The effects of breast reduction with superomedial and inferior pedicle techniques on radiological breast imaging.

BACKGROUND: Several breast reduction techniques have been introduced, and the reliability of these techniques has been demonstrated in clinical practice. However, it is still controversial how patients should be evaluated radiologically both preoperative and postoperative. This study aims to compare the radiological findings seen following reduction mammoplasty with two different techniques (inferior pedicle and superomedial pedicle), in connection with the surgical steps. METHODS: Medical records of 141 patients and a total of 278 breasts who underwent breast reduction with the diagnosis of macromastia were retrospectively analyzed. Demographic and operative data such as age, type of pedicle, preoperative and postoperative nipple-areola complex (NAC) position, and NAC transfer distance were recorded. Radiological evaluation was performed by two radiologists experienced in breast imaging by reinterpreting preoperative and postoperative mammography images. RESULTS: The rate of postoperative structural distortion (p < 0.001), thickened areola (p = 0.011), and retroareolar fibrotic band (p < 0.001) were observed to be significantly higher in the superomedial group. The risk of fat necrosis increases as the NAC transfer distance increases and a value of >9.5 cm in the NAC transfer distance can be considered as the cutoff value in terms of fat necrosis development, especially in those using superomedial pedicle technique. CONCLUSION: Surgical technique-specific benign radiological changes occur following reduction mammoplasty. However, these changes do not significantly affect the Breast imaging, reporting, and data system category. The localization of fat necrosis differs depending on the surgical technique, and the risk of fat necrosis increases as the NAC transfer distance increases, especially in those who have undergone superomedial pedicle breast reduction surgery.

Rate of Incidental Pathological Lesions in Reduction Mammoplasty Specimens and Incidence of Invasive Breast Carcinoma Following Breast Reduction Operation.

INTRODUCTION: Reduction mammoplasty (RM) is one of the most frequently performed surgical procedures. The incidental determination of significant pathologic lesions (SPL), that is precursor and malignant lesions, in RM specimens is rare. The aim of this study was to determine the frequency of SPL in RM specimens, to evaluate the relationship between SPL and clinicopathological factors, and to examine the incidence of invasive breast carcinoma forming in the remaining breast tissue during the postoperative follow-up period developing in patients after RM operation. MATERIAL AND METHOD: This retrospective study included 874 females who underwent RM operation between January 2012 and January 2021. Demographic, clinicopathological findings, and preoperative radiological findings were recorded. The patients were followed up after the RM operation in respect of the first occurrence of breast cancer. RESULTS: Invasive carcinoma was determined in 0.2% and SPL in 3.5% in RM. The probability of SPL determination was greater in patients aged ≥ 40 years and with ≥ 4 paraffin blocks (p=0.038, p=0.01, respectively). No statistically significant difference was found between patients with and without SPL in respect of radiological findings (p=0.35). The mean postoperative follow-up period was 53.6 months, and invasive carcinoma was diagnosed during follow-up in 0.2% of all patients (6.9% of the patients with SPL). CONCLUSION: Age over 40 years and an increased number of sampled blocks were found to be factors increasing the possibility of the determination of precursor and malignant lesions in RM specimens. RM could decrease the risk of the development of breast cancer. LEVEL OF EVIDENCE IV: 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 .

Comparison of the Effects of Pectoral Nerve Block and Local Infiltration Anesthesia on Postoperative Pain for Breast Reduction Surgery: A Prospective Observational Study.

OBJECTIVE: To evaluate the effects of the Pecs II block on postoperative pain in patients undergoing breast reduction surgery. MATERIALS AND METHODS: This prospective, comparative, and observational study was conducted with 53 patients, with American Society of Anesthesiologists I-II, between the ages of 18 and 65, and undergoing bilateral breast reduction surgery. The patients were divided into two groups: Pecs II block with general anesthesia (Pecs group; n = 26) and local infiltration anesthesia with general anesthesia (control group; n = 27). The patients' demographic data, duration of surgery and anesthesia, hemodynamic parameters, perioperative analgesia requirements, postoperative visual analog scale (VAS) scores (at zero, one, three, six, nine, and 12 hours postoperative), the number of patients who needed analgesia at least once, the length of the hospital stay, and block-related complications were recorded. RESULTS: There was no statistical difference in terms of the duration of surgery and anesthesia and hemodynamic parameters. Intraoperative total fentanyl consumption (128.85 ± 25.19 mcg in the Pecs group and 227.77 ± 44.58 mcg in the control group; P < .001) and postoperative analgesic requirement were significantly lower in the Pecs group (P < .001). The number of patients who needed analgesia at least once in the Pecs group was four (15.3%). Postoperative VAS scores were significantly lower (P < .001) and the length of the hospital stay was significantly shorter in the Pecs group (P < .001). No block-related complications were observed. CONCLUSION: Pecs II block with general anesthesia may significantly contribute to reducing intraoperative and postoperative analgesia requirements and provide long-lasting and more effective postoperative pain in breast reduction surgery.

Reconstruction of the Distal Leg and Foot Using Free Anterolateral Thigh Flaps in Patients With High-Voltage Electrical Burns.

In a patient with a high-voltage electrical burns, the extent of burning is greatest at the entrance and exit points of the electric current. As the exit point is usually the ankle and/or foot, these areas may be the most severely damaged. As local tissue is limited in this region, free tissue transfer is usually required for reconstruction. Eleven anterolateral thigh free flaps were placed for the reconstruction of foot and ankle defects caused by electrical burns. When the defects were large, we placed the flaps with two or three perforators. In six patients, recipient vessels were prepared in the trauma region or immediately adjacent thereto. Reconstructions were performed at an average of 23.18 days after the burns, and the average hospitalization time was 42.27 days. Patients with burns on the dorsum of the foot often required toe amputations. In patients who underwent direct reconstruction (without debridement), re-operations were required because of graft loss in other burnt areas. The foot and ankle are the regions most damaged by electrical burns. Vessels in the trauma zone or immediately proximal thereto can serve as recipient vessels. Even when the defect is sizeable, a large anterolateral thigh flap with multiple perforators can be harvested. No vascular problem was encountered during early or late reconstruction. The free flap is very reliable when used to reconstruct foot tissue defects caused by electrical burns.

Acquired Localized Hypertrichosis Following Pressure Garment and/or Silicone Therapy in Burn Patients.

Hypertrichosis is characterized by excessive and abnormal hair growth anywhere on the skin and may develop after prolonged local irritation, such as application of a cast, injury, or a bite. Pressure garment/silicone therapy is often used to prevent hypertrophic scar formation. The adverse effects of gel sheet application include rash, skin breakdown, cessation of scar responsiveness, pruritus, contact dermatitis, and dry skin. We report on 7 burn patients who developed hypertrichosis following application of pressure garment/silicone therapy to prevent hypertrophic scarring.

Use of a perforator/subcutaneous pedicled propeller flap for reconstruction of lower eyelid defects.

Full-thickness skin grafts (FTSGs) and flaps from the upper eyelid or cheek can be used for reconstruction of lower eyelid defects, including the anterior lamella. However, the upper eyelid has a limited and insufficient amount of skin, whereas cheek flaps have a restricted arch of rotation. Here we report the procedure and outcomes of a perforator/subcutaneous pedicled propeller flap for reconstruction of lower eyelid defects including the anterior lamella. A retrospective study of 12 patients who underwent treatment for eyelid anterior lamella defects with perforator/subcutaneous pedicled propeller flaps was conducted between March 2015 and June 2017. The propeller flap was planned to rotate around the perforator (as the pivot point), which was detected with a hand-held Doppler in the vicinity of the defect. The flaps were perforator pedicled for 10 patients and subcutaneous pedicled for the other two patients. The flap was rotated around the pedicle and placed on each patient's defect without tension. No vascular compromise occurred with any of the flaps. The most important complications were post-operative oedema and ecchymosis. Inferior eyelid defects including the anterior lamella could be reconstructed by using propeller flaps from the adjacent tissue. The main advantages of this flap included easy access to the defect, no impairment in eyelid function and very good aesthetic results.

Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction.

BACKGROUND: More attention is focused on sensory outcomes following breast reduction operations. We conducted this prospective, non-randomized study to compare two commonly used breast reduction techniques, superomedial pedicle and inferior pedicle, regarding sensation of the nipple-areolar complex. METHODS: We prospectively assigned 60 patients with macromastia into the superomedial pedicle group (SMP group, n = 30) or the inferior pedicle (IP group, n = 30) group. Six patients who withdrew from the study and another six patients who did not attend return visits were excluded. Algometry was used to measure the sensation of breast skin, cardinal points of the areola and the nipple. Two-point discrimination was also measured on the areola. Measurements were performed before surgery, at 3 weeks, and 6 months postoperatively. RESULTS: There were 20 patients in the SMP group and 28 patients in the IP group. The mean ages of the patients were 43.2 ± 12.7 and 45.9 ± 10.8 years, respectively (p = 0.438). The mean BMI of the patients were 32.4 ± 6.7 and 30.4 ± 5.3 kg/m2, respectively (p = 0.257). The mean weights of resected tissues were 802.5 (280-2180) versus 773.7 (349.5-1425.0) g, respectively (p = 0.900). Although breast sensation did not change in the SMP group, sensation in the upper medial and lower lateral portions of breast skin was reduced in the IP group. Two-point discrimination test results did not change in either group. The amount of changes in algometry and two-point discrimination tests were similar in both groups. CONCLUSION: Both superomedial and inferior pedicle breast reduction techniques are safe and reliable in terms of sensory changes. LEVEL OF EVIDENCE III: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term follow-up results of a pediatric brachial plexus laceration.

A rare case of pediatric brachial plexus laceration is presented. A five-year-old boy who sustained a sharp laceration on his right axillary region was immediately operated. The axillary artery, radial, ulnar and musculocutaneous nerve branches of the brachial plexus, and the lateral root of the median nerve were totally lacerated. The medial root of the median nerve was partially transected. All of the lacerated brachial plexus elements and axillary artery were immediately repaired. Significant functional recovery was determined even six months after the repair. Motor and sensory functions of the affected extremity were almost totally restored at the postoperative 21st month, except for the ulnar nerve motor functions. There was no cold intolerance or trophic change at the injured extremity. Primary repair of a brachial plexus laceration injury in the pediatric population can be expected to produce successful functional recovery results, even in a relatively short period after the repair.

Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction.

Scrotal skin has unique cosmetic and functional features that make its reconstruction difficult. Coverage of the testicles and constituting a good cosmetic appearance are major expectations from a successful reconstruction. Usually flaps are the choice for scrotal reconstruction, but every single flap has its own characteristics. In our series, between January 2006 and January 2010, the medial circumflex femoral artery perforator flap was used in 7 male patients for scrotal coverage after Fournier gangrene. Six flaps were raised based on a single perforator from the gracilis muscle; however in one flap 2 perforators were used. Flaps were carried to the defect either by transposition or by V-Y advancement. Donor areas were closed directly in all patients, and stable scrotal coverage was achieved with an acceptable scrotal contour and cosmesis. No major complication was seen due the perforator flap surgery, in 2 patients wound dehiscence were noted and they healed by secondary intention or by secondary suturing. For scrotal reconstruction, the medial circumflex femoral artery perforator flap is a good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and direct closure of the donor site. All these advantages can be accomplished in 1 procedure.

Clinical experience with free anterior interosseous flaps.

Despite versatility of the forearm as a flap source, anterior interosseous flaps from the dorsal forearm has not gained popularity among other alternatives. In our clinical experience, we investigated the feasibility of free anterior interosseous flap as a donor site. Between January 2002 and January 2006, 10 free anterior interosseous flaps were used in 10 consecutive cases. Five flaps were used for coverage of the defects of the hand and fingers, whereas another 5 flaps were used for head and neck defects. In all cases, this flap was selected when a thin flap was needed. All flaps survived completely except 1, where partial marginal necrosis was seen, and this necrosis was healed by secondary intention. Only 2 donor sites could be closed directly, and the others were skin grafted. Free anterior interosseous flap is a useful alternative with distinct advantages: it is a thin flap, major extremity arteries are preserved, the vascular pedicle is long enough and caliber is satisfactory for microsurgery, composite flaps with tendon, bone, nerve, and muscle are available, and it has a good texture, especially for hand defects. The 2 major disadvantages are visible donor area scar and technically demanding dissection. In conclusion, free anterior interosseous flaps are a good selection and should be in the armamentarium of a microsurgeon, when a thin flap is needed for hand and head and neck reconstruction.

Effect of cyclooxygenase-2 on ischemic preconditioning of skin flaps.

Ischemic preconditioning is a useful tool to fight against reperfusion injury. This phenomenon is very complex and the underlying mechanism has various branches. Every study on ischemic preconditioning helps us to better understand this process. We aimed to investigate the effectiveness of cyclooxygenase-2 (COX-2) on ischemic preconditioning of skin flaps in the rat. A 6 x 3 cm-sized left epigastric artery flap was used and the pedicle was isolated to perform the ischemic preconditioning via microvascular clamp application. The preconditioning protocol was 2 cycles of 15 minutes ischemia and 15 minutes reperfusion periods. Sixty female Wistar rats weighing between 210 and 260 g were used for the experiment. Animals were allocated randomly into 6 groups, each group containing 10 animals. Group 1: Only 6 hours of ischemia was done after the flap elevation, neither ischemic preconditioning nor COX-2 inhibitor was used; Group 2: 6 hours of global ischemia was induced just after the ischemic preconditioning; Group 3: In addition to the same procedures in group 2, 2 doses of COX-2 inhibitor were given before and after the final ischemic insult; Group 4: 6 hours of ischemia was applied to the flap 24 hours after its elevation, no preconditioning or any other interventions were done; Group 5: The same ischemic protocol was used after the flap elevation but the 6 hours of ischemia was performed 24 hours after the preconditioning; Group 6: The same procedures of group 5 were done and in addition, 2 doses of COX-2 inhibitor was given, starting 24 hours after the ischemic preconditioning. All flaps were followed for 1 week then necrotic flap portions were measured and represented as a percentage to the whole flap area. Statistical analyses revealed meaningful differences between groups 2 and 3 (P < 0.05), 2 and 1 (P < 0.05), 5 and 6 (P < 0.05), 5 and 4 (P < 0.05). However, there was no statistical difference between groups 3 and 1 (P > 0.05), 6 and 4 (P > 0.05). As a conclusion, ischemic preconditioning has both early and late protective effects on ischemia-reperfusion injury in the skin flap model. By antagonizing COX-2 receptors the beneficial effects of IP were reversed. This result indicated that COX-2 has a specific role in the mechanism of both early and late effects of ischemic preconditioning in skin flaps.