from a concrete burn, a fast and competent initial treatment is imperative in order to prevent worse. The presented patient cases prove the value of these rare but devastating medical conditions. Therefore, it is essential to implement the given treatment recommendations for a sustainable patient care.

Corrigendum to "Evaluation of Complication Rates after Breast Surgery Using Acellular Dermal Matrix: Median Follow-Up of Three Years".

[This corrects the article DOI: 10.1155/2017/1283735.].

Functional Reconstruction with Latissimus Dorsi Flap following Resection of an Extensive Basal Cell Carcinoma in the Shoulder Region: A Case Report.

Large and ulcerating skin tumors have become a rarity in the modern Western world. However, these conditions can cause serious life-threatening complications. The case of a 60-year-old male Caucasian patient is reported, who had suffered from an extensive basal cell carcinoma in the right shoulder region for several years. The patient kept the lesion secret from his friends and family and delayed presentation to health care services. After an episode of tumor-related heavy bleeding, the patient was referred to our clinic and received a radical surgical tumor resection-followed by defect coverage with a latissimus dorsi myocutaneous flap. An alternative treatment option that could be offered to the patient would have been a mutilating surgical procedure with an arm amputation. By using this plastic reconstructive surgical technique, the main function of the shoulder joint was conserved. The presented case demonstrates options for defect coverage of problematic wounds in anatomically complex body regions-like the shoulder-by using a functional reconstruction using myocutaneous flaps.

Trendy Tattoos-Maybe a Serious Health Risk?

BACKGROUND: The literature reports many cases of cutaneous malignancy in the setting of skin tattoos. In this study, we review the reported incidence of and risk factors for tattoo-associated skin cancer. METHODS: A PubMed literature review was performed for all cases of tattoo-associated skin cancer, including squamous cell carcinoma, basal cell carcinoma, malignant melanoma, keratoacanthoma, and other rare skin malignancies (source: PubMed/until June 2017). RESULTS: The authors identified 51 publications and 63 total cases of tattoo-associated skin cancer. We also report on a single new case of tattoo-associated skin cancer observed at one of our co-authors' institutions. Among these 64 total cases, 58% were associated with black and blue inks and 34% were associated with red ink. CONCLUSIONS: Overall, while the strength of association remains unclear, the literature reports many cases of tattoo-associated skin cancer. Among these cases, black, blue, and red inks were particularly worrisome for their carcinogenic potential. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of Complication Rates after Breast Surgery Using Acellular Dermal Matrix: Median Follow-Up of Three Years.

INTRODUCTION: Acellular dermal matrices (ADMs) are now commonly used for breast reconstruction surgery. There are various products available: ADMs derived from human (HADM), porcine (PADM), or bovine (BADM) sources. Detailed long-term follow-up studies are necessary to detect differences in complication rates between these products. MATERIAL AND METHODS: From 2010 to 2015, forty-one patients underwent 52 ADM-breast reconstructions in our clinic, including oncologic breast reconstructions and breast augmentation revisions (n = 52). 15x HADMs (Epiflex®/DIZG), 21x PADMs (Strattice®/LifeCell), and 16x BADMs (Tutomesh®/RTI Surgical) were implanted. Retrospective data collection with median follow-up of 36 months (range: 12-54 months) was performed. RESULTS: Overall complication rate was 17% after ADM implantation (HADM: 7%; PADM: 14%; BADM: 31%). In a composite endpoint of complications and Red Breast Syndrome, a lower event probability was observed between BADMs, PADMs, and HADMs (44%, 19%, and 7%, resp.; p = 0.01 for the trend). Furthermore, capsular contracture occurred in 6%, more frequently as compared to the current literature. CONCLUSIONS: When ADM-based reconstruction is indicated, the authors suggest primarily the use of HADMs and secondary the use of PADMs. It is shown that BADMs have the highest complication probability within our patient cohort; nevertheless, BADMs convey physical advantages in terms of flexibility and better aesthetic outcomes. The indication for the use of ADMs should be filled for each case individually.

Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas.

BACKGROUND: Urogenital fistulas are devastating complications occurring after tumors or trauma. Surgical treatment is challenging. Thus, further surgical repair options are needed for treatment of complex fistulas within the pelvic region. METHODS: Twelve patients with urogenital fistulas were surgically treated in our department from 2004 to 2012. These selected cases fulfilled eligibility criteria for continence-preserving surgery - a history of fistula recurrences with ongoing incontinence after receiving at least two surgical attempts. Five VRAM and eight gracilis flaps were used to cover up given tissue defects and to perform functional continence-preserving reconstruction with mean follow-up of 6.3 years. Data were retrospectively reviewed, and standardized survey was performed to evaluate quality of life of all living patients (n = 10). RESULTS: In all cases, final surgical treatment of the given fistulae by VRAM or gracilis flaps could be achieved, with mean operating time of 5:31 h (range: 4:50-6:48 h) for VRAM flap and 3:11 h (range: 2:04-4:42 h) for gracilis flap. Outcome measures were primarily to avoid fistula recurrence after plastic surgical treatment, and secondary quality of life and survival. All patients had their continence preserved, but two patients died during follow-up period. Postoperative assessment revealed the following: VRAM flap patients (n = 3) showed slight incontinence during the follow-up period, whereas continence was restored in all patients with gracilis flap reconstruction (n = 7). Quality-of-life assessment indicated restoration of quality of life in comparison to general population (women > men). Furthermore, key points of the two presented surgical techniques are demonstrated in detail. CONCLUSION: With preformed VRAM or gracilis flaps, complex urogenital fistulas can be successfully eradicated and continence is restored. The main focus should be the recovery of quality of life, which could be successfully regained. Nevertheless, the continence success rate has to be defined on an individual, case-by-case basis. LEVEL OF EVIDENCE: Original work, cohort study level III.

Squamous-cell Carcinoma Arises in Red Parts of Multicolored Tattoo within Months.

SUMMARY: Skin cancer formation is on the rise. Only a few case reports, which focus on skin cancer being caused by tattoos, have been published so far. Our aim is to determine whether skin cancer occurrence can be triggered by tattoos. In our presented case, a squamous-cell carcinoma developed inside of the red areas of a multicolored tattoo within months. Furthermore, surgical removal of the cancerously mutated skin area without mutilating the design of the tattoo was challenging. Due to widespread skin alterations in other red areas of the tattoo, those affected skin regions were surgically removed and split-skin grafting was performed. After 1-year follow-up period, the patient has been tumor free. Squamous-cell carcinoma is an unusual reaction that can occur in tattoos. Nevertheless, this skin cancer should be included in the list of cutaneous complications related to tattooing.

Intravascular leiomyosarcoma of the brachiocephalic region -- report of an unusual tumour localisation: case report and review of the literature.

BACKGROUND: Intravascular leiomyosarcoma is a rare tumour entity originating from venous vessel structures and most frequently affecting the inferior vena cava. CASE PRESENTATION: A 69-year old patient presented with a biopsy proven leiomyosarcoma of the right supraclavicular region. Tumour resection and histological assessment verified the intravascular tumour origin arising from the internal jugular vein and extending into the surrounding soft tissue. CONCLUSION: In the presence of a biopsy proven diagnosis of leiomyosarcoma the rare condition of an intravascular tumour origin has to be considered even without signs of venous stases. This may result in an altered surgical strategy. Microthrombembolism and pulmonary metastases may complicate the course of the disease.