Meshed Dermal Sling for Prepectoral Breast Reconstruction.

The best breast reconstruction solution after mastectomy remains a topic of wide debate. Recently, the focus in the field of implant-based reconstruction has been on the increasing indications for prepectoral reconstruction. This offers undoubted advantages over subpectoral reconstruction, ranging from better aesthetic results and patient comfort to a less invasive procedure that spares the pectoralis major muscle, reducing pain and postoperative recovery time. The dermal sling is a reconstructive variant introduced by Bostwick in the 1990s and is commonly used to complete the subpectoral pocket in one- or two-stage reconstruction, creating a dual-plane reconstruction. This method may be indicated after mastectomy for both therapeutic and prophylactic purposes. It can also be used for unilateral and bilateral reconstructions. We propose a new meshed dermal sling technique that allows complete prepectoral reconstruction without the use of acellular dermal matrix, thus reducing the cost of reconstruction. It also allows the indication for complete prepectoral reconstruction to be extended to patients with medium breast volume and grade 1 or 2 ptosis, without the need to use acellular dermal matrix or the pectoralis major muscle to complete the breast pocket.

Immediate post-mastectomy prepectoral breast reconstruction with animal derived acellular dermal matrices: A systematic review.

BACKGROUND: Animal-derived acellular dermal matrices (ADMs) are increasingly being used in prepectoral direct-to-implant (DTI) breast reconstruction. However, the indications and complication profile associated with this type of reconstruction remain unclear. This study aimed to perform a systematic review of the available literature on the use of animal-derived ADM in prepectoral DTI breast reconstruction. METHODS: Three different literature databases, namely, PubMed, Web of Sciences, and Embase were screened using the following keywords: "immediate" AND "pre-pectoral" OR "prepectoral" AND "ADM breast reconstruction." Animal-derived ADM used (porcine - Braxon® and non-Braxon® - and bovine - Surgimend®) anthropometric information, clinical data, and complications profile were considered. RESULTS: A total of 340 articles were initially identified, of which only 45 articles (5089 patients and 6598 reconstructed breasts) satisfied our inclusion criteria. The most widely used ADM was Braxon® in the context of conservative mastectomies. In most studies, a subcutaneous layer > 1 cm and lack of previous radiotherapy were considered prerequisites for this type of reconstruction. An increased risk of complications was found in smokers, patients who underwent radiation treatment, patients with high breast volumes, and patients with cancers requiring axillary dissection. Data related to the role of diabetes, high body mass index, and breast implant size on surgical outcomes were instead inconcludent. Age was not directly proportional to the complications. CONCLUSION: The complications associated with different animal-derived ADMs are generally comparable. The profile of patients required for eligibility for this type of reconstruction appears to have been identified and is in line with current recommendations.

Treatment of a Case of Toe Hair-Thread Tourniquet Syndrome With Hirasè Technique.

ABSTRACT: Hair-thread tourniquet syndrome (HTTS) is an uncommon condition that affects mostly babies, usually a few months old. It happens when a strand of hair or cloth fiber encircles an appendage causing a condition of total or subtotal ischemia (West J Med 1976;125:335-336). This condition has been described several times in the recent literature. Appendages involved include toes, fingers, genitalia, uvula, and neck (N Engl J Med 1965;273:866-867). The mechanism of injury usually involves the fiber cutting the skin deeply through soft tissues, veins, and arteries. As HTTS occurs in small babies and hidden parts of the body, sometimes this event can be very difficult to detect and irritability may be the only symptom. The treatment consists of releasing the circumferential constriction and restoring the arteriovenous flow also with microsurgical techniques if vessel interruption is present. Unfortunately, the fiber or the thread often penetrates so deep that, once an HTTS is recognized, it may be very challenging to identify and trim. The authors present a case of HTTS of the second toe of the right foot in a 2-month-old baby treated with surgical release and Hirasè technique. After the thread was successfully cut and removed, the forefoot was covered with aluminum foil, and a bag with ice was immediately put all around. After 3 days, we observed a complete survival of the toe without any sign of necrosis. Later control at 6 months showed complete restitutio ad integrum of the affected digit with a normal perfusion and absence of any onychopathy. Hirasè technique represents a simple, safe, and low-cost option of treatment for HTTS.

The Adipo-Fascial ALT Flap in Lower Extremities Reconstruction Gustillo IIIC-B Fractures. An Osteogenic Inducer?

RESULTS: Mean time from injury to flap coverage was 72 hours. The mean size of bone defects was 4-7,6 cm. All flaps were Antero Lateral Tight flaps, and the fracture sites did not have any evidence of infection. None of the patients was a smoker. A solid bone union was reached, and full wearing was in a mean of 11 (4-20) weeks after the injury. The lower limb was saved in 100% of the cases. CONCLUSION: Despite the goods results, further studies applied on a large number of patients are needed to confirm authors theory, however, we can consider the fascial ALT flap as a valid help for bone healing in 3B-C open tibial fractures.

Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies): Level of evidence: IV (therapeutic studies).

BACKGROUND: The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap. METHODS: Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40-73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery. RESULTS: The mean MFCFF size was 2-3.8 cm × 2.25-2.5 cm with a mean pedicle length of 6.3 cm (range 4.1-9.4 cm). The postoperative period was uneventful. The mean follow-up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function. CONCLUSIONS: In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.

Sandwich Fascial Anterolateral Thigh Flap in Head and Neck Reconstruction: Evolution or Revolution?

INTRODUCTION: The anterolateral thigh perforator flap (ALT) represents the workhorse for most reconstructive efforts in the head and neck regions. The main advantages of this flap are its versatility, the length of the pedicle, and the low morbidity of the donor site. The major drawback is the bulkiness of this flap with the frequent need for secondary revisions. To overcome this, we have developed a novel way to harvest and inset the ALT, called the sandwich fascial ALT flap (SALT). METHODS: All patients undergoing head and neck reconstruction using the SALT flap from January 2013 to March 2016 were included in this retrospective analysis. The SALT flap was harvested as a composite flap including the superficial fascia, the subscarpal fat, and the deep fascia. At the recipient site, the flap was inset with the deep fascia facing out. A split thickness skin graft (± dermal substitute) was used to cover the deep fascia and the pedicle. RESULTS: Eleven patients were included: 8 cases of orbital exenteration, 1 case of forehead reconstruction, and 2 cases of palatal reconstruction after radical maxillectomy. Flap survival was 100%. One patient required an early take back for venous thrombosis. The reconstruction was effective in all cases, allowing a prosthetic rehabilitation when required. Donor-site morbidity was minimal. CONCLUSIONS: The reconstruction of head and neck defects with a bulky fasciocutaneous ALT flap might not be the best option in every case. The SALT flap could represent a valid alternative for selected cases, with encouraging functional and cosmetic outcomes.

Thumb Reconstruction With Thin Proximal Ulnar Perforator Free Flap.

Soft tissue defects of the thumb with exposure of tendons, periosteum, or neurovascular bundles require a complex reconstruction aimed at restoring both skin coverage and the essential function of pinching and manipulation. When large defects are involved, a free tissue transfer is indicated. The proximal ulnar perforator flap represents an interesting solution without the drawbacks of other more widespread free flaps. This report describes the case of a patient with a squamous cell carcinoma of the thumb that required circumferential resection of the soft tissue of the distal phalanx and the interphalangeal joint. The exposed structures were covered with pliable and texture-matching skin harvested from the proximal volar forearm and based on the proximal ulnar perforator. After 12-month follow-up, the patient was satisfied with the aesthetic outcome. Donor-site morbidity was minimal and no functional impairment in daily-life activities was reported. Even though a skilled microsurgical technique is required for the dissection of the perforator, its constant vascular anatomy and the low risk of damage to the main neurovascular bundle should make this flap reliable for the majority of hand surgeons.

Medial Femoral Condyle Free Flap for Nasal Reconstruction: New Technique for Full-Thickness Nasal Defects.

The nose is a functionally complex organ implicated in breathing, olfaction, and phonation, with a critical role also in the aesthetic appearance of a person. This latter aspect should be carefully considered whenever a total or subtotal rhinectomy is performed for resection of locally advanced nasal cancer. To reconstruct large nasal defects, several techniques were described, including the use of cartilaginous grafts, bony grafts, local flaps, and free flaps. In cases of extensive full-thickness resections, free flaps probably represent the most adequate option. The aim of this report is to present the functional and aesthetical outcomes of a reconstruction of the nose after rhinectomy, using the medial femoral condyle free flap associated with the forehead flap.

Long-Term Computed Tomographic Evaluation of Alveolar Bone Formation in Patients with Unilateral Cleft Lip and Palate after Early Secondary Gingivoalveoloplasty.

BACKGROUND: The goal of this study was to evaluate with a three-dimensional method the long-term quality of alveolar ossification in unilateral cleft lip and palate patients who underwent early secondary gingivoalveoloplasty according to the Milan surgical protocol. METHODS: The sample consisted of 63 computed tomographic scans of unilateral cleft lip and palate patients in permanent dentition. The average age at the time of assessment was 15.7 years. Alveolar thickness, nasoalveolar height, nasal floor ossification, and hard palate morphology were evaluated using dental, axial, and coronal cuts on computed tomographic scans and three-dimensional models. All measurements were normalized and ratios of the affected side versus the nonaffected side were provided. Volume measurements and ratios of each hemimaxilla were added. The presence or absence of the permanent lateral incisor on the cleft side was also recorded. RESULTS: Alveolar thickness and height were ideal or good, respectively, in 89.5 and 91.4 percent of the sample. Insufficient ossification (<25 percent) was found in three patients (5.2 percent), and only one of them (1.7 percent) presented no bone bridging. A statistically significant association was detected between the degree of alveolar ossification, the type of nasal floor ossification, and volume ratio. CONCLUSIONS: Early secondary gingivoalveoloplasty seemed to allow an adequate ossification of both the alveolar and nasal region. Three-dimensional evaluation of the alveolar cleft ossification provided further information on alveolar bridging and allowed evaluation of the bone availability for implant placement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.