[Update and Trends in Breast Reconstruction After Mastectomy]. / Update und Trends bei der plastisch-chirurgischen Brustrekonstruktion nach Mastektomie.

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

FACE-Q Patient Report-Assisted Subjective and Objective Evaluation of Blepharoplasty Outcomes Using Two Different Suturing Techniques: A Randomized and Patient-Blinded Pilot Study.

BACKGROUND: /Objectives To compare two suturing techniques in patients undergoing upper eyelid blepharoplasty by using the FACE-Q™ Eye Module questionnaire to assess patient-reported outcomes and by blinded Likert-scale gradings of two experienced surgeons. METHODS: 90 patients undergoing bilateral blepharoplasty were randomly assigned to a suturing technique (running cutaneous or subcuticular closure) using Prolene 6.0. Patients completed the FACE-Q eye module questionnaire before surgery and 7 days and 3 months after surgery. Further, two trained oculoplastic surgeons assessed the outcome. FACE-Q ratings were RASCH-transformed, and linear models were fitted for appraisal and satisfaction results. Intraclass correlation coefficient (ICC) was calculated to assess the surgeons' rating agreement. RESULTS: There was no statistically significantly difference in patients' FACE-Q self-assessments regarding satisfaction with eyes and appraisal of upper eyelids between the two suturing techniques investigated, both 7 days and 3 months after blepharoplasty. The more content the patient at baseline, the less the increase in satisfaction after 3 months. There was good agreement between blinded graders in outcome assessment expressed by an ICC of 0.86. Dry-eye symptoms increased after surgery, independent of the suturing technique, patient age or sex. CONCLUSION: In conclusion, this study shows that post operative patient satisfaction is independent of suturing technique, but depends on baseline FACE-Q reports. These findings are valuable in patient communication and selection and are in line with observer-based assessments. LEVEL OF EVIDENCE III: 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 http://www.springer.com/00266 .

Silk-in-Silk Nerve Guidance Conduits Enhance Regeneration in a Rat Sciatic Nerve Injury Model.

Advanced nerve guidance conduits can provide an off-the-shelf alternative to autografts for the rehabilitation of segmental peripheral nerve injuries. In this study, the excellent processing ability of silk fibroin and the outstanding cell adhesion quality of spider dragline silk are combined to generate a silk-in-silk conduit for nerve repair. Fibroin-based silk conduits (SC) are characterized, and Schwann cells are seeded on the conduits and spider silk. Rat sciatic nerve (10 mm) defects are treated with an autograft (A), an empty SC, or a SC filled with longitudinally aligned spider silk fibers (SSC) for 14 weeks. Functional recovery, axonal re-growth, and re-myelination are assessed. The material characterizations determine a porous nature of the conduit. Schwann cells accept the conduit and spider silk as growth substrate. The in vivo results show a significantly faster functional regeneration of the A and SSC group compared to the SC group. In line with the functional results, the histomorphometrical analysis determines a comparable axon density of the A and SSC groups, which is significantly higher than the SC group. These findings demonstrate that the here introduced silk-in-silk nerve conduit achieves a similar regenerative performance as autografts largely due to the favorable guiding properties of spider dragline silk.

Myelination, axonal loss and Schwann cell characteristics in axonal polyneuropathy compared to controls.

INTRODUCTION: Polyneuropathy is a debilitating condition characterized by distal sensory and motor deficits. Schwann cell dysfunction and axonal loss are integral factors in pathophysiology and disease progression of polyneuropathy. AIMS: The aim of this study was the assessment of Schwann cell characteristics, nerve fibers and myelination parameters in polyneuropathy patients compared to controls. METHODS: Nerve tissue was obtained from polyneuropathy patients (n = 10) undergoing diagnostic sural nerve biopsies. Biopsies of healthy peripheral nerves (n = 5) were harvested during elective sural nerve grafting for chronic peripheral nerve lesions. Exclusion criteria for the healthy control group were recent neurological trauma, diabetes, neurological and cardiovascular disease, as well as active malignancies and cytotoxic medication within the last 12 months. The over-all architecture of nerve sections and myelination parameters were histomorphometrically analyzed. Immunofluorescent imaging was used to evaluate Schwann cell phenotypes, senescence markers and myelination parameters. RESULTS: Histomorphometric analysis of nerve biopsies showed significant axonal loss in polyneuropathy patients compared to controls, which was in accordance with the neuropathological findings. Immunofluorescent staining of Schwann cells and myelin basic protein indicated a significant impairment of myelination and lower Schwann cell counts compared to controls. Phenotypic alterations and increased numbers of non-myelinating p75-positive Schwann cells were found in polyneuropathy patients. DISCUSSION: This study provided quantitative data of axonal loss, reduced myelination and Schwann cell dysfunction of polyneuropathy patients compared to neurologically healthy controls. Phenotypic alterations of Schwann cells were similar to those seen after peripheral nerve injury, highlighting the clinical relevance of Schwann cell dysfunction.

Functional results after facial reanimation in iatrogenic facial palsy.

BACKGROUND: Iatrogenic facial nerve injury is a common cause of long-standing facial palsy. This study aimed to assess functional results after facial reanimation in iatrogenic facial palsy and to determine correlating patient factors. METHODS: The data of 128 iatrogenic facial palsy patients were analyzed for this case series. Inclusion criteria for assessment of facial function by three-dimensional video analysis were preoperative and postoperative (>18 months) video sets for facial marker tracking, which were available in 63 patients. Demographic factors and treatment concepts were analyzed and correlations to functional outcomes calculated. RESULTS: One hundred and twenty-eight patients with iatrogenic facial palsy underwent facial reanimation procedures and were included in this study. The mean duration of facial palsy was 7.8 years. The most common procedures leading to iatrogenic facial palsy were acoustic neuroma resection (29.7%), parotidectomy (21.1%), and brainstem/cerebellopontine angle tumor resection (21.1%). Selected functional results were significantly improved after facial reanimation surgery. The mean lagophthalmos during eyelid closure reduced from 7.3 ± 4.1 mm to 5.4 ± 4 mm (p < .001). The function of the mouth was significantly improved, both statically (static asymmetry: 10.3 ± 7.6 mm preoperatively, 0.8 ± 9.5 mm postoperatively; p < .001), and during smile movement ("Dynamic Symmetry Index": 0.16 preoperatively, 0.39 postoperatively; p < .001). The mean duration of facial palsy correlated with postoperative smiling function (r = .358, p = .011). CONCLUSION: Facial reanimation significantly improves facial function in iatrogenic facial palsy. Early referral to a facial nerve center is crucial as duration of facial palsy influences functional outcomes.

Bladder augmentation in children: current problems and experimental strategies for reconstruction.

Bladder augmentation is a demanding surgical procedure and exclusively offered for selected children and has only a small spectrum of indications. Paediatric bladder voiding dysfunction occurs either on a basis of neurological dysfunction caused by congenital neural tube defects or on a basis of rare congenital anatomic malformations. Neurogenic bladder dysfunction often responds well to a combination of specific drugs and/or intermittent self-catheterization. However, selected patients with spinal dysraphism and children with congenital malformations like bladder exstrophy and resulting small bladder capacity might require bladder augmentation. Ileocystoplasty is the preferred method of bladder augmentation to date. Because of the substantial long-and short-term morbidity of augmentation cystoplasty, recent studies have tried to incorporate new techniques and technologies, such as the use of biomaterials to overcome or reduce the adverse effects. In this regard, homografts and allografts have been implemented in bladder augmentation with varying results, but recent studies have shown promising data in terms of proliferation of urothelium and muscle cells by using biological silk grafts.

["Pathway protection" - enhanced motoneuron regeneration by end-to-side coaptation of sensory axons]. / "Pathway protection" ­ Verbesserte Motoneuron-Regeneration durch additive End-zu-Seit-Koaptation sensorischer Axone.

Proximal nerve injuries and delayed nerve repair lead to reduced peripheral nerve regeneration. Poor functional results after nerve injury are clinically a very challenging problem. Experimental studies defined "chronic axotomy" of the neuron and the proximal part of a dissected nerve that are separated from their distal target, as well as "chronic denervation" of the distal nerve stump as an independent factors that reduce regenerative capacity of injured nerves. The denervated distal nerve undergoes changes associated with Wallerian degeneration. Denervated Schwann cells change their phenotype to interact with in-growing axons and increase the expression of growth factors. These changes lead to a pro-regenerative environment in the distal nerve stump. This growth-permissive environment deteriorates with time leading to significantly reduced nerve regeneration. Clinically, delayed nerve repair and long regeneration distances often result in inadequate functional outcomes. Different "pathway protection" techniques were developed to improve nerve regeneration and reduce the chronic denervation of the distal nerve. Most of these "babysitter" procedures used a motor donor nerve which was coapted usually end-to-side to the denervated distal nerve stump. Experimental studies showed that in-growing donor axons increase neurotrophic factor levels and improved reinnervation of distal targets. Motor "babysitter" procedures are, however, associated with a motor donor nerve deficit. In recent years, sensory "pathway protection" was investigated to avoid such motor deficit. Motoneuron regeneration of its axons can, in experimental animal models, be improved by end-to-side coaptation of sensory donor axons to either a denervated distal nerve stump or to a long autologous nerve graft, both of which undergo changes associated with chronic denervation. Sensory "pathway protection" has already been successfully clinically applied, however long-term functional analysis awaits.

Axon numbers and landmarks of trigeminal donor nerves for corneal neurotization.

PURPOSE: Corneal anesthesia leads to chronic corneal injury. This anatomical study characterizes the donor nerve branches of the supratrochlear and supraorbital nerves used for corneal neurotization. METHODS: In 13 non-embalmed cadavers, the supratrochlear and supraorbital nerves were dissected and distances to anatomical landmarks measured. Cross-sections of supratrochlear and supraorbital donor nerves were harvested and histomorphometrically analyzed to assess the number of myelinated axons. RESULTS: The donor axon counts were 3146 ± 1069.9 for the supratrochlear and 1882 ± 903 for the supraorbital nerve distal to the supraorbital notch. The supratrochlear nerve was dissected on the medial upper eyelid 2 cm lateral to the facial midline and the branch of the supraorbital nerve 1 cm medial to the mid-pupillary line. CONCLUSION: The supraorbital and supratrochlear branches of the trigeminal nerve are potent donor nerves for corneal neurotization in the treatment of neuropathic keratopathy and can be reliably dissected using anatomical landmarks.

Quality of life and functional assessment of facial palsy patients: A questionnaire study.

BACKGROUND: Facial palsy leads to functional and aesthetic deficits, which impair the quality of life of affected patients. General health-related and disease-specific questionnaires are available for quality of life assessment. In this study, observer-based analysis of facial function (Sunnybrook Facial Grading Scale) was compared patient-based to facial palsy-specific gradings (Facial Clinimetric Evaluation Scale and Facial Disability Index), and general health-related quality of life questionnaires (SF-36). We hypothesized that only facial palsy-specific instruments capture functional and social impairments of affected patients. METHODS: Thirty facial palsy patients treated at a tertiary referral centre were included in this study. Inclusion criteria were unilateral facial palsy with stable facial function, age over 18 years and fluency in German. Facial function was assessed with general and disease-specific patient-reported outcome measures and subsequently evaluated by the treating facial plastic surgeon. Statistical analysis included descriptive statistics for all assessed measurements. Correlations were calculated to compare general and facial palsy-specific instruments, as well as observer-based grading. RESULTS: Observer-based evaluation of facial function correlated well to the patients-based assessment of physical function, however social subscores did not correlate demonstrating the limited correlation of patient distress and facial nerve impairment. Physical function scores of disease-specific instruments did not correlate with general health assessment scores, while social function scores showed moderate to good correlations. CONCLUSION: Validated disease-specific instruments are essential for the assessment of facial palsy patients. Patient-reported outcome measures like the FaCE Scale and the Facial Disability Index should be applied in addition to standardized observer-based ratings to capture the patients' perspective on functional and social impairments associated with facial palsy to fully assess the burden of disease.

The surgical anatomy of the vascularized lateral thoracic artery lymph node flap-A cadaver study.

BACKGROUND: One promising surgical treatment of lymphedema is the VLNT. Lymph nodes can be harvested from different locations; inguinal, axillary, and supraclavicular ones are used most often. The aim of our study was to assess the surgical anatomy of the lateral thoracic artery lymph node flap. MATERIALS AND METHODS: In total, 16 lymph node flaps from nine cadavers were dissected. Flap markings were made between the anterior and posterior axillary line in dimensions of 10 × 5 cm. Axillary lymph nodes were analyzed using high-resolution ultrasound and morphologically via dissection. The cutaneous vascular territory of the lateral thoracic artery was highlighted via dye injections, the pedicle recorded by length, and diameter and its location in a specific coordinate system. RESULTS: On average, 3.10 ± 1.6 lymph nodes were counted per flap via ultrasound. Macroscopic inspection showed on average 13.40 ± 3.13. Their mean dimensions were 3.76 ± 1.19 mm in width and 7.12 ± 0.98 mm in length by ultrasonography, and 3.83 ± 2.14 mm and 6.30 ± 4.43 mm via dissection. The external diameter of the lateral thoracic artery averaged 2.2 ± 0.40 mm with a mean pedicle length of 3.6 ± 0.82 cm. 87.5% of the specimens had a skin paddle. CONCLUSIONS: The lateral thoracic artery-based lymph node flap proved to be a suitable alternative to other VLNT donor sites.

Unsuspected central nervous system gummas in a case of "cerebral infarct" associated with cocaine use.

A 54-year-old African-American male was hospitalized with a left "cerebrovascular accident," altered mental status, agitation, rhabdomyolysis, and hypernatremia. Laboratory tests found cocaine in his system and a positive RPR (rapid plasmin reagin test). A CAT (computed axial tomography) scan without contrast taken 8 days prior to his death showed a left middle cerebral artery infarct, with edema and mass effect, and a 1-cm midline shift to the right. He underwent symptomatic treatment, eventually suffered cardiopulmonary arrest and multiorgan failure, and expired 8 days after admission. The left cerebral lesion diagnosed clinically as a cerebral infarct was actually determined to be a syphilitic gumma on postmortem neuropathologic examination. Neurosyphilis, although rare, should be considered in the differential diagnosis of space-occupying lesions in the brain because cases of syphilis continue to occur both sporadically and as an opportunistic infection associated with acquired immunodeficiency syndrome (AIDS) and because neurosyphilis is treatable.

December 2002: 19-year old male with febrile illness after jet ski accident.

The December 2002 COM. A 19-year-old healthy male fell into stagnant water of the intercostal waterway (salt water of South Florida), following a jet ski accident. He sustained minor superficial injuries but engulfed significant quantities of water and sediment. A few days later he developed bifrontal headaches, vomiting, a stiff neck and a temperature of 102 degrees F. A CT scan on admission without contrast was negative. The CSF had markedly elevated white count but bacterial and fungal cultures were negative. He became progressively lethargic. On the fifth day he developed seizure activity. He expired the next day despite antibiotics. Gross examination of the brain at autopsy revealed edema, cerebellar tonsillar herniation and purulent meningitis. Microscopic examination revealed a massive leptomeningeal inflammatory infiltrate composed of neutrophils, lymphocytes, and numerous histiocyte-like cells. The inflammatory infiltrate extended into the cerebral parenchyma in numerous areas also involving the cerebellum, brainstem and ventricular system. Given the exposure to stagnant water (later confirmed to be a man-made fresh water lake), and the numerous histiocytic-like cells, suspicion for an amebic etiology of the disease process was raised and the CDC identified the ameba as Naegleria Fowleri. Infection by Naegleria Fowleri, a free-living ameba, occurs after exposure to polluted water in man-made fresh water lakes, ponds, swimming pools, particularly during the warm weather months when the thermophilic ameba grows well. The pathologic substrate of the infection is an acute hemorrhagic, necrotizing meningo-encephalitis mainly at the base of the brain, brainstem and cerebellum occurring in young, healthy individuals.