The short scar three-block L-wing technique.

INTRODUCTION: Numerous techniques have been proposed for the plastic surgical treatment of hypertrophic breasts. Challenges of the procedure include the preservation of vascular supply and sensitivity of the nipple areola complex (NAC), breast feeding, and an esthetically pleasing result. OBJECTIVES: In the present preliminary report, we introduce a new technique called the three-block L-wing reduction mammaplasty that addresses the aforementioned difficulties. MATERIALS AND METHODS: The three-block L-wing reduction mammaplasty with a thick hemispheric superiorly based NAC pedicle and a medial as well as lateral pillar was performed in a total of 60 patients. RESULTS: Our technique increases both, vascular safety and the sensory supply to the NAC, as it conceptually decreases the need for dissection of breast tissue and skin. The incidence of fat necrosis and wound healing disorders may be reduced with this technique. Because the ducts of the breast-gland underneath the NAC are not dissected, this technique also promises a higher probability of regular breast-feeding. Finally, our technique permits a cosmetically pleasing round-shaped mound of the breast. CONCLUSION: The three-block modification simplifies the procedure of the superior pedicle L-wing mammaplasty markedly. It may increase the esthetic as well as the functional outcome and decrease postoperative complications.

The proximal medial sural nerve biopsy model: a standardised and reproducible baseline clinical model for the translational evaluation of bioengineered nerve guides.

Autologous nerve transplantation (ANT) is the clinical gold standard for the reconstruction of peripheral nerve defects. A large number of bioengineered nerve guides have been tested under laboratory conditions as an alternative to the ANT. The step from experimental studies to the implementation of the device in the clinical setting is often substantial and the outcome is unpredictable. This is mainly linked to the heterogeneity of clinical peripheral nerve injuries, which is very different from standardized animal studies. In search of a reproducible human model for the implantation of bioengineered nerve guides, we propose the reconstruction of sural nerve defects after routine nerve biopsy as a first or baseline study. Our concept uses the medial sural nerve of patients undergoing diagnostic nerve biopsy (≥ 2 cm). The biopsy-induced nerve gap was immediately reconstructed by implantation of the novel microstructured nerve guide, Neuromaix, as part of an ongoing first-in-human study. Here we present (i) a detailed list of inclusion and exclusion criteria, (ii) a detailed description of the surgical procedure, and (iii) a follow-up concept with multimodal sensory evaluation techniques. The proximal medial sural nerve biopsy model can serve as a preliminary nature of the injuries or baseline nerve lesion model. In a subsequent step, newly developed nerve guides could be tested in more unpredictable and challenging clinical peripheral nerve lesions (e.g., following trauma) which have reduced comparability due to the different nature of the injuries (e.g., site of injury and length of nerve gap).

Retrograde tracing and toe spreading after experimental autologous nerve transplantation and crush injury of the sciatic nerve: a descriptive methodological study.

Evaluation of functional and structural recovery after peripheral nerve injury is crucial to determine the therapeutic effect of a nerve repair strategy. In the present study, we examined the relationship between the structural evaluation of regeneration by means of retrograde tracing and the functional analysis of toe spreading. Two standardized rat sciatic nerve injury models were used to address this relationship. As such, animals received either a 2 cm sciatic nerve defect (neurotmesis) followed by autologous nerve transplantation (ANT animals) or a crush injury with spontaneous recovery (axonotmesis; CI animals). Functional recovery of toe spreading was observed over an observation period of 84 days. In contrast to CI animals, ANT animals did not reach pre-surgical levels of toe spreading. After the observation period, the lipophilic dye DiI was applied to label sensory and motor neurons in dorsal root ganglia (DRG; sensory neurons) and spinal cord (motor neurons), respectively. No statistical difference in motor or sensory neuron counts could be detected between ANT and CI animals.In the present study we could indicate that there was no direct relationship between functional recovery (toe spreading) measured by SSI and the number of labelled (motor and sensory) neurons evaluated by retrograde tracing. The present findings demonstrate that a multimodal approach with a variety of independent evaluation tools is essential to understand and estimate the therapeutic benefit of a nerve repair strategy.

Importance of the suprasternal notch to nipple distance (SSN:N) for vascular complications of the nipple areola complex (NAC) in the superior pedicle vertical mammaplasty: a retrospective analysis.

BACKGROUND: The superior pedicle, frequently used with vertical mammaplasty, bears some risk for vascular complications of the nipple areola complex (NAC) particularly in large breasts. The suprasternal notch to nipple distance (SSN:N), geometrically associated with the longitudinal axis of the breast and length of the superior pedicle, might be an indicative parameter to assess these complications. Importance of the SSN:N for vascular complication of the NAC was focussed upon in this study. MATERIAL AND METHODS: Arterial and venous complications of 104 patients following the superior pedicle vertical mammaplasty were retrospectively evaluated both sided (n=208 breasts), according to the preoperatively measured SSN:N. Binary logistic regression (p≤0.05) was used for statistical evaluation. RESULTS: Probability of vascular compromise of the NAC is influenced by the SSN:N within the context of the superior pedicle vertical mammaplasty. An SSN:N>30 cm (n=112 breasts) is subject to venous (p=0.002) as well as arterial (p=0.232) complications of the NAC, both of which may result in partial necrosis of the tissue (p=0.029). CONCLUSION: The SSN:N measurement can be helpful to identify patients at risk for vascular complications of the superiorly stalked NAC. Modifications of the superior pedicle or other pedicles potentially providing enhanced vascular impact might be considered with an SSN:N beyond 30 cm to reduce vasculature-related complications of the NAC.

The anterior Obturator Artery Perforator (aOAP) flap: surgical anatomy and application of a method for vulvar reconstruction.

OBJECTIVE: Vulvar reconstruction following oncologic resection is challenging. Some flaps used for reconstruction can show adverse characteristics such as excessive tissue bulk or increased distance to the defect. Region of the sulcus genitofemoralis is of thin and pliable tissue proximate to the vulva. Vasculature and suitability of that region used for vulvar reconstruction were focused in this work. METHODS: Vascular architecture of the region comprising the sulcus genitofemoralis was examined bilaterally on 10 female corpses (n = 20 specimens). In addition, tissue characteristics and suitability of that region to form a fasciocutaneous flap for vulvar reconstruction were anatomically examined and clinically proven. RESULTS: Vasculature of the sulcus genitofemoralis is reflected by either a musculocutaneous perforator (80%, 16/20) piercing the gracilis muscle or a septocutaneous perforator (20%, 4/20) passing the posterior border of the gracilis muscle 1.3 ± 0.3 [cm] laterally to the inferior pubic ramus. Both types of perforators derive from the anterior branch of the obturator artery and accompanying vein. This perforator, the anterior obturator artery perforator (aOAP), supplies a skin territory of about 7 × 15 [cm] centered on the sulcus genitofemoralis. The aOAP flap proved its suitability and versatility for vulvar reconstruction. CONCLUSIONS: The sulcus genitofemoralis is of a constant vascular anatomy reflected by the aOAP vessel. Especially the tunneled aOAP island flap offers outstanding characteristics beneficial for reconstruction of a more anatomically normal vulva. Scars are limited within anatomic borders of the urogenital region improving self-image. The aOAP flap clearly enlarges the surgical options available to restore the form and function of the vulva.

Perforator vessel anatomy of the papilla umbilicalis: topography and importance for reconstructive abdominal wall surgery.

PURPOSE: Separation of midline abdominal wall components or other procedures involving the papilla umbilicalis within the context of abdominal wall reconstruction can significantly affect vasculature of the umbilicus. Adjusting dissection to the vascular anatomy of that region may evade such complications. For this purpose, an anatomic microdissection study was performed, focusing on the vascular architecture of the papilla umbilicalis in the midst of the stratigraphical anatomy of the midline abdominal wall. METHODS: Ramifications of the epigastric vessels were filled with dye on 27 abdominal walls originating from 15 female and 12 male corpses. Vascular architecture of the midline abdominal wall was examined by X-ray imaging and microdissection focusing region of the papilla umbilicalis. RESULTS: Vasculature of the papilla umbilicalis is provided by both myocutaneous and septocutaneous perforator vessels originating from the medial branch of the arteria epigastrica inferior and accompanying veins. On their way to the inferiolateral basis of the papilla umbilicalis, these perforators prove an intimate and regular association with the rectus abdominis muscle, and different components of the rectus sheath. CONCLUSIONS: Vasculature of the papilla umbilicalis is susceptible to damage resulting from separation of midline abdominal wall components or periumbilical dissections. To secure vasculature of the papilla umbilicalis, the integrity of the loose areolar fascia covering the posterior surface of the rectus abdominis muscle must be kept from being harmed by dissection. In addition, the musculo-fibrous-aponeurotic anatomy on either the left or the right side of the papilla umbilicalis must be left in structural continuity.

The bivectorial full-thickness superiorly based NAC flap: a new option to increase plasticity and decrease tension in the superior pedicle vertical mammaplasty technique.

The standard split-thickness superior pedicle vertical mammaplasty technique sometimes suffers from tension on the nipple-areola complex (NAC). We suggest a bisected full-thickness superiorly based flap that offers two vectors for transposition within the context of superior pedicle vertical mammaplasty. The procedure increases both upper-pole fullness and projection of the breast while decreasing tension on the NAC. The surgical procedure presented contributes to a natural appearance of the breast. It should provide a useful and simple surgical option, increasing the versatility of the superior pedicle vertical mammaplasty technique.

Evaluation of functional nerve recovery with Visual-SSI--a novel computerized approach for the assessment of the static sciatic index (SSI).

Complete nerve transection (neurotmesis) of the rat sciatic nerve is a well-established animal model. The most frequently used behavioural for evaluation of neurotmesis-induced deficits is the walking track analysis with calculation of the sciatic functional index (SFI). More recently, the static sciatic index (SSI) has been developed, which shows a good correlation with the SFI. However, despite all advantages (high accessibility, easy handling, high accuracy, cost-effectiveness), the SSI is still not widely used. We, therefore, developed a novel programme ("Visual-SSI"), which will be made freely available for the assessment of the SSI. As gold-standard for the treatment of neurotmesis-induced nerve gaps, autologous nerve transplantation studies in the rat sciatic nerve model (n=16 [6 weeks], n=8 [12 weeks]) were carried out to test the effectiveness and feasibility of the Visual-SSI software. We observed a significant recovery starting from the pre-operative condition over the 3rd, 6th, 9th weeks until the 12th week after surgery (p<0.05). Theoretically, the SSI can be calculated from both rearing and normal standing position of the rats and we investigated whether the SSI is affected differentially by these positions. We observed no significant differences between animals in a rearing and normal standing stance (p>0.05). The present method combines efficiency (simplicity of use, rapid and economical setup) with accurate and precise quantification of the functional regeneration in the sciatic nerve lesion model of the rat.

Ablative targeting of fatty-tissue using a high-powered diode laser.

BACKGROUND AND OBJECTIVE: Concerning current clinical practice, laser-assisted lipoplasty is still secondary to other procedures. In order to evaluate effects of thermal interaction with fatty-tissue, a near infrared diode laser was examined under reproducible conditions. METHODS: Based on optical spectroscopy of fatty-tissue, a high-powered diode laser (lambda = 940 nm) was used to irradiate n = 59 fat samples of fresh corpses in non-contact mode. Thermal effects were histologically evaluated by computer based metric measurements. Calculated values included ablation rate (AR) and the ratio of cavity diameter to diameter of collateral damage (CCD(ratio)). Pearson's correlation and analysis of covariance (ANCOVA) were used for statistical evaluation. P values of less than 0.05 were considered to indicate statistical significance. RESULTS: Regarding the conditions examined, irradiances from 250 to 400 W/cm(2) revealed both increased ablation capacities and decreased collateral damages. An average irradiance of 370+/-0 W/cm(2) shows an average CCD(ratio) of 2:1 and an average AR of 9.98+/-7.65 mm(3)/second. CONCLUSION: Near infrared high-powered diode laser energy proved to be eligible for tissue protective ablation of fat in vitro. Further studies are necessary to improve efficiency and safety of this procedure.

Vascular reliability of nipple-areola complex-bearing pedicles: an anatomical microdissection study.

BACKGROUND: Vascular-dependent necrosis of the nipple-areola complex following reduction mammaplasty is still present. Concerning anatomy, there is a lack of literature comparing the vasculature of different nipple-areola complex-bearing pedicles in detail. Including six arterial sources supplying the breast, this anatomical work intends to clarify arterial impact and vascular reliability of different nipple-areola complex-bearing pedicles. METHODS: Microdissections of anterior chest walls following vessel filling with dye were performed to examine the architecture of the arteries supplying the breast and their contribution to the blood supply of the nipple-areola complex on seven female corpses (14 breasts). RESULTS: Four of six arterial sources supporting the breast were found to be mainly responsible for the blood supply of the nipple-areola complex. These are, in descending order of reproducibility, branches originating from the lateral thoracic artery, the internal mammary artery, the anterior branches of the intercostal arteries, and those deriving from the highest thoracic arteries. Despite vessel variability, both arrangements and subcutaneous courses of arteries advancing to the nipple-areola complex showed characteristic relationships. CONCLUSIONS: Vascular variability and overlap may account for the remarkable safety of diverse nipple-areola complex-bearing pedicles, even though pedicle thickness influences vascular reliability. Lateral and medial approaches, however, clearly show vascular advantages over that which can be observed in inferior and superior pedicles. The former may therefore be regarded as more reliable. Especially the full-thickness glandular dermal superolaterally based pedicle should regularly enclose dominant branches originating from the lateral thoracic artery and supplementary arteries deriving from minor important sources in this region.

Accidental burns during surgery.

The purpose of this report is to increase awareness of intraoperative burns during standard procedures, to discuss their possible causes and warning signs and to provide recommendations for prevention and procedures to follow after their occurrence. A total of 19 patients associated with intraoperative burn accidents were treated surgically and analyzed after a mean follow-up of 5 +/- 3.5 months. Review included retrospective patient chart analysis, clinical examination, and technical device and equipment testing. A total of 15 patients recently underwent cardiac surgery, and 4 pediatric patients recovered after standard surgical procedures. A total of 15 patients had superficial and 4 presented with deep dermal or full-thickness burns. The average injured TBSA was 2.1 +/- 1% (range, 0.5-4%). Delay between primary surgery and consultation of plastic surgeons was 4.5 +/- 3.4 days. A total of 44% required surgery, including débridment, skin grafting or musculocutaneous gluteus maximus flaps, and the remaining patients were treated conservatively. Successful durable soft-tissue coverage of the burn region was achieved in 18 patients, and 1 patient died after a course of pneumonia. Technical analysis demonstrated one malfunctioning electrosurgical device, one incorrect positioned neutral electrode, three incidents occurred after moisture under the negative electrode, eight burns occurred during surgery while fluid or blood created alternate current pathways, five accidents were chemical burns after skin preparation with Betadine solution, and in one case, the cause was not clear. The surgical team should pay more attention to the probability of burns during surgery. Early patient examination and immediate involvement of plastic and burn surgeons may prevent further complications or ease handling after the occurrence.