Myosonographic study of abdominal wall dynamics to assess donor site morbidity after microsurgical breast reconstruction with a DIEP or an ms-2 TRAM flap.

BACKGROUND: Currently, autologous breast reconstruction with a free tissue transfer from the lower abdomen is considered to be a safe method that provides a stable long-term solution. The DIEP-flap and the ms-2-TRAM-flap reconstructions have helped reduce donor site morbidity. In order to assess the potential differences between these techniques, we carried out myosonographic evaluations that assessed the muscle dynamics pre- and post-operatively. In addition to investigating the properties of the rectus abdominis muscle post-operatively, this prospective study also allowed us to analyse the muscle preoperatively and to investigate the prospects for harvesting a DIEP-flap as opposed to a TRAM-flap. MATERIALS AND METHODS: Sixty patients underwent breast reconstruction with 71 (11 bilateral) free abdominal wall flaps (DIEP-: n = 48; ms-2-TRAM-flap: n = 23). Myosonographic examinations were performed preoperatively and at 3 and 6 months post-operatively. The thickness of the muscle at relaxation and maximum contraction and the difference between the muscle thickness measured at the two states were measured. A general-linear-model (GLM) was used for statistical analysis. The main variable was the surgical method, and the co-variables included BMI and patient age. The decision on whether to harvest a DIEP- or ms-2-TRAM-flap was made intra-operatively and based on the dominant perforator. RESULTS: It shows that the patients who underwent breast reconstruction with a DIEP-flap had significantly better muscle function (p < 0.05) in the follow-up. In addition, the analysis revealed that better muscle function before surgery made it more likely that a patient would undergo a DIEP-flap-reconstruction successfully. Patient age also had a highly significant effect on muscle recovery (p < 0.0005). CONCLUSIONS: This prospective study used a dynamic ultrasound evaluation of the abdominal wall and showed that the DIEP-flap significantly reduces donor site morbidity compared to the ms-2-TRAM-flap. The study also showed that good preoperative muscle function might increase the probability of surgeons performing a DIEP-flap reconstruction.

Massive Hemi-facial Edema After Permanent Filler Removal in an HIV-Positive Patient. Precautions and Patient Information.

UNLABELLED: HIV-related lipodystrophy and facial lipo-atrophy are well-described problems stigmatizing many HIV patients. As these patients often require large volumes of filler material, a more permanent solution is necessary. Before the popularization of lipofilling, synthetic permanent fillers have mostly been used. We describe a case report of a patient who had undergone removal of a permanent filler, polyacrylamide gel, because of dislocation of the filler, but who presented a massive hemi-facial edema immediately after the removal. Swelling subsided after 5 days. The use of permanent fillers has diminished due to frequent early and late complications, but a high awareness for permanent filler removal complications remains necessary. Possible pathways to explain these late complications are described. LEVEL OF EVIDENCE V: 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 www.springer.com/00266 .