Donor-Site Morbidity and Quality of Life after Autologous Breast Reconstruction with PAP versus TMG Flap.

The transverse myocutaneous gracilis (TMG) and the profunda artery perforator (PAP) flap are both safe choices for autologous breast reconstruction originating from the same donor region in the upper thigh. We aimed to compare the post-operative outcome regarding donor-site morbidity and quality of life. We included 18 patients who had undergone autologous breast reconstruction with a PAP flap (n = 27 flaps). Prospective evaluation of donor-site morbidity was performed by applying the same questionnaire that had already been established in a previous study evaluating TMG flap (n = 25 flaps) outcome, and results were compared. Comparison of the two patient groups showed equivalent results concerning patient-reported visibility of the donor-site scar and thigh symmetry. Still, the TMG group was significantly more satisfied with the scar (p = 0.015) and its position (p = 0.001). No difference was found regarding the ability to sit for prolonged periods. Donor-site wound complications were seen more frequently in the PAP group (29.6%) than in the TMG group (4.0%). Both groups expressed rather high satisfaction with their quality of life. Both flaps show minimal functional donor-site morbidity and high patient satisfaction. To minimize wound healing problems in PAP patients, thorough planning of the skin paddle is necessary.

Long-Term Outcome Analysis and Technical Refinements after Autologous Breast Reconstruction with PAP Flap: What We Have Learnt.

Introduction: The profunda artery perforator (PAP) flap represents a valuable alternative to the deep inferior epigastric artery perforator flap which, nowadays, is considered the golden standard for autologous breast reconstruction. The goal of this study was to evaluate the long-term satisfaction, functional outcomes of the donor site following PAP flap-based breast reconstruction and to present our personal learning experience along with suggestions for technique refinements. Methods: In this prospective single-center appraisal, 18 patients who underwent PAP flap-based breast reconstruction between January 2016 and November 2019 were enrolled. The Patient and Observer Scar Assessment Scale (POSAS) and the Breast-Q questionnaire were employed to evaluate the results 12 months postoperative. Data were analyzed with the Q-Score program. Complications were recorded in the medical database and classified with the Clavien-Dindo classification. Results: In the questionable time frame, 164 female patients underwent free flap breast reconstruction. Of those, 18 patients that received PAP flaps (9 bilateral) were included in this study. We recorded one flap loss because of venous failure. Most complications concerned the donor site, including hematoma, seroma, and wound healing problems. Patients' satisfaction was high at 12 months post-surgery, despite critical evaluation of the donor site scar. Conclusion: The PAP flap serves as an excellent option for breast reconstruction in patients who do not have abundant abdominal tissue. The overall clinical outcome was good and patients' evaluation showed high satisfaction after 12 months despite high complication rates. Modifications in planning and flap harvesting might improve the donor site outcome and the overall complication rate.

Simple, but effective: Nasal splinting for airway securement in free flap reconstruction following orbital exenteration.

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino-orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

Memory Effect of the Median Nerve: Can Ultrasound Reliably Depict Carpal Tunnel Release Success?

Purpose To evaluate whether ultrasound findings of the median nerve cross-section area (CSA) and wrist-to-forearm ratio (WFR) correlate with neurophysiological and patient-reported outcome after surgery for carpal tunnel syndrome (CTS). Materials and Methods Subjective pain, CSA, WFR, postoperative scar tissue formation and nerve conduction velocity in 21 hands of 20 patients with clinically confirmed CTS were examined before and after carpal tunnel release surgery. Group differences were compared via a 2-sided ratio paired t-test or one-way ANOVA, and correlations were calculated using a linear regression model. Results There were no significant pre- and postoperative changes of the CSA of the median nerve (p = 0.293, 95 % CI 0.826 - 1.063) or WFR (p = 0.230, 95 % CI 0.757 - 1.074). The nerve conduction velocity (p < 0.0001, 95 % CI 0.753 - 0.886) and subjective pain during rest (p = 0.001, 95 % CI 1.615 - 5.797) and exercise (p = 0.008, 95 % CI 0.760 - 4.888) improved significantly, though. There was no correlation between changes in the median nerve CSA and nerve conduction velocity (p = 0.357, r = 0.217, R2 = 0.047) or reported pain intensity (p = 0.441, r = 0.200, R2 = 0.040). Conclusion Contrary to common assumptions, there is no significant reduction of the CSA of the median nerve after successful carpal tunnel release. Morphologic median nerve changes may persist for a longer period regardless of successful surgery and clinical improvement. Accordingly, ultrasound appears unsuitable as the primary means of assessing surgical success due to this "memory effect". Key Points · CSA of the median nerve does not change significantly after successful carpal tunnel release.. · Morphologic median nerve alterations may persist regardless of functional outcome ("memory effect").. · Therefore, ultrasound imaging is not ideally suited to assess the outcome after carpal tunnel release.. Citation Format · Steinkohl Fabian, Gruber Leonhard, Gruber Hannes et al. Memory Effect of the Median Nerve: Can Ultrasound Reliably Depict Carpal Tunnel Release Success?. Fortschr Röntgenstr 2017; 189: 57 - 62.

Transverse musculocutaneous gracilis flap for treatment of capsular contracture in tertiary breast reconstruction.

Capsular contracture is a common complication associated with implant-based breast reconstruction and augmentation leading to pain, displacement, and rupture. After capsulectomy and implant exchange, the problem often reappears. We performed 52 deepithelialized free transverse musculocutaneous gracilis (TMG) flaps in 33 patients for tertiary breast reconstruction or augmentation of small- and medium-sized breasts. The indications for implant removal were unnatural feel and emotion of their breasts with foreign body feel, asymmetry, pain, and sensation of cold. Anyway, most of the patients did not have a severe capsular contracture deformity. The TMG flap is formed into a cone shape by bringing the tips of the ellipse together. Depending on the contralateral breast, the muscle can also be shaped in an S-form to get more projection if needed. The operating time for unilateral TMG flap breast reconstruction or augmentation was on average 3 hours and for bilateral procedure 5 hours. One patient had a secondary revision of the donor site due to disruption of the normal gluteal fold. Eighty percent of the unilateral TMG flap reconstructions had a lipofilling procedure afterward to correct small irregularities or asymmetry. The advantages of the TMG flap such as short harvesting time, inconspicuous donor site, and the possibility of having a natural breast shape make it our first choice to treat capsular contracture after breast reconstruction and augmentation.

Extraordinary giant basal cell carcinoma with full-thickness infiltration of the abdominal wall: single-staged resection and simultaneous reconstruction.

BACKGROUND: Basal cell carcinoma (BCC) is the most frequent form of invasive skin cancer. BCCs usually show a slow progression and rarely metastasize; however, around 1% achieve a "giant" size, larger than 5 cm in diameter. Rarely, BCCs larger than 20 cm are reported in the literature. OBJECTIVE: We report a case of a giant BCC, measuring 25 × 13 × 5 cm, involving the abdominal wall. The article describes the curative surgical procedure, which resulted in an excellent aesthetic result.

Donor-site morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: short-term and long-term results.

BACKGROUND: The authors have used the transverse musculocutaneous gracilis flap technique for autologous breast reconstruction after skin-sparing mastectomy since August of 2002. The donor site is closed in the manner of a medial thigh lift. The authors examined the short-term and long-term results of donor-site morbidity in their first 22 patients. METHODS: Nineteen patients underwent unilateral and three patients received bilateral breast reconstruction with a transverse musculocutaneous gracilis flap after skin-sparing mastectomy. Using a questionnaire, patients were asked about complaints resulting from elevation of the gracilis muscle and their satisfaction with the result, general condition, and sexuality. Cosmetic evaluations of the thigh donor site were performed independently by two plastic surgeons. RESULTS: To evaluate short-term results, mean follow-up of the 22 patients was 10 months. All patients were satisfied with the scar in the inguinal region. Concerning thigh symmetry, 42 percent of patients showed excellent results, 40 percent had good results, and 18 percent had fair results. With regard to the scars, 24 percent of patients had excellent results, 46 percent had good results, and 30 percent had fair results. Thigh shape was evaluated as excellent by 26 percent, good by 52 percent, and fair by 22 percent. Patients who had a unilateral gracilis donor site had a difference in maximal thigh circumference of 2.368 cm. Four years postoperatively, all patients would choose this kind of operation again. CONCLUSIONS: The medial thigh region allows the removal of a moderate amount of tissue, even in thin patients, with a very inconspicuous scar. The transverse musculocutaneous gracilis flap is safe for immediate reconstruction of small and medium-sized breasts, with minimal functional donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Capsular flap for coverage of an exposed implant after skin-sparing mastectomy and immediate breast reconstruction.

Native skin-flap necrosis following skin-sparing mastectomy (SSM) is treated by raising a capsular flap, formed as a consecutive physiological reaction around breast implant. Using this highly vascularised thin tissue layer as an implant coverage withdraws pressure from the defect and allocates a good background for wound healing.

Hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management.

BACKGROUND: Hypertrophic scars and keloids result from an abnormal fibrous wound healing process in which tissue repair and regeneration-regulating mechanism control is lost. These abnormal fibrous growths present a major therapeutic dilemma and challenge to the plastic surgeon because they are disfiguring and frequently recur. OBJECTIVE: To provide updated clinical and experimental information on hypertrophic scars and keloids so that physicians can better understand and properly treat such lesions. METHODS: A Medline literature search was performed for relevant publications and for diverse strategies for management of hypertrophic scars and keloids. CONCLUSION: The growing understanding of the molecular processes of normal and abnormal wound healing is promising for discovery of novel approaches for the management of hypertrophic scars and keloids. Although optimal treatment of these lesions remains undefined, successful healing can be achieved only with combined multidisciplinary therapeutic regimens.

Restoration of elbow flexion after brachial plexus injury by free functional rectus femoris muscle transfer.

SUMMARY: A 22-year-old patient sustained a complex injury of the left brachial plexus. Primary brachial plexus reconstruction did not lead to any functional recovery. Twenty-six months later, the patient showed an upper brachial plexus palsy, which precluded the possibility for a latissimus dorsi muscle transfer. To re-establish elbow flexion, a free myocutaneous neurovascular rectus femoris flap, harvested from the left thigh, was neurotised to the accessory nerve using a sural nerve graft. Ten months after the free functional rectus femoris transfer, early electromyographic results were detected, and 7 months later, strong reinnervation signs occurred. Due to dissatisfaction with the aesthetic results including an impression in the left shoulder and pectoral region, two silicon implants were inserted 41 months after rectus femoris muscle transfer. A few hours after the operation, the patient experienced palsy of the transplanted muscle. The silicon implants were removed immediately. Initial recovery of muscle function was detected by electromyography 4 months later and complete reinnervation was observed 8 years postoperative. Elbow flexion was rated M4, and the patient had no functional donor-site morbidity. The authors conclude that free rectus femoris muscle transfer offers excellent results when effort is put into postoperative rehabilitation with extensive training programs.

Microvascular transplantation of adipose tissue and serum level of adipocyte products.

Microvascular transplantation of subcutaneous adipose tissue is an essential step in reconstructive surgery after breast carcinoma. Serum levels of adipose tissue products may serve as indicators for transplant function. This study aimed to determine serum leptin and tumor necrosis factor (TNF)-alpha plasma levels pre-, intra-, and postoperatively in 20 patients undergoing reconstructive breast surgery and in 7 women undergoing abdominoplasty operation. In the patients undergoing reconstructive breast surgery, the serum leptin levels decreased intraoperatively from 14.5 +/- 13.1 to 9.1 +/- 7.3 ng/ml, a decrease of 63%. An increase in serum leptin levels to 13.5 +/- 12.7 ng/ml (93% of the initial value) was found on postoperative day 1. This was paralleled by similar changes in the plasma levels of TNF-alpha (preoperatively, 20 +/- 7.3 pg/ml; intraoperatively, 17 +/- 11.4 pg/ml; postoperatively, 21 +/- 10.8 pg/ml). In the patients undergoing abdominoplasty, plasma leptin and TNF-alpha levels decreased intraoperatively (20% and 27%, respectively) and postoperatively (44% and 27%, respectively). The results of our pilot study indicate that a postoperative increase in the level of serum leptin after reconstructive breast surgery may be related to successful transplant function.

Nerve injury caused by removal of an implantable hormonal contraceptive.

Implanon insertion and removal are relatively uncomplicated procedures in the hands of medical professionals familiar with the technique. However, injury to branches of the medial antebrachial cutaneous nerve during Implanon insertion and removal can result in impaired sensibility, severe localized pain, or the formation of painful neuroma that can be quite devastating to the patient. The best way to avoid injury to the medial antebrachial cutaneous nerve is to better understand its position relative to the standard area of Implanon insertion. In the event that an injury to the nerve is recognized, immediate plastic surgical measures should be undertaken to avoid displeasing sequels of nerve injuries. Therefore, the benefit of this generally well-tolerated, highly effective, and relatively cost-efficient contraception is guaranteed only in the hands of medical professionals familiar with the technique.

Reduction mammaplasty and axillary-subclavian venous thrombosis.

We present a woman with distinct mammahypertrophy and simultaneous catheter-associated axillary-subclavian venous thrombosis characterized only by chronically dilated collateral vein over the chest. Despite this massively dilated subcutaneous vein covering the chest on the affected side, bilateral reduction mammaplasty of modified Pitanguy method was successfully performed among protection of this collateral vein.

Respecting the aesthetic unit in autologous breast reconstruction improves the outcome.

BACKGROUND: In postmastectomy breast reconstruction, a patchwork-like appearance and a double-bubble phenomenon may result from scar contracture and the possible destruction of the normal inframammary fold during mastectomy. Restoring an age-related breast ptosis can be difficult, and often contralateral breast surgery has to be performed to achieve symmetry. The purpose of this article is to present a technique that respects the aesthetic unit in autologous reconstruction, improves the outcome, and minimizes secondary surgery. METHODS: The area between the resected mastectomy scar and the marked inframammary fold is deepithelialized. The inferior skin margin of the flap is sutured to the lower line of the deepithelialized area, which corresponds to the inframammary fold of the contralateral side. The degree of ptosis can be adjusted by insetting greater or lesser amounts of skin. From December of 2000 to June of 2004, 12 patients underwent secondary breast reconstruction using this technique. The patients' ages ranged from 39 to 63 years (median, 51 years). Three patients had reduction mammaplasty of the contralateral breast. RESULTS: Mean patient follow-up was 14.7 months (range, 4 to 45 months). There were no free flap failures. Cosmetic evaluation of the reconstructed breasts by two independent plastic surgeons showed good results with regard to symmetry in 10 patients and fair results in two patients. Concerning visibility of the inferior scar, 11 patients had a good result and one patient had a fair result. All patients had a good result in terms of age-appropriate ptosis. CONCLUSIONS: The authors' technique facilitates the formation of an age-appropriate ptosis. Altogether, the aesthetic unit of the breast is restored.

Nipple reconstruction using a modified arrow flap technique.

Nipple reconstruction is the perfection of breast reconstruction. Although many reconstruction techniques are available, all come with the risk of projection loss. Most of the commonly used local flap techniques give reliable immediate results, but are associated with a loss in projection of 50 to almost 70% over the first three postoperative years. We herein present a modification of the nipple reconstruction technique as presented by Thomas et al. in 1996. By forming a deepithelialized area when closing the skin donor site, a firm foundation plate for the new nipple is created. The authors observed that this solid foundation plate, as well as the separation of the nipple cavity of the subcutaneous fat, results in less nipple projection loss.

Predictors of carpal tunnel syndrome: accuracy of gray-scale and color Doppler sonography.

OBJECTIVE: The purpose of this study was to retrospectively assess the accuracy of gray-scale and color Doppler sonography in the diagnosis of carpal tunnel syndrome. MATERIALS AND METHODS: A total of 206 wrists in 151 patients with a clinical suspicion of carpal tunnel syndrome were examined with high-resolution sonography using a 7-15-MHz linear array transducer. The presence of median nerve swelling, edema, and flattening and increased bowing of the flexor retinaculum was evaluated with gray-scale sonography, and the presence of nerve hypervascularization was evaluated with color Doppler sonography. Sensitivity and specificity were calculated for each sonographic feature in comparison with nerve conduction studies as the standard of reference. Multivariate logistic regression analysis was used to determine variables predictive of carpal tunnel syndrome. RESULTS: Carpal tunnel syndrome was confirmed in 172 wrists at nerve conduction studies. A median nerve cross-sectional area of at least 0.11 cm2 was calculated as a definition of median nerve swelling. In comparison with nerve conduction studies, nerve swelling showed the highest accuracy (91%) among gray-scale sonography criteria, and the presence of intraneural hypervascularization showed the highest accuracy (95%) among all sonography criteria. Logistic regression analysis showed that nerve hypervascularization was the only variable that independently predicted median nerve entrapment (odds ratio, 16.4; 95% confidence interval, 8.7-31.1; p <0.001). CONCLUSION: Color Doppler sonography is more accurate than gray-scale sonography for characterizing median nerve involvement in patients with suspected carpal tunnel syndrome.