Sensory reinnervation of autologous tissue TRAM flaps after breast reconstruction.

The use of the transverse rectus abdominis musculocutaneous (TRAM) flap has come to the forefront for breast reconstruction following mastectomy. Despite our ability to create surgically a supple breast mound, simulate the nipple with local skin flaps, and pigment the skin to create an areola, one of the last drawbacks has been the reestablishment of normal sensation. Some patients have anecdotally reported some sensory return in the reconstructed breast mound. We sought to quantitate the pattern of sensory return in TRAM flaps in 24 patients to identify factors that favor sensory reinnervation of the flap. Patients were recalled for sensory testing after unilateral or bilateral breast reconstruction following mastectomy for cancer or premalignant mastopathy. The interval from surgery varied from 3 to 41 months. Sensation was evaluated using the Semmes-Weinstein monofilament test, hot/cold recognition, and vibratory sensation measured in 16 segments of the reconstructed breast mound and compared to the opposite, unoperated breast or to volunteer controls. Thirty-four flaps were evaluated. The Semmes-Weinstein measurements demonstrated measurable sensation in 32 of 34 flaps with 2 flaps developing sensation equal to the control unoperated breast. The return of hot recognition occurred in 21 of 34 flaps, cold recognition in 22 of 34 flaps, and vibratory sensation in 26 of 34 flaps. Our findings suggest that excellent sensory return occurs in the majority of patients via nerve ingrowth into the flap from the mastectomy bed. It would appear that a natural breast reconstruction with some sensation can be a reality for the majority of patients in the absence of additional complex surgical maneuvers such as nerve preservation or nerve-nerve coaptation.

Cutaneous blood-flow patterns in free flaps determined by laser Doppler flowmetry.

Accurate monitoring of tissue perfusion in microvascular surgery is paramount to flap survival. Many methods have been proposed for monitoring of flaps, but none have achieved widespread acceptance. The laser Doppler has been shown to be beneficial in monitoring flap perfusion. Trends have been noted in laser Doppler measurements over time in free TRAM, free latissimus dorsi, and free iliac-crest osteomyocutaneous flaps. TRAM flaps demonstrated a slow increase in the laser Doppler index (LDI), with a peak increase in skin blood flow of over 600 percent at 52 to 80 hr postoperatively (LDI 6.77 +/- 3.51), and then a gradual decline to previous baseline. Latissimus dorsi flaps also demonstrated a slow increase until about 80 hr postoperatively (LDI 9.8 +/- 10.65), indicating an increase in skin blood flow of almost 900 percent. Iliac-crest osteomyocutaneous free flaps had a slow increase in blood flow until approximately 70 hr postoperatively, when the LDI (5.5) increased, representing an increase in skin blood flow of over 500 percent. These changes in skin blood flow over time, seen with continuous laser Doppler measurements, depict the dynamic nature of skin blood flow and allow predictive patterns to be established, instead of single normal values, by which to gauge adequate flap perfusion.

Effectiveness of neonatal screening for congenital dislocation of the hip.

Despite the examination of neonates for congenital dislocation of the hip, this condition is being diagnosed after the newborn period at a rate not very different from that reported before the introduction of screening. The majority of late-diagnosed cases had been examined after birth, and the sensitivity of the tests used routinely is called into question. Re-examination of all infants at 3-6 months is proposed to reduce the number of missed cases and so minimise late sequelae.