Abdominal Wall Closure in Intestinal and Multivisceral Transplantation: A State-Of-The-Art Review of Vascularized Abdominal Wall and Nonvascularized Rectus Fascia Transplantation.

Failure to close the abdomen after intestinal or multivisceral transplantation (Tx) remains a frequently occurring problem. Two attractive reconstruction methods, especially in large abdominal wall defects, are full-thickness abdominal wall vascularized composite allograft (AW-VCA) and nonvascularized rectus fascia (NVRF) Tx. This review compares surgical technique, immunology, integration, clinical experience, and indications of both techniques. In AW-VCA Tx, vascular anastomosis is required and the graft undergoes hypotrophy post-Tx. Furthermore, it has immunologic benefits and good clinical outcome. NVRF Tx is an easy technique without the need for vascular anastomosis. Moreover, a rapid integration and neovascularization occurs with excellent clinical outcome.

Widespread Vascularization and Correlation of Glycosaminoglycan Accumulation to Tendon Pain in Human Plantar Fascia Tendinopathy.

BACKGROUND: Plantar fasciitis is a painful tendinous condition (tendinopathy) with a high prevalence in athletes. While a healthy tendon has limited blood flow, ultrasound has indicated elevated blood flow in tendinopathy, but it is unknown if this is related to a de facto increase in the tendon vasculature. Likewise, an accumulation of glycosaminoglycans (GAGs) is observed in tendinopathy, but its relationship to clinical pain is unknown. PURPOSE: To explore to what extent vascularization, inflammation, and fat infiltration were present in patients with plantar fasciitis and if they were related to clinical symptoms. STUDY DESIGN: Descriptive laboratory study. METHODS: Biopsy specimens from tendinopathic plantar fascia tissue were obtained per-operatively from both the primary site of tendon pain and tissue swelling ("proximal") and a region that appeared macroscopically healthy at 1 to 2 cm away from the primary site ("distal") in 22 patients. Biopsy specimens were examined with immunofluorescence for markers of blood vessels, tissue cell density, fat infiltration, and macrophage level. In addition, pain during the first step in the morning (registered during an earlier study) was correlated with the content of collagen and GAGs in tissue. RESULTS: High vascularization (and cellularity) was present in both the proximal (0.89%) and the distal (0.96%) plantar fascia samples, whereas inconsistent but not significantly different fat infiltration and macrophage levels were observed. The collagen content was similar in the 2 plantar fascia regions, whereas the GAG content was higher in the proximal region (3.2% in proximal and 2.8% in distal; P = .027). The GAG content in the proximal region was positively correlated with the subjective morning pain score in the patients with tendinopathy (n = 17). CONCLUSION: In patients with plantar fasciitis, marked tissue vascularization was present in both the painful focal region and a neighboring nonsymptomatic area. In contrast, the accumulation of hydrophilic GAGs was greater in the symptomatic region and was positively correlated with increased clinical pain levels in daily life. CLINICAL RELEVANCE: The accumulation of GAGs in tissue rather than the extent of vascularization appears to be linked with the clinical degree of pain symptoms of the disease.

Vascularized Temporoparietal Fascial Flap: A Novel Surgical Technique to Bypass the Blood-Brain Barrier in Glioblastoma.

BACKGROUND: The major difficulty in treating glioblastoma stems from the intrinsic privileged nature of the brain. This complicates therapy, as many traditionally potent chemotherapeutics cannot access their target sites in the brain. Several techniques have been investigated to overcome this barrier and facilitate drug delivery. However, these techniques have inherent shortcomings related to the delivery system, the drug itself, or its bioactivity. Periosteal flaps and temporoparietal fascial flaps (TPFFs) are widely used options because they have predictable vasculature and a wide rotational arc. These flaps are not restricted by the blood-brain barrier, as they derive their vascular supply from branches of the external carotid artery, which can be readily identified with Doppler ultrasound. We hypothesized that transposition of a vascularized TPFF to the walls of a resected tumor surgical cavity may bring autologous tissue not restricted by the blood-brain barrier in close vicinity of the resected tumor bed microenvironment. This offers a nonselective, long-lasting gateway to target the residual tumor cells nesting in the brain adjacent to the tumor. CASE DESCRIPTION: A 47-year-old, right-handed woman with newly diagnosed multifocal glioblastoma underwent excision of the tumor and TPFF placement. This illustrative case report represents the first case of the use of this novel surgical technique with radiologic follow-up. CONCLUSIONS: The blood-brain barrier is identified as a major barrier for effective drug delivery in glioblastoma. This study demonstrates the feasibility of the TPFF technique to bypass this barrier and help facilitate the goal of improving drug delivery.

[Scientific interpretation of membrane anatomy theory and standardized application of membrane anatomy terms].

There has been an upsurge of the theory of membrane anatomy in China, but it is still in the initial stage of establishing preliminary framework. The concept of fasciae in membrane anatomy actually refers to the fasciae constituting the particular plane or the 'holy plane'. Therefore, the membrane anatomy can't simply be defined as the anatomical relationship among fascia. The application of the membrane anatomy is also not just to pursue the avascular plane in the surgical field. Nowadays, nonstandard anatomical terms and diversification of views impede the development of the theory of the membrane anatomy. Fasciae occur in embryonic stage, undergo a series of changes in rotation and fusion, and lose the original features, which bring difficulties in understanding the anatomy of fasciae. In this paper, we restore the origin and continuity of fasciae related to the colorectal surgery by cadaveric study, surgical observation and literature review. Taking the TME for example, we also discuss the core content about the fasciae and plane related to 'mesenteric envelope' and complete mesorectal excision. From the perspective of the fasciae integrity, we illustrate the definitions of important anatomical structure and standardized the terminology of fasciae. To study the origin and architecture of fasciae in the view of embryology, integrity and continuity will contribute to establish the standard theoretical system of membrane anatomy.

[Better understanding of interfacial planes in colorectal cancer surgery and the value of small vessels on fascia in the identification of interfacial planes].

The introduction of total mesorectal excision and wider use of laparoscopic surgery pushed the field of colorectal surgery into an era of interfasical dissection. The Japanese suggestion of fascial arrangement of the trunk in a multilaminar, symmetrical and parallel way helps in better understanding of fascial relationship and interfascial planes surrounding the colon and the rectum. However, different interpretations of the multilayer retroperitoneal fascial relationship, complexity of fascial structures within the pelvis and dense adhesion between two apposed fasciae at special points make it still challenging for the surgeon to decide on the precise interfascial plane for colorectal mobilization. Small vessels on fasica propria of the rectum and various retroperitoneal fascia, especially ureterohypogastric fascia show distinctive features. The root of small vessels on fascia propria of the rectum helps to identify the anterolateral and posterolateral interfascial plane in the middle and low rectum. The longitudinal trajectory of small vessel on ureterohypogastric fascia and scarcity interfascial vascular communication between mesocolic and retroperitoneal fascia help the surgeon to find and stay in the interfacial plane during colorectal mobilization. More knowledge of fascial and interfascial plane will certainly help achieve better mesocolic mesorectal integrity and reduce the risk of injuries to autonomic nerves. More anatomical, histological and embryological studies are warranted with respect to relationship between small vessels and fasciae.

The 'multilayer' theory of Denonvilliers' fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization.

AIM: Denonvilliers' fascia is thought to be a multilayered fascial structure, based on its embryological development with the neurovascular bundle embedded within it. Recently, this theory had been proven histologically and by confocal microscopy in many published articles. However, the literature does not report on how surgeons can identify these structures. We aimed to determine the optimal surgical approach for preserving these critical structures. METHOD: Eighteen cadavers (13 male/five female) were included and treated according to the ethical considerations stated in the donation consent of our institution. Dissection was performed with the assistance of binocular loupes for better anatomical detail. The compositions of the prerectal fascia and the neurovascular bundle were observed and recorded at different levels of dissection using a high-definition camera. RESULTS: The theoretical multilayered fascia was found in male specimens as three fascial layers originating from the perineal body, seminal vesicles and posterior bladder neck. The first layer merged posterolaterally and fused with the rectosacral fascia (Waldeyer's fascia). The neurovascular bundle in male specimens was observed piercing the second and third layers, while the first layer acted as a protective cover. Dissection of female specimens demonstrated only one layer in the prerectal space. CONCLUSION: Intiating anterior rectal mobilization by incising the peritoneum posterior to its reflection seems to be anatomically correct to preserve DVF. However, its applicability may be difficult in a narrow chanllenging pelvis. The lateral rectal ligaments and Waldeyer's fascia should be dissected from their attachments to the proper fascia of the rectum.

Opioid-related compartment syndrome and associated morbidity.

INTRODUCTION: Opioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS). METHODS: We used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05. RESULTS: All cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p <  0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3-6) than for the NORCS group (median, 3; IQR 2-4) (p =  0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16-38) compared with the NORCS group (median, 9 days; IQR: 5-13) (p <  0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p <  0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p <  0.001). All ORCS patients presented >8 h after immobilization in a dependent position. CONCLUSION: Patients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.

Fast degrading elastomer stented fascia remodels into tough and vascularized construct for tracheal regeneration.

Tracheal reconstruction remains a major surgical challenge, mainly owing to the scarce of resilient hollow grafts with identifiable vascular pedicle in humans. In this study, we developed a three-layer, elastomeric, trachea-like composite made of poly glycerol sebacate (PGS) and polycaprolactone (PCL), which presented appropriate resilient property, timely degradation and interconnected pores. C shape PCL rings fabricated with selective laser sintering (SLS) techniques are regularly positioned around porous PGS tubes and fixed by PCL electrospinning sheath. Such an elastomeric composite underwent host remodeling including rapid vascularization and tissue infiltration after fascia wrapping. With degrading of PGS, C rings well incorporated into growing fascia and lead to the formation of pedicled tracheal grafts, which attributes to the strong and resilient properties of generated hollow grafts thus enabled orthotopic transplantation in segmental tracheal defect. Progressive remodeling on such vascularized and mechanically stable grafts resulted in epithelium regeneration on luminal side as well as production of adequate amount of collagen and elastin, which warrantees the air passage during breathing. Future study employing large animal models more representative of human tracheal regeneration is warranted before clinical translation. Using fast degrading PGS combined with PCL rings represents a philosophical shift from the prevailing focus on tough grafts in airway reconstruction and may impact regenerative medicine in general.

Sub-Scarpa's Lipectomy in Abdominoplasty: An Analysis of Risks and Rewards in 723 Consecutive Patients.

BACKGROUND: During the course of performing abdominoplasties, a plastic surgeon will encounter a certain body habitus characterized by a thick, tethered, and excessively redundant upper skin flap. Often these patients also demonstrate diffuse and substantial fascial laxity. One approach to this problem involves direct thinning and release of the flap by resection of the sub-Scarpa's fat pad. In theory, this resection should be safe from a flap perfusion standpoint. However, the safety of the sub-Scarpa's resection has not been completely documented. OBJECTIVES: The author sought to assess the safety and efficacy of sub-Scarpa's lipectomy in abdominoplasty. METHODS: A total 723 patients were retrospectively examined and divided into 2 groups: those with (Group B) and those without (Group A) a sub-Scarpa's lipectomy component to the abdominoplasty. Because of differences in the baseline characteristics between the 2 groups, data analysis was performed with a logistic regression model and with propensity score matching. RESULTS: The sub-Scarpa's lipectomy technique allowed for substantial thinning of the flap: the average weight of the resected fat pad was 411 g. Wide undermining allowed for substantial fascial correction, and excellent results were obtainable even in challenging cases. The sub-Scarpa's lipectomy group did not demonstrate an increase in either minor (<5 cm2) or major (>5 cm2) flap necrosis. However, there was a statistically significant increase in fat necrosis and seroma formation in Group B compared with Group A. In both groups, an increasing body mass index was a risk factor for fat necrosis and major flap necrosis. CONCLUSIONS: The implementation of a sub-Scarpa's lipectomy during abdominoplasty is a useful technique to consider for selected abdominoplasty candidates. The risks of minor and major flap loss do not seem to be increased compared to the standard abdominoplasty, but the risks of fat necrosis and seroma formation may be greater.

Radial Artery Fascial Flow-Through Free Flap for Complex Cerebral Revascularization: Technical Notes and Long-Term Neurologic and Radiographic Outcomes.

BACKGROUND: Surgical innovation is critical for the management of challenging cerebrovascular pathology. Flow-through free flaps are versatile composite grafts that combine viable tissue with a revascularization source. Neurosurgical experience with these flaps is limited. OBJECTIVE: To provide an in-depth technical description of the radial artery fascial (and fasciocutaneous) flow-through free flap (RAFF and RAFCF, respectively) for complex cerebral revascularizations. METHODS: An Institutional Review Board-approved, prospective database was retrospectively reviewed to identify patients that underwent extracranial-to-intracranial cerebral bypass with a RAFF or RAFCF. Patient demographics, underlying pathology, surgical treatment, complications, and outcomes were recorded. RESULTS: A total of 4 patients were treated with RAFFs or RAFCFs (average age 40 ± 8.8 yr). Two patients with progressive moyamoya disease involving multiple vascular territories with predominantly anterior cerebral artery (ACA) symptoms and flow alterations underwent combined direct ACA and indirect middle cerebral artery (MCA) bypass with a RAFF. The third patient with moyamoya disease and concomitant proximal fusiform aneurysms requiring internal carotid artery sacrifice underwent dual direct ACA and MCA bypass and indirect MCA revascularization with posterior tibial artery and RAFF grafts. The fourth patient with a large MCA bifurcation aneurysm and recurrent wound complications underwent a direct MCA bypass and complex wound reconstruction using a RAFCF. Good neurologic outcomes (Glasgow Outcomes Scale score ≥4 at discharge) were achieved in all patients. There were no perioperative surgical complications, and graft patency was confirmed on long-term follow-up. CONCLUSION: The RAFF and RAFCF are versatile grafts for complex cerebral revascularizations.

The Occipital Artery-Based Fascial Flap for Ear Reconstruction.

BACKGROUND: The temporoparietal fascia flap is frequently used in ear reconstruction. When the temporoparietal fascia flap is unavailable, options for primary or secondary salvage reconstruction are limited. In these patients, an inferiorly based occipital artery fascia transpositional flap is a good alternative for soft-tissue coverage over a framework. This article describes the use of the occipital artery fascia flap for ear reconstruction in conjunction with a porous polyethylene framework. METHODS: The authors included all patients who underwent occipital artery fascia flap surgery with a porous polyethylene framework for ear reconstruction performed by the first author from 1992 to 2017. RESULTS: A total of 83 patients received an occipital artery fascia flap: 24 for primary microtia reconstruction and 59 for revision or salvage of unsatisfactory results. All had contraindications for temporoparietal fascia flap use: prior use, flap injury from previous surgery, trauma, inappropriate flap location, or inadequate flap perfusion. Twelve patients (14 percent) developed occipital artery fascia flap complications (infection or necrosis) and underwent further revision to achieve satisfactory results. CONCLUSIONS: Given the paucity of reported techniques for large-scale auricular salvage/revision, the authors offer a versatile option that remains available when other conventional flaps are unavailable. The occipital artery fascia flap may be used with either alloplastic or autologous frameworks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abnormal dartos fascia in buried penis and hypospadias: Evidence from histopathology.

INTRODUCTION: The importance of the pathology of the dartos fascia in hypospadias and buried penis is still debatable. Understanding the properties of connective tissue of dartos fascia in hypospadias and buried penis may give a clue to the underlying mechanism. OBJECTIVE: This study aimed to compare connective tissue and vascularization of dartos fascia between normal penis, buried penis, and hypospadias. STUDY DESIGN: We conducted this prospective study from May 2013 to November 2016. We collected dartos fascia specimens from three groups: buried penis, hypospadias, and normal penis as control. All of the patients underwent primary surgery in all groups. Patients with penile abnormalities, such as phimosis or Balanitis Xerotica Obliterans (BXO) were excluded from the normal penis group. We compared the fibers between these groups using Masson trichrome histochemical staining, Gomori's silver impregnation staining, Weigert resorcin-fuchsin staining, and CD31 immunohistochemistry staining for evaluation of collagen fibers, reticulin fibers, elastin fibers, and endothelial cells of blood vessels, respectively. The collagen fibers, reticular fibers, elastic fibers, and vascular vessels were counted with ImageJ and manually calibrated and counted and were analyzed using the one-way ANOVA test. The assessment conducted by two pathologists was blinded, without knowing the clinical diagnosis of patients. RESULTS: There was a total of 60 patients with 20 patients in each group. Collagen fibers for most cases of buried penis and hypospadias showed thicker but fewer collagen fibers than the normal penis. There was a reduction of total collagen and elastin of dartos fascia in hypospadias and buried penis cases. On the other hand, the ratio of reticulin fibers, which represents collagen type III to total collagen, was increased compared to normal penis. DISCUSSION: Although the dartos fascia in buried penis and hypospadias is thick and inelastic when palpated or during traction/counter traction, it is well-vascularized tissue. This inelastic dartos fascia tissue is an abnormal tissue, but its characteristics are not similar to fibrotic tissue. However, further study with a larger sample is warranted and should differentiate the degree of chordee in patients with hypospadias and buried penis. CONCLUSIONS: There was a difference between connective the tissue of dartos fascia in buried penis and patients with hypospadias compared with normal penis. Inelastic dartos fascia tissue in patients diagnosed with buried penis and hypospadias is an abnormal tissue. Therefore, it is suggested that this tissue is excised during reconstructive surgery. Further research is needed to unveil the pathophysiology of the condition.

Validity of the use of a subfascial vessel as the recipient vessel in a second free flap transfer: A retrospective clinical review.

Performing a greater number of free flap procedures inevitably results in an increase in the number of cases that experience free flap failure. In cases that require a second free flap after the failure of the first, recipient vessel selection becomes difficult. Furthermore, recipient vessel selection can be complicated if the vessel is deep in the recipient site, or if there is an increased risk of vessel damage during the dissection. Thus, we present our experience where a subfascial vessel beneath the deep fascia was used as a recipient vessel for a second free flap in lower extremity reconstruction due to total or partial first flap failure.Between January 2010 and April 2015, 5 patients underwent second free flap reconstruction using a subfascial vessel as the recipient vessel. The flaps were anastomosed in a perforator-to-perforator manner, using the supermicrosurgery technique. We measured the sizes of the flaps, which varied from 5 × 3 to 15 × 8 cm, and the recipient subfascial vessel diameters.The mean time for the dissection of the recipient perforator was 45 minutes. All the flaps exhibited full survival, although a partial loss of the skin graft at the flap donor site was observed in 1 patient; this defect healed with conservative management.We recommend using a subfascial vessel as the recipient vessel for both first and second free flaps, especially if access to the major vessel is risky or challenging.

Polyethylene Ear Reconstruction: A State-of-the-Art Surgical Journey.

BACKGROUND: The use of a porous high-density polyethylene implant for ear reconstruction is gradually gaining acceptance because it allows for a pleasing ear reconstruction in young children before they enter school. In response to this growing interest, the authors decided to write an article clarifying in detail all the steps of this challenging procedure. In this article, the authors also answer all the common questions that surgeons have when they come to observe the operation, or when they go back to their respective practices and start performing this procedure. METHODS: The authors describe in detail the operative steps that allow for a successful ear reconstruction using porous high-density polyethylene. The key parts of this operation are to meticulously harvest a well-vascularized superficial temporoparietal fascia flap and to use appropriate color-matched skin grafts. RESULTS: This method allows for a pleasing ear reconstruction with excellent definition, projection, symmetry, and long-term viability. CONCLUSION: The use of porous high-density polyethylene with a thin superficial temporoparietal fascia flap coverage is the authors' preferred method of ear reconstruction because it can be performed at an earlier age, in a single stage, as an outpatient procedure, and with minimal discomfort and psychological trauma for the patients and parents.

Perforators of the fibular artery and suprafascial network.

INTRODUCTION: Soft tissue defect on lower limb can result in an intractable wound. Surgeons resort in flaps to cover these injuries. Including fascia as in the case of a fasciocutaneous flap increases survey of the flap. Rising a perforator flap avoids to sacrifice a major vessel whence the nourishing perforator artery is born. We wanted to explore suprafascial distribution of the fibular skin perforator arteries supposing possible to find out a vascular axis composed of anastomoses of the fibular perforator vessels. MATERIALS AND METHODS: Systematic observation was carried out on ten injected legs about the fibular perforator distribution, and especially their suprafascial course. RESULTS: Dissection allowed us to raise in all specimens a large fasciocutaneous paddle including a fine arteriolar vessel connecting fibular perforators. Perforators were isolated along from the leg and we found suprafascial arteriole connecting all perforators from the fibular head to the lateral malleolus. There were a total number of 126 perforators for 10 legs. The mean length of the fibula was 32.9 cm. No perforator was located at more than 2 cm from fibular posterior border. Proximal perforators were closer to posterior fibular side than distal perforators. We found that fibular perforators clustered in the middle and upper third of the leg. CONCLUSION: This study proves the real existence of a microvascular suprafascial axis formed by fibular perforator anastomoses and stretching over the entire length of the fibula, from the fibular head to the distal tip of the lateral malleolus. This suprafascial vascular axis could be an anatomical basis for a fasciocutaneous fibular flap.

The indeterminable resilience of the fascial system.

The most recent information on fascial tissue indicates that there are not fascial layers, but polyhedral microvacuoles of connective tissue, which connect the body systems and, by hosting specialized cells, permit several functions, such as motor, nervous, vascular and visceral. These microvacuoles (a repetition of polyhedral units of connective fibrils) under internal or external tension change shape and can manage the movement variations, regulating different body functions and ensuring the maintenance of efficiency of the body systems. Their plasticity is based on perfect functional chaos: it is not possible to determine the motion vectors of the different fibrils, which differ in behavior and orientation; this strategy confers to the fascial continuum the maximum level of adaptability in response to the changing internal and external conditions of the cell. The present commentary deals with this concept, providing clinical examples of different disease patterns, providing contrary examples in which this adaptability does not occur, and lastly suggesting considerations for the approach to manipulative therapy of the fascial tissue. The fascial continuum is like a flock of birds flying together without a predetermined logic and maintaining their individuality at the same time.

Serratus Anterior Fascia Flap Versus Muscular Flap for Expander Coverage in Two-stage Breast Reconstruction Following Mastectomy: Early Post-operative Outcomes.

INTRODUCTION: The demand for reconstructive breast surgery after mastectomy is increasing among women and the two-stage option remains the most commonly performed technique. We conducted a self-controlled prospective clinical trial comparing the use of the serratus anterior fascia with the serratus anterior detached fibers to cover the inferolateral aspect of the expander in immediate two-stage breast reconstruction following conservative mastectomies as oncological or risk-reducing procedures. PATIENTS AND METHODS: We analyzed the surgical outcome of 29 bilateral mastectomies and immediate reconstruction with the positioning of a tissue expander in a pocket beneath the pectoralis major and serratus anterior muscle on one side and in a pocket beneath the pectoralis major and a serratus anterior fascia flap on the other side. We considered all complications presenting in the first month after surgery and patient-reported early post-operative pain. RESULTS: Complication rates in the two groups did not significantly differ (p = 0.237). The total amount of drainage and the time of drainage permanence were significantly lower for the subfascial group (p < 0.05). Patient-reported early post-operative pain was significantly different between the two groups both at 24 h (p < 0.05) and at 5 days (p < 0.05) with significantly lower pain scores reported by the patients in the subfascial group. DISCUSSION: Our self-controlled prospective trial demonstrated an advantage in performing an implant-based two-stage breast reconstruction using a serratus anterior fascia flap when compared with the serratus muscle fibers use for inferolateral implant coverage following mastectomy. The use of the anterior serratus fascia flap for inferolateral implant coverage in two-stage breast reconstructions following mastectomy could be considered as a safe and effective technique, presenting lower morbidity for the patient when compared with the serratus muscle fibers use and lower costs when compared with biological and synthetic meshes use, achieving good outcomes in terms of post-operative complications and women's quality of life and satisfaction levels. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Alternative Posterosuperior Auricular Fascia Flap for Ear Elevation During Microtia Reconstruction.

BACKGROUND: Advances in staged total auricular reconstruction have resulted in improved anterior auricular appearance; however, satisfactory postreconstruction esthetics of the retroauricular fold remain challenging. The postauricular appearance of the reconstructed ear depends largely upon optimizing the covering material. When used as the covering soft tissue for ear elevation, a flap containing primarily the upper portion of the retroauricular fascia has potential advantages over the conventional book cover-type retroauricular fascia flap. METHODS: We developed a geometrically designed, posterosuperior auricular fascia flap to replace the conventional retroauricular fascia flap for ear elevation. During the second-stage operation, the posterosuperior auricular fascia flap is rotated downward and turned over to wrap around the inner strut and entire posterior auricular surface. RESULTS: Compared to the conventional book cover-type retroauricular fascia flap, the novel posterosuperior auricular fascia flap was easier to harvest and the operative time significantly decreased (110.3 vs. 121.5 min, p < 0.01). The modified flap produced a thin and natural contour of the postauricular surface, as well as reduced the incidence of postauricular hypertrophic scarring (from 24.7 to 13.2%, p = 0.03) and partial skin graft necrosis (from 43.4 to 31.2%, p = 0.01). CONCLUSION: The geometrically designed posterosuperior auricular fascia flap improves ear elevation. Compared to the conventional book cover-type retroauricular fascia flap, this covering tissue is easier to perform so the surgical time is decreased. It was highly vascularized, well defined, thinner, and yields reliable results. Thus, favorable postauricular surface results can be achieved during auricular reconstruction by using the modified fascia flap. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Effects of platelet rich plasma on fascial healing in rats with fecal peritonitis

PURPOSE: To evaluate the effects of platelet rich plasma (PRP) on the healing of fascia wherein peritonitis has been created. METHODS: Twenty eight Wistar Albino rats were divided into four groups. Only a primary fascial repair following laparotomy was performed on Group 1, a primary fascial repair performed and PRP treatment applied following laparotomy on Group 2, and a fecal peritonitis created following laparotomy and a primary fascial repair carried out on Group 3. A fecal peritonitis was created following laparotomy and primary fascial repair and PRP treatment on the fascia was carried out on Group 4. RESULTS: TNF-α was found to be significantly lower in the control group (Group 1). It was detected at the highest level in the group in which fecal peritonitis was created and PRP applied (Group 4). TGF-ß was determined as being significantly higher only in Group 4. Histopathologically, the differences between the groups in terms of cell infiltration and collagen deposition were not found to be significant. CONCLUSION: When platelet rich plasma was given histologically and biochemicaly as wound healing parameters cellular infiltration, collagen accumulation, and tissue hydroxyiproline levels were not increased but neovascularization, fibroblast activation and TNF Alfa levels were increased and PRP accelerated wound healing.