OUR PRELIMINARY EXPERIENCE WITH A NEW METHOD OF DIEAp FLAP DISSECTION.

BACKGROUND: The abdominal tissue is an ideal source for autologous breast reconstruction. We propose a new approach for intramuscular dissection of a DIEP flap in this paper. METHODS: A total of 84 women underwent breast reconstruction after mastectomy. From this group, 49 patients were treated with traditional DIEP flap of which 21 had unilateral procedure and 28 had bilateral procedure. This new type of dissection was performed in 35 women, with unilateral approach in 14 cases and bilateral approach in 21 cases. RESULTS: The statistical differences are not significant in the two groups with regards to complications (p > 0.1). Mean operative time in this new approach was 3 hours and 10 minutes per flap. Mean operative time in the traditional dissection of DIEP was 3 hours and 41 minutes per flap. The operative time of the new approach is significantly shorter than the dissection of the traditional DIEP flap (p < 0.01). CONCLUSION: The approach to DIEP flap dissection proposed by the authors is a new concept in autologous breast reconstruction. In this type of dissection no fascia is resected and it is more reliable than a traditional DIEP flap for the ease of dissection and for the presence of a small protective cuff of muscle around the vessel with a lower risk of perforator injury.It is a reproducible option of dissection, useful also in less experienced hands and it is a time reducing technique compared with the traditional DIEP flap.

Reconstruction of large facial and orbital defects by combining free flap transfer with craniofacial prosthesis.

The reconstruction of complex craniofacial and orbital defects should satisfactorily restore functional and aesthetic integrity. Autologous reconstruction of nasal, periorbital and auricular facial subunits as a whole using a locoregional or a free flap is very challenging and the results are not sometimes ideal. With advanced technologies that are currently available it is possible to plan and produce authentic facial prosthesis that can satisfactory substitute these facial subunits. We demonstrate an alternative reconstructive concept for complex craniofacial defects based on a free flap combined with a facial prosthesis for the replacement of periorbital or auricular facial subunits. This approach was used in two patients with very satisfactory results. Combination of a free flap with a facial prosthesis may become a preferable approach for the reconstruction of complex craniofacial defects. Clinical outcomes of the reconstructions may be enhanced respecting the principle of aesthetic facial subunits.

A NOVEL MODEL TO EVALUATE THE LEARNING CURVE IN MICROSURGERY: SERIAL ANASTOMOSIS OF THE RAT FEMORAL ARTERY.

The rat's femoral artery is definitely the most frequently used model in microsurgical training for its easy dissection. Our model, consisting in the creation of several anastomoses in a row, helps the novice surgeon to assess his microsurgical level and to improve his capacity. Indeed, this leads to an amplification of the trainee surgeon's mistakes, which add up to each other as the anastomoses are performed. We propose a simple method to evaluate the surgeon microsurgical skills during the training.

TWISTED DISTAL LATERAL ARM FLAP FOR IMMEDIATE RECONSTRUCTION OF THUMB AVULSION INJURY.

BACKGROUND: Replantation is a complicated procedure in avulsion injuries in majority of the cases. When replantation of an avulsed thumb is not feasible, it is mandatory to find an appropriate reconstruction choice as soon as possible due to the importance of the thumb function in the dynamics of the handgrip. MATERIALS AND METHODS: Three patients with skin avulsion injury underwent immediate reconstruction by twisted lateral arm flap in our department since 2004. RESULTS: No infection, hematoma, partial or complete flap necrosis were observed after the procedure. All of the flaps healed without complications. CONCLUSION: Although the gold standard in reconstruction of these trauma defects is the use of local skin flaps or distant inguinal flap, these reconstructive choices have multiple drawbacks such as the loss of sensibility and they are thicker. In thispaper we propose a modification of distally planned lateral arm flap design and a new technique of its spiral shaping for immediate thumb reconstruction.

DELAY PROCEDURE IN THE PERFORASOME ERA: A CASE IN A DIEAP FLAP.

The deep inferior epigastric artery perforator (DIEAp) flap is becoming a widely used method of autologous breast reconstruction. Despite the huge use of the DIEAp flap in reconstructive field, an evidenced based approach in perforator selection has not yet been developed. Unfortunately there is no clear evidence about the relation between the number and dimension of the perforator vessel and the prediction of flap survival in a living model. An old technique like the vascular delay could be extremely useful as a lifeboat procedure when the vascularization of the flap after the dissection is inadequate.

VASOSPASM OF THE FLAP PEDICLE--MAGNESIUM SULPHATE RELIEVES VASOSPASM OF AXIAL FLAP PEDICLE IN PORCINE MODEL.

BACKGROUND: The effect of magnesium sulphate on mechanically provoked vasospasm of the flap pedicle on porcine model was not studied yet. Positive effect of magnesium sulphate on vasospasm was proved in previous studies on rat. METHODS: The bilateral pedicled flaps based on the caudal superficial epigastric arteries were raised on 8 pigs. Flaps on the right side were the treatment group; flaps on the left side were the control group. The vasospasm was provoked by the tension applied on the pedicle in the axial direction using 160g weight. The blood perfusion of the flap was monitored using laser-Doppler. The duration of the vasospasm was defined as the time from the release of the tension until the blood flow began to rise. These times were detected using an automated computerized detection. In the treatment group, magnesium sulphate was given topically on the vessel; saline was used in the control group. RESULTS: The duration of the vasospasm in the treatment group was significantly shorter than in the control group (P = 0.024). CONCLUSION: Magnesium sulphate 10% shortened significantly the mechanically provoked vasospasm on caudal superficial epigastric flap in a porcine model. Further clinical studies are needed to prove the effect in humans.

Vasospasm of the flap pedicle - the new experimental model on rat.

BACKGROUND: An experimental model for testing vasodilating drugs on vasospasm caused by standardized traumatisation of a pedicle has not been described yet. The aim of this study was to develop such model and to compare the effects of different types of surgical manipulations that can provoke vasospasm during flap dissection. MATERIAL AND METHODS: The pedicled groin flap was dissected in 185 male Wistar rats under standardised conditions. The blood perfusion curves of the flap were obtained using the Laser Doppler flow-meter. The vasospasm was provoked by the following manoeuvres: pulling on the pedicle; compression of the pedicle by vascular clamps; dissection of the vessels and by presence of blood around the pedicle. The perfusion recording curves were processed and two important time periods describing the progress of spasm were extracted. Combined non-parametrical ANOVA and WILCOXON tests were used to compare the time parameters between the groups. On the basis of statistical evaluation, we divided the factors responsible for vasospasm into categories labelled as strong and weak. The strong stimuli included dissection of the vessels; pulling on the pedicle using 15g, 20g and 25g weights and presence of blood around the pedicle. The weak stimuli included compression of the pedicle using vascular clamps and pulling on the pedicle using 10g weight. Pulling on the pedicle using 15g weight was chosen as the most appropriate stimulus for the experimental model. RESULTS: A new experimental model for studying vasospasm caused by tension on the pedicle was developed. This model is well defined, easily repeatable and reproducible, produces vasospasm of appropriate duration and permits standardized topical application of vasodilating drugs. DISCUSSION AND CONCLUSION: The finding that certain kind of surgical traumatisation causes vasospasm that is longer than the others may help microsurgeons to review their methods of surgical manipulation.

[Treatment of a ruptured extensor policis longus tendon by extensor carpi radialis longus transfer]. / Vliv slachového transferu extensor carpi radialis longus - extensor pollicis longus na funkci ruky.

PURPOSE OF THE STUDY: Two tendons, i.e., the extensor indicis proprius (EIP) and the extensor carpi radialis longus (ECRL), are commonly used to reconstruct the function of a ruptured extensor pollicis longus (EPL) tendon. We reviewed a group of patients with EPL ruptures treated by ECRL tendon transfer to the EPL tendon, which was the method of choice. The aim was to evaluate the results and to assess the effect of ECRL detachment on hand function. MATERIAL AND METHODS: Twenty patients were treated surgically for a subcutaneous rupture of the EPL tendon between 2003 and 2007. Each patient was examined at 2 years after surgery. The range of motion (ROM) of both the injured and the contralateral hand was recorded and evaluated with a modified Geldmacher scoring system; a response to the DASH questionnaire was obtained. The mean follow-up was 24 months (19-31 months). RESULTS: For the ROM of the operated hand, the mean Total Active Motion (TAM) of 98.75 degrees (60-140, SD 22.74) was calculated. The mean extension lag at the interphalangeal (IP) joint was 5.42 degrees (0-25, SD 8.77) and the mean IP flexion was 65.8 degrees (40-80, SD 13.2). In order to evaluate body side differences, the ROM of the contralateral thumb was recorded. The values were as follows: mean TAM, 141.3 degrees (115-190, SD 20.43); mean IP extension lag, 0 degrees (0-0, SD 0); mean IP flexion, 68.8 degrees (50-80, SD 9.6). DISCUSSION: The extension lag at the IP joint was detected in both the operated and the contralateral hands. The patients examined at a longer interval after surgery showed an increase in extension lag. This may have been caused by undesired adaptation of the donor muscle, the presence of adhesions or suture loosening. CONCLUSIONS: The results showed increased adaptation of thumb motion to the extension lag at the IP joint, which had a mild effect on the patient's hand function. The difference in wrist extension between the operated and the contralateral hand corresponded to the pre-operative condition.

[Surgical prevention of breast carcinoma in patients with hereditary risk]. / Chirurgická prevence karcinomu prsu u pacientek s dedicným rizikem.

BACKGROUND: Women with BRCA1 gene mutation have 85% risk of breast cancer; the risk for BRCA2 carriers is 45%. The aim of the study was to verify if prophylactic mastectomy with immediate breast reconstruction can prevent breast cancer in BRCA positive patients. MATERIAL: There were 100 BRCA positive women in which prophylactic mastectomy with immediate reconstruction, 75 dieps, 25 with implants, performed in period 2000-2011. Group A was composed of healthy, non-affected 41 patients, group B of 59 patients in remission after breast cancer treatment. These groups were compared to group C that consisted of 219 healthy carriers of BRCA1/2, non-operated, from registry of genetic department of the Masaryk Memorial Cancer in Brno, from 2000-2011. METHOD: Follow-up for oncology status was done in September 2011 for all 3 groups. RESULTS: Average follow-up of 21 months revealed that in group A there was no breast cancer, in group B 4 patients died and 2 had treatment for metastases. In group C, there were 16 new cases of breast cancer. CONCLUSION: Bilateral prophylactic mastectomy with immediate reconstruction can be an effective way in breast cancer prevention in healthy carriers of BRCA1/2 mutation. In BRCA positive patients treated for breast cancer, the effect of prophylactic mastectomy is unclear. Their survival is more influenced by their previous disease than by a new tumor in the breast.

Nasal reconstruction in children with the combination of nasolabial and island flaps.

BACKGROUND: The reconstruction of the nose is one of the most complicated aesthetic-reconstructive procedures. The difficulty of the procedure lies is in the necessity for reconstruction not only to capture the very complicated, various shapes of the nose but also to preserve the function of the nose: to allow the patient to breathe through the nose. MATERIALS AND METHODS: 12-year-old girl had loss injury of the part of left wing of the nostril. We used the compound nasolabial flap with a small excess to resolve the mucosal and skin defect. One year after the first operation relief of natural transition of the new wing of the nostril and cheek was created with small island flap. RESULTS AND CONCLUSIONS: The reconstruction of a wing of the nostril in multistage procedures with combined nasolabial flap and island flap allowed us to perform precise modelation of the nostril wing with the natural transition to the cheek. An island flap with its scars creates the required contour of a nostril wing and prevents the collapse and flattening of the nostril wing externally.

Evaluation of early dynamic splinting versus static splinting for patients with transposition of the extensor carpi radialis longus to the extensor pollicis longus.

We present a group of 20 patients who underwent transposition of the extensor carpi radialis longus to the extensor pollicis longus between April 2003 and September 2007. The group was divided into ten patients with an early dynamic splint and ten patients with a static plaster cast following the standard rehabilitation protocols. We compared these two rehabilitation protocols. The post-rehabilitation total range of motion was 87.5 degrees in the dynamic group and 58.75 degrees in the patients treated by the static protocol. The total time of rehabilitation was 10.2 weeks in the dynamic and 14.2 weeks in the static group. The overall mean follow-up was 12.2 weeks. We conclude that early dynamic splinting brings shorter recovery time, shorter time off work and significantly better movement of the thumb.

Reconstruction of defect after radical vulvectomy by the use of four-flap local transfer--a case report.

Malignant vulvar tumors must be treated by radical removal of the tumor as well as a sufficient amount of surrounding healthy tissue. The resulting defects can be resolved by skin transplants, local transfers, skin flaps, muscle flaps or free tissue transfers. We describe the case history of a patient who underwent radical vulvectomy for a malignant tumor with immediate reconstruction by local flaps from the area of inner thighs and mons pubis. The advantages and disadvantages of this method are compared to other reconstructive surgery methods.

The efficacy of magnesium sulfate on resolving surgically provoked vasospasm of the flap pedicle in an experiment.

BACKGROUND: Vasospasm frequently accompanies manipulation of small vessels during free flap surgeries and replantations. The purpose of this experimental study was to evaluate the effect of magnesium sulphate on vasospasm provoked by surgical manipulation (axial tension) on the flap pedicle. This kind of surgical manipulation of the vessel cannot be studied in a clinical environment without putting flap viability into risk. MATERIAL AND METHODS: Forty male Wistar rats weighing around 300 g each were classified in two experimental groups (n=20 in each). In the treatment group (group A) Magnesium Sulphuricum 10% (Biotika, Czech Republic) was applied; the second group (group B) served as a control. The vasopasm was provoked by pulling the pedicle of the right groin flap of the rat. The peripheral blood perfusion of the flap was continuously measured using laser-Doppler recording. In the study group, magnesium sulphate was applied topically on the flap pedicle to relieve vasospasm, and duration of the vasospasm was compared to the control group. RESULTS: A statistically significant difference (p=0.01) between the groups was found. The duration of vasospasm was significantly shorter in the treatment group A. CONCLUSIONS: We conclude that in an experimental environment magnesium sulphate is effective in relieving surgically provoked vasospasm of the flap pedicle. This finding is in accordance with our clinical observations.

The effect of blood around a flap pedicle on flap perfusion in an experimental rodent model.

BACKGROUND: The vasospasm has been studied to a considerable extent in the neurosurgical literature. Little experimental and basic scientific literature about vasospasm of flap pedicle is available in the field of reconstructive microsurgery. The purpose of the study was to investigate the effect of presence of blood around the pedicle on a flap perfusion. MATERIAL AND METHODS: Blood flow through a right groin flap was continuously measured using Laser Doppler flowmetry on 40 male Wistar rats. A segment of the flap's pedicle was surgically cleared of adventitia and bathed in blood. The blood used was either collected from the tail of the rat (group A) or from the bleeding branch of the pedicle itself (group B). The differences between the signal amplitudes before and after exposure of the pedicle to blood were recorded. RESULTS: The presence of blood around the pedicle resulted in a significant decrease in perfusion of the flap in both groups. However, no significant differences in the duration of impaired blood flow between the groups were observed. CONCLUSIONS: In conclusion, the presence of blood around the vascular pedicle may cause a significant decrease in the perfusion of a flap, while the origin of the blood does not appear to be an important factor.

Arterialized venous free flaps--a reconstructive alternative for large dorsal digital defects.

Venous free flaps should be considered as potential reconstructive options for large dorsal digital defects with exposed bone, joint and/or extensor tendons, if local flaps are inadequate or unusable. We describe our experience of thirteen venous free flaps in twelve patients with large dorsal digital defects. Our survival rate for these flaps is comparable to the published data. The forearm donor site was closed primarily in all cases with minimal morbidity. The flaps should be monitored with Doppler devices as clinical evaluation is misleading secondary to the venous congestion inherent in these flaps. This reconstructive option has become a well-established procedure in our hands and is the alternate reconstructive method of choice for large dorsal digital defects where local flaps are not usable or inadequate due to complex hand injuries or multiple finger defects.

The preservation of a spare hemi-abdominal flap in unilateral breast reconstruction with abdominal free flap in high risk patients.

BACKGROUND: Unilateral breast reconstruction with a free abdominal TRAM or DIEP flap restores the shape of the amputated breast with acceptable donor site morbidity. In patients with small breasts and ample lower abdominal tissue this can be achieved by using only a hemi-abdominal flap. In these cases, the contra-lateral flap is usually discarded, but it could potentially be left in situ as a "spare" hemi-abdominal flap, especially in patients at high risk for contra-lateral breast cancer or flap failure. We report our early experience with this preservation technique. MATERIAL AND METHODS: The authors report two cases of unilateral breast reconstruction with hemi-abdominal DIEP free flaps in women at high risk for contra-lateral breast cancer and/or flap failure, who opted not to have prophylactic contra-lateral mastectomies. They consented to having the unused "spare" hemi-abdominal deepithelialized flap left in situ in case the need for a secondary flap arose. RESULTS: The "spare" hemi-abdominal flap was used for immediate reconstruction as an SIEA free flap when the first patient's original flap necrosed secondary to microcirculation problems. The second patient's spare flap was left in situ by burying it after de-epithelialization. CONCLUSIONS: We believe that patients undergoing unilateral breast reconstruction who are at high risk for contra-lateral breast cancer and/or free flap failure, and who choose not to undergo an immediate contra-lateral prophylactic mastectomy, should have the "spare" hemi-abdominal flap buried. This tissue could be used as a potential bailout flap in cases of original flap failure or for contralateral breast reconstruction at a later date.

An objective evaluation of contraction power of neo-phallus reconstructed with free re-innervated LD in female-to-male transsexuals.

AIMS: Objective evaluation of contraction power of the neo-phallus reconstructed with a novel technique in female-to-male transsexuals. PATIENTS AND METHODS: From December 2001 to September 2005, 22 patients with gender identity disorder underwent neo-phalloplasty with the re-innervated latissimus dorsi free flap. All the patients were subjected to an early rehabilitation protocol of the transferred muscle; the beginning time of neo-phallus voluntary contraction was recorded in 18 patients. 14 patients, who came for examinations, were objectively evaluated for the strength of transplanted muscle contraction in neo-phallus by electromyography and measurement of the maximum weight lifted. RESULTS: 18 patients were able to voluntarily contract the neo-phallus after an average period of 4.11 months. In 14 of them, the average weight lifted was 1129 g. After electromyography, the mean number of positive peaks in the 100 ms period was 31.5; the mean amplitude from 10 highest positive peaks, measured peak-to-peak, was 0.99 mV. DISCUSSION AND CONCLUSION: The advantage of this technique is non-requirement of the prosthesis for sexual activity due to the development of strong voluntary contraction of the neo-phallus. Our findings document objectively the strength of voluntary contraction of the neo-phallus as a consequence of re-innervation of the transferred muscle. Furthermore, data represent useful tool for clinical assessment and comparison.

Neo-phalloplasty with re-innervated latissimus dorsi free flap: a functional study of a novel technique.

Twenty two patients with gender dysphoria underwent neo-phalloplasties using a novel technique. Latissimus dorsi musculocutaneus re-innervated free flap was used to allow voluntary rigidity of the neo-penis. From the first 22 patients, 18 have obtained motoric function of reconstructed penis; the "paradox erection" was obtained. 14 patients came for examination after a follow-up period of mean 26.4 months. We evaluated the motility and shape changes of neo-phallus measuring its different size and dimension during relax and muscle contraction. The range of neo-phallus length in relaxed position was between 7 and 17 cm (mean 12.2 cm), its circumference in the same position had a range between 13 and 20 cm (mean 13.7 cm). All patients were able to contract the muscle with an average length reduction of 3.08 cm and an average circumference enlargement of 4 cm. In this study, the dimensions and motility were quantified demonstrating the neo-phallus function and size changes during sexual intercourse.

Unusual case of resistant actinomycosis following facial trauma.

A case of actinomycosis is reported which appeared as a complication of a ski-pole injury of the face. A 16-year-old girl was treated for 10 years for resistant actinomycosis. She took long-term antimicrobial therapies, underwent repeated excisions, hyperbaric oxygen therapy, repeated skin grafting, immunological treatment, and free flap transfer. The conservative antibiotic treatment was complicated by mycosis and pseudomembranous colitis. After the defect healed up, satisfactory contour of the face was restored with additional free flap transfer. The patient has also been satisfied with the final aesthetic result. The authors highlight the importance of early diagnosis and proper antimicrobial treatment in combination with surgical excisions of granulation tissue preserving vital structures.

The proximal first dorsal metacarpal artery free flap for reconstruction of complex digital defects.

We describe our experience and outcome with the 'Proximal first dorsal metacarpal artery free flap'. Ten consecutive cases utilizing the proximal first dorsal metacarpal artery free flap for complex digital defects were studied. Surgical technique, patient demographics, and flap outcome data were collected. Patient satisfaction was analysed using a questionnaire. All defects healed successfully with no loss of free flaps. The short-pedicle proximal first dorsal metacarpal artery free flap enables primary closure of the donor site up to 2 cm of width (in nine of the ten donor sites). The flap is a reliable and versatile alternative in selected cases of complex digital injuries.