Omega "Ω" Pulley Plasty for Surgical Management of DeQuervain's Disease.

BACKGROUND: DeQuervain tenosynovitis, refractory to medical conservative treatment, has been traditionally treated by a simple division of the pulley, a procedure associated with several complications. Many authors attempted to prevent these complications by describing techniques of pulley reconstruction after its release necessitating suturing the different flaps and subsequently promoting extensor tendons adhesions. The authors present an alternative procedure for the first extensor compartment pulley decompression: "Omegaplasty". METHODS: 25 Patients with 29 DeQuervain tenosynovitis cases were enrolled in a prospective, nonrandomized clinical trial from 2012 to 2016. At enrollment they were offered the option of Omegaplasty as a surgical treatment modality for their cases. The procedure is based on liberating the anterior attachment of the pulley from the anterior lip of the styloïd process while respecting its continuity with the periosteal flap as well as promoting expansion of the tunnel volume. All operated patients were evaluated using the "Opposition Kapandji Score". RESULTS: The authors present the results of 29 different "Omegaplasty" procedures. Based on the Kapandji opposition score, twenty cases scored 10/10 while the remaining nine cases yielded an 8/10 score each. CONCLUSIONS: The described technique is simple, reliable and respects the extensor tendons gliding physiology and biodynamics. By preserving the anatomical continuity of the first extensor compartment pulley at the wrist, the risk of adhesion formation is reduced. The preliminary results are encouraging and provide the "Ω" plasty the potential to be considered as a surgical option for treatment of De Quervain Tenosynovitis.

The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery-Personal Experience.

The inframammary fold (IMF) is the most critical visual landmark that affects final aesthetic outcome of augmentation mammoplasty and even post-mastectomy alloplastic breast reconstruction. Unfortunately, structural integrity of this landmark is greatly overlooked and very often neglected. Excessive undermining of the lower breast pole with aggressive disruption/lowering and subsequent poor reconstitution of the IMF scaffold combined with imbalanced implant-tissue dynamics may result in downward implant displacement with creep bottoming and upward tilt of the nipples. The current report reviews the experience of the senior author (BA) over 30 years in breast aesthetic and reconstructive surgery with IMF reconstruction and fixation to the chest wall at the inferior border of the implant. Illustrative cases are presented. LEVEL OF EVIDENCE V: 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 .

Perforator Mapping and Optimizing Design of the Lateral Arm Flap: Anatomy Revisited and Clinical Experience.

BACKGROUND: The lateral arm flap remains an underused flap, especially as a free flap. In this article, the authors describe the perforator anatomy to optimize flap design and harvest. METHODS: Perforator locations were mapped in 12 cadavers (24 arms), and a retrospective review was conducted of 51 patients undergoing lateral arm flap surgery. RESULTS: One to three reliable perforators supply the lateral arm flap. Based on cadaveric dissections, from the deltoid insertion, the A, B, and C perforators were located at 7.2 ± 1.0 cm, 9.9 ± 1.2 cm, and 11.8 ± 0.8 cm, which was 0.44, 0.61, and 0.72 of the distance from the deltoid insertion, respectively. The average pedicle length was 7.0 ± 1.1 cm. The cadavers were entirely symmetric in the number and location of the perforators between the right and left arms. All 51 patients (24 male and 27 female patients) had at least one perforator with an average pedicle length of 7.0 ± 1.3 cm, an average arterial diameter of 1.7 ± 0.3 mm, and a vein diameter of 2.5 ± 0.5 mm. All but one flap was performed as a free flap for head and neck reconstruction, with one pedicled flap for shoulder reconstruction. The average flap size was 72.2 ± 37.1 cm (range, 21 to 165 cm). The nondominant arm was used for all free flaps. There were no total or partial flap losses. Twenty-eight patients reported donor-site numbness, with one infection, one hematoma, and one wound dehiscence. CONCLUSION: The lateral arm flap can be harvested reliably based on well-defined perforators and anatomical landmarks with minimal donor-site morbidity and should be included among the techniques used by reconstructive microsurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Deltopectoral Flap Revisited: The Internal Mammary Artery Perforator Flap.

Pharyngo-esophageal and tracheostomal defects pose a challenge in head and neck reconstruction whenever microanastomosis is extremely difficult in hostile neck that is previously dissected and irradiated. The deltopectoral (DP) flap was initially described as a pedicled flap for such reconstruction with acceptable postoperative results. A major drawback is still that the DP flap is based on 3 perforator vessels leading to a decreased arc of rotation. The DP flap also left contour deformities in the donor site. The internal mammary artery perforator flap was described as a refinement of the deltopectoral flap. It is a pedicled fasciocutaneous flap based on a single perforator, with comparable and reliable blood supply compared with the DP flap, giving it the benefit of having a wide arc of rotation. It is both thin and pliable, with good skin color match and texture. The donor site can be closed primarily with no esthetic deformity and minimal morbidity. The procedure is relatively simple and does not require microvascular expertise. In this report, the authors describe a patient in whom bilateral internal mammary artery perforator flaps were used for subtotal pharyngo-esophageal reconstruction and neck resurfacing. The flaps healed uneventfully bilaterally with no postoperative complications.

The V-Plasty: A Novel Microsurgical Technique for Anastomosis of Vessels with Marked Size Discrepancy.

BACKGROUND: The art of reconstructive microsurgery is still progressing after Carrel's original description of "vascular repair" in 1902. Reports of the successful repair of vessels smaller than 1 mm in diameter are currently commonplace. However, the technique of microvascular anastomosis to connect vessels with large diameter discrepancy, greater than 1 mm, has not yet been perfected. This article reports a novel option to anastomose two vessels of different sizes by adapting the diameters of the two stumps and creating a gentle slope that dramatically reduces turbulences in the blood stream. METHODS: The "V-plasty" consists in designing a v-shaped flap on the wall of the large vessel and a longitudinal incision on the small one. The V-flap is then introduced into the V-defect of the small vessel, creating a smooth transition of the diameters between the two vessels. Mathematical calculation of the dimensions of the V-flap was conducted with different ratios' discrepancies of the two vessels ranging from 1.5 to 4. Clinically, 14 microvascular V-plasty were performed in 8 patients. RESULTS: The theoretical simulation and our clinical experience of 14 cases allowed us to propose the different dimensions (length and width) of the V-plasty according to the ratio of vessels discrepancies. CONCLUSION: The V-plasty microanastomosis is an alternative method to attach vessels with size discrepancy. It simply equalizes the donor and recipient vessels' diameters. Its main advantage is to maintain a linear axis between the two vessels whatever the discrepancy ratio is.

Caso original de lipo-hipertrofia simétrica: relato de caso e revisão de literatura / An original case of symmetric lipohypertrophy: case report and review of the literature

Paciente do sexo feminino, saudável, meia-idade e com história prolongada de massas com crescimento lento localizadas bilateralmente e simetricamente nos membros superiores e inferiores, próximas às principais articulações. Exames de imagem e patológicos após excisão das massas revelaram massas constituídas por gordura subcutânea normal. Não houve evidências de lipomas bem-circunscritos. Na revisão de literatura, destacaram-se diversos distúrbios lipo-hipertróficos, com possível apresentação simétrica. As características das afecções encontradas não eram, porém, totalmente concordantes com as características de nossa paciente. Embora não de modo absoluto, a doença que mais estreitamente se assemelhou ao caso foi lipodistrofia simétrica rara, conhecida como doença de Madelung. Dos 150 casos relatados, em apenas 3 foi descrito comprometimento dos membros inferiores, como ocorreu em nosso caso. Este relato apresenta descrição detalhada do caso, seu manejo e seguimento no pós-operatório. Os tipos distintos de lipodistrofias simétricas também são discutidos.

A middle-aged healthy woman who presented with longstanding history of slow growing masses located bilaterally and symmetrically on the upper and lower extremities closed to major joints. Imaging and pathology tests following excision of masses revealed normal subcutaneous fat. There was no evidence of well-circumscribed lipomas. A review of the literature identified a number of lipohypertrophic disorders, which may be present in a symmetrical fashion. The characteristics of the disorders, however, did not fully agree with characteristics observed in our patient. Although not absolute, the closest disease found to fit our case is a rare symmetrical lipodystrophy known as Madelung's disease. Of 150 reported cases, only 3 described involvement of lower extremities as seen in our case. We report a detailed description of a case, its management and post-operative follow-up. Different types of symmetrical lipodytrophies are also discussed.

Abdominoplastia reversa tensionada para reconstrução de defeito estendido após mastectomia / Tensioned reverse abdominoplasty for reconstruction of large post-mastectomy defects

As opções reconstrutivas para defeitos da parede anterior do tórax podem ser desafiadoras especialmente quando o defeito é extenso e sujeito a radioterapia pré-operatória. Apresenta-se caso de paciente com carcinoma ductal invasivo de mama não tratado que realizou radioterapia e quimioterapia incompleta no pré-operatória. O exame patológico revelou carcinoma ductal invasivo de 11,5 cm, grau III, com invasão linfovascular e linfonodos axilares positivos (20/20). Após a mastectomia, defeitos estendidos seguido de longa excisão de pele mediram 25 x 20 cm, sendo esses cobertos imediatamente com retalhos em abdominoplastia reversa tensionada. Trata-se do primeiro caso relatado de excisão larga de mastectomia reconstruída exclusivamente com retalhos avançados em abdominoplastia reversa e alta tensão progressiva de pontos de adesão demostrando que nos pacientes selecionados, a pele abdominal pode ser avançada superiormente com segurança e facilidade para atingir a área superior do tórax e cobrir a área com defeito significante.

Reconstructive options for anterior chest wall defects can be challenging especially when the defect is large and has been subject for preoperative radiotherapy. We report a case of a patient with a neglected large invasive ductal carcinoma of the breast who had received incomplete preoperative radiotherapy and chemotherapy. The pathology examination revealed an 11.5 cm invasive ductal carcinoma, grade III, with lymphovascular invasion and positive axillary lymph nodes (20/20). The post mastectomy large defect following wide skin excision measured 25 x 20 cm and it was immediately covered with a tensioned reverse abdominoplasty flap. To our knowledge, this is the first case reported of a wide skin excision mastectomy reconstructed solely with a reverse abdominoplasty advancement flap and progressive high-tension with quilting sutures demonstrating that, in the selected patients, abdominal skin can be safely and easily advanced superiorly to reach the upper chest area and cover an area of significant defect.

Gynecomastia: Simultaneous Subcutaneous Mastectomy and Areolar Reduction with Minimal Inconspicuous Scarring.

Acceptable scar positioning on the anterior male chest is very limited. In Gynecomastia surgery, an obvious areolar incision is the most sensitive indicator of a previous operation; a less apparent scar is indispensable for the patient's psychological satisfaction. Whenever only areolar diameter reduction is required, the circumareolar incision must be performed in a position leaving the least conspicuous scar. Standard excision of an outer doughnut of areolar skin results in a visible and unnatural peri-areolar scar. The peri-nipple excision of areolar skin leaves the skin-areola junction undisturbed. When combined with a transverse areolar infra-nipple incision, access for subcutaneous mastectomy is facilitated. With this approach, risk of nipple vascular compromise is thought to be reduced, and necrosis of areolar pigmented skin virtually impossible. EBM LEVEL V: 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.

Introduction of "Papazian Pusher: " A Modified-Design Knot Pusher for Surgical Repair of Cleft Palates.

Tying sutures is an integral aspect of any surgery and reliable instruments are essential for hassle-free procedures including craniofacial surgeries. Knot pushers have been widely known for their application in various laparoscopic, arthroscopic, and anal surgeries. The literature reveals numerous articles pertaining to knot pushers, as well as improvements on existing designs. Nevertheless, no application of knot pushers in the surgical repair of cleft palates has been described. We describe a new knot pusher "Papazian Pusher" (PP) finely designed for application in oral surgeries in general and repair of cleft palates in particular. The instrument was used satisfactorily in repair of cleft palate surgeries and no complications were encountered. The PP was found, overall, to be easy to use, and helps in performing faster, stronger, smooth, and secure knots.

Overcoming limitations of short scar minimal access cranial suspension facelift for enhanced rejuvenation.

The minimal access cranial suspension lift, a short-scar facelift, has been described to correct sagging and laxity of the lower and middle third of the face. It does not, however, fully address the neck or the lateral periorbital area frequently needing rejuvenation in most patients. Another shortcoming of the minimal access cranial suspension lift technique is visible scarring anterior to the temporal hairline that usually occurs despite the suggested surgical maneuvers consisting in zigzag beveled incisions. We describe modifications of the standard subcutaneous musculoaponeurotic system lift technique, increasing its indications for full-face and neck rejuvenation (excluding the forehead) and improving final aesthetic outcome.

Preoperative assessment tool for the planning of inframammary incision and implant profile in breast augmentation.

When using the inframammary access incision for breast augmentation, careful planning is critical to allow the surgeon to set the inframammary fold (IMF) at the most optimal position, minimize scar visibility, and mitigate the main disadvantage of this approach. Current popular evaluation systems for breast augmentation include the High Five and Randquist systems and they base their calculations on inconsistent variables like skin stretch measurements. We propose a simple method that is not dependent on skin stretch measurements to properly determine implant size, profile, and position of the inframammary fold. Excluding digital scans and computer-based systems that are not universally available, the proposed simplified assessment tool was compared to the two most popular manual measuring tools (High Five and Randquist). Twenty-five female volunteers were included in the study. The projected IMF positions over the midsternal line for each measuring tool were recorded on each patient and the sternal notch (SN) to projected IMF distance SN-IMF1 (simplified evaluation system), SN-IMF2 (High Five System), and SN-IMF3 (Randquist system) were compared. The anticipated new IMF position is determined based on the vertical implant dimension and not on breast base width. For most subjects, the differences between the three evaluation systems were minimal. The proposed breast measurement tool constitutes a new, much simpler, and practical method that proved to be successful in our hands.