A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap.

Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.

Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study.

INTRODUCTION: Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. METHOD: This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. RESULTS: One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. CONCLUSION: bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.

An imprint method to produce surface asperities for EHL and RCF experiments.

A method was developed for creating single well-defined surface asperities using an imprint technique. The proposed method enables:•Creation of well-defined micrometre high asperities•Creation of asperities which survived more than 35 million EHL contact cycles•Damage tracing thanks to the possibility to control the damage initiation sites.The technique is based on rolling a hard disc with indents against a soft disc for creating single surface asperities. The contact pressure causes plastic deformation forcing material into the indents to create the asperities. The height of the asperities can be controlled by adjusting the applied force. After initial reshaping during the run-in process, the asperities were strong enough to survive more than 35 million elastohydrodynamic lubrication cycles, which should be of great interest for the researchers who investigate rolling contact fatigue experimentally. The method could also aid the research on the run-in process by enabling tracing the development of specific surface defects. Since the method can produce high and strong asperities it might also prove useful for investigations how asperities deform under sever contact conditions.

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap.

INTRODUCTION: After extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap. METHOD: Patients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed. RESULTS: Thirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap. CONCLUSION: This long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.

Blood flow dynamics in reconstructed auricles.

Ear reconstruction with autologous rib cartilage is performed in stages. Restitution of blood flow between the separate stages is crucial to obtain a good result. Laser Doppler perfusion imaging (LDPI) and local temperature were measured in reconstructed and normal ears in response to indirect heating. Ten persons who had had a unilateral ear reconstruction were included in the study. At a minimum, 157 days had passed since the last operation. LDPI showed no difference in blood flow between the reconstructed ear and the normal ear, neither before nor after indirect heating. The upper part of the normal ear was slightly cooler than the corresponding part in the reconstructed ear. Indirect heating caused an increase of LDPI-values and temperatures in the upper, middle, and lower part of the ear both in the reconstructed ear and the normal one. Skin blood flow recovers after 3-stage ear reconstruction and shows normal dynamic response upon indirect heating.

A comparison of digital morphometry and clinical measurements of ears.

Clinical measurements are necessary in many routine follow-ups and scientific evaluations, but the accuracy of these measurements is seldom challenged. The size of the reconstructed ear is one important parameter in the follow-up regarding patients operated on due to microtia. With the introduction of digital morphometry one was obliged to evaluate its accuracy in comparison to its analogue equivalents. In a first series of measurements the ears of 30 persons were assessed using digital morphometry, compass and ruler, and calliper to test the accuracy of these methods. In a second series of measurements, 10 patients with reconstructed unilateral microtia were assessed with digital morphometry to test the inter-individual variation of this method. The accuracy of digital morphometry was of the same magnitude as the manual methods. When the inter-individual variation of accuracy was assessed in digital morphometry it was found that random error differed from person to person. In scientific settings, for instance when evaluating possible growth of the cartilage framework, the specific individual accuracy must therefore be taken into account in order to draw safe conclusions.

Patients' satisfaction after ear reconstruction with autologous rib cartilage.

Patients' satisfaction is an important outcome measure in reconstructive surgery and quality assurance is today central in the clinical practice. The aim of this study was to evaluate the patients' satisfaction with the process and final result after reconstruction for congenital microtia. A questionnaire was designed and sent to 78 patients who had undergone unilateral ear reconstruction with autologous rib cartilage during the period 2000-2010. For a multidimensional view the patients answered 42 questions about aesthetic, functional, psychosocial, and clinic-related outcomes. The response rate was 76% (59/78 patients). The patients were generally satisfied with the aesthetic result of the ear and had function gain in being able to wear glasses; however, some patients did report new different functional problems after the operation. Still, almost all patients felt that the ear was a part of them and would have chosen the same operative procedure if they could do it again. The patients were overall highly satisfied with the care process. This surgery-specific questionnaire is an important tool for quality assurance in this clinical practice. These findings can help to improve the preoperative information to meet the patients' notions, expectations, and fears.

Threshold of tactile perception in a reconstructed auricle.

There are more important outcome variables than the aesthetic when it comes to a successful result in reconstruction of the ear for microtia. The protective sensitivity, for example, is important to avoid damage to the skin covering the cartilaginous framework. We studied 39 patients with unilateral microtia and recorded their skin sensitivity more than six months after the last operation. The Semmes-Weinstein Monofilament Test (SWMT) was used to assess the threshold of protective sensitivity in three particular areas: the helix, the anthelix, and the lobule. The opposite ear served as control. A monofilament of 4.31 or less was regarded as acceptable protective sensitivity. Thirty-two patients had acceptable sensitivity in the whole ear, but the helix gave a poor result in seven patients and in one of them so did the anthelix.

Thermosensitivity in a reconstructed microtic ear.

The aim of this study was to evaluate thermo-thresholds in autologous reconstructed microtic ears. Nineteen patients with unilateral microtia were investigated no less than two years after the last operation (3.6+/-1.7 years). Their normal corresponding ear acted as controls. Eight healthy children were also investigated to illustrate technical differences between measuring the two sides. Thermal sensitivity was tested quantitatively using a SENSELab MSA Thermotest. The skin temperature was also tested. Three different areas of the ear were examined: the lobe, the antihelix, and the helix. The reconstructed ear had a significantly higher skin temperature for all investigated areas compared with the normal ear (reconstructed ear 30.2+/-1.2 degrees C, normal ear 28.6+/-0.9 degrees C). For the controls there were no significant differences in any area. For the patients there were small differences in perception of cold between the reconstructed and the normal ear. There were significant differences in the antihelix region and the helix in heat perception in the reconstructed ear compared with the normal one (helix reconstructed ear 43.9+/-3.8 degrees C, helix normal ear 38.3+/-3.0 degrees C, antihelix reconstructed ear 39.9+/-3.0 degrees C, antihelix normal ear 36.4+/-1.7 degrees C). The reconstructed ear had a changed thermosensitivity, but there did not seem to be any clinical disadvantages.

Linear theory, dimensional theory, and the face-inversion effect.

We contrast 2 theories within whose context problems are conceptualized and data interpreted. By traditional linear theory, a dependent variable is the sum of main-effect and interaction terms. By dimensional theory, independent variables yield values on internal dimensions that in turn determine performance. We frame our arguments within an investigation of the face-inversion effect--the greater processing disadvantage of inverting faces compared with non-faces. We report data from 3 simulations and 3 experiments wherein faces or non-faces are studied upright or inverted in a recognition procedure. The simulations demonstrate that (a) critical conclusions depend on which theory is used to interpret data and (b) dimensional theory is the more flexible and consistent in identifying underlying psychological structures, because dimensional theory subsumes linear theory as a special case. The experiments demonstrate that by dimensional theory, there is no face-inversion effect for unfamiliar faces but a clear face-inversion effect for celebrity faces.