Treatment algorithm for abdomino-torso body contouring in massive weight-loss patients in the presence of scars--a comprehensive review.

BACKGROUND: Patients requiring surgical skin excision after massive weight loss are challenging and require a structured approach. The characteristic abdominal deformity includes a draping apron of panniculus, often extending to the glutaeal, back and thigh areas. Occasionally, these deformities are associated with previous surgical scars in the upper abdomen resulting from open gastric bypass surgery or from other procedures, such as open cholecystectomy. These scars can compromise the blood supply of the abdominal skin. For adequate and safe body contouring, both the excess skin and fat as well as the remaining perfusion of the remaining tissues must be addressed to achieve satisfactory results. METHOD: We propose an algorithmic treatment approach for body contouring of the abdomino-torso area in the presence of scars in the upper abdomen. RESULTS: The key to satisfactory results is a thorough analysis of the horizontal and vertical skin and fat excess of the abdomino-torso, buttock and flank areas and choosing an adequate and safe procedure addressing the respective areas of skin and fat excess while preserving the blood supply of the abdomino-torso area in a scarred abdomen. Our algorithmic approach can help in achieving these goals. CONCLUSION: Our algorithmic approach enables the surgeon to perform safe abdomino-torso body contouring through a structured analysis of the fat and skin excess in the respective body areas even in the presence of surgical scars in the upper abdomen.

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.

Primary simultaneous lip and nose repair in the unilateral cleft lip and palate.

BACKGROUND: "Do not touch the nose in primary repair of the unilateral cleft lip and palate!" In the past, this dogmatic attitude caused functional and aesthetic (psychological) problems for the child until secondary corrections during adolescence were performed. In the 1950s, surgeons started to correct at least a few features of the nasal deformity and to develop radically corrective measures. Since 1970, a new and very comprehensive concept of correction has been used at the authors' department of plastic and reconstructive surgery. METHODS: Methods of primary nasal repair by various surgeons are presented chronologically. The main features of the authors' strategy are special incision lines, extensive mobilization of all dislocated structures, straightening of the deviated septum, correction of the deformed ala and nasal tip, induction of bone growth in hypoplastic areas under the alar base and along the piriform aperture, and a special suture technique of the orbicularis muscle to form a better philtrum. RESULTS: Improvement of the aesthetic and functional results can be achieved with this type of nasal repair. Since 1970, approximately 500 patients have been operated on with this method at the authors' hospital and elsewhere, with 80 percent showing satisfactory results and 20 percent revealing deficiencies. Severe nasal deformities, which were common when no primary repair was applied, were not observed. This observation period provides evidence that no growth retardation occurs. CONCLUSIONS: Because of the good results of this method and the lack of growth retardation, this approach is to be recommended. It also benefits children in underdeveloped countries, where frequent surgery is not possible.

Transfer of pedicled musculocutaneous latissimus dorsi flap for restoration of shoulder contour after neurogenic atrophy.

Neurogenic atrophy of the deltoid muscle due to brachial plexus injury will lead to a disfiguring deformity of the shoulder contour, apart from the functional deficit. When there is no possibility for functional restoration of the shoulder movement, this contour defect will become the patient's major concern. We present a new method in which the ipsilateral latissimus dorsi muscle was used as a pedicled musculocutaneous flap to augment the shoulder contour in 3 patients. In all patients, there was a concomitant lesion to the thoracodorsal nerve, with subsequent palsy of the latissimus dorsi muscle. Therefore, donor-site morbidity was minimal. The final esthetic appearance was pleasing, and the patient satisfaction was quite high.

Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis.

The deep inferior epigastric perforator (DIEP)-flap continues to be the standard treatment in microsurgical breast reconstruction. Reasons for the popularity of the DIEP-flap include the availability of a large amount of tissue for the reconstruction of large breasts, a reliable vascular anatomy and an aesthetically pleasing donor site scar. However, the DIEP-flap is not considered the optimal choice as the donor tissue in all patients. Previous abdominal surgeries with resulting scars may threaten the success of a free DIEP-flap due to compromised vascularity within the flap. We elaborated a technique to increase the safety of breast reconstruction with the DIEP-flap in the presence of an infraumbilical vertical scar. After raising the DIEP-flap in a traditional manner on one side with harvesting of a considerate length of the inferior epigastric vessels, a segment of the superior epigastric vessels is left attached to the main pedicle. This stump of the superior epigastric vessels is now anastomosed under the microscope to a paraumbilical perforator on the contralateral side of the flap for in-flap microvascular augmentation. The above-mentioned technique was applied in five patients who presented with an infraumbilical vertical scar and were reconstructed with a DIEP-flap because of breast cancer. In three of the five patients there was an additional risk factor present such as smoking or diabetes mellitus. In all five patients no major complication due to marginal perfusion of the contralateral side of the flap was encountered. In two patients there was minor breakdown of fatty tissue that was managed conservatively in both cases. In-flap microvascular augmentation of DIEP-flaps is a valuable tool for the plastic surgeon in microvascular breast reconstruction. It permits usage of the lower abdominal tissue even if perfusion is compromised due to midline scarring. We recommend this technique as a safe alternative in patients seeking autologous breast reconstruction in the presence of a midline abdominal scar.

Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation.

Major upper arm amputations are often accompanied by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. In these cases the goal is not only the re-establishment of circulation, but also functional outcome. Some patients require further reconstruction for functional restoration of elbow flexion and additional soft tissue coverage. Five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation at our institution. The transfer was unipolar in four patients and bipolar in one. The patients' ages ranged from seven to 55 years. The time period between replantation and transfer ranged from two weeks to 12 months. All flaps healed well with minimal donor site morbidity. At mean 43-month follow-up (range: 22-65 months), functional results were good with M4 in three patients and M3 in two patients for elbow flexion. The pedicled latissimus dorsi muscle flap is a valuable tool to restore elbow flexion and provide coverage of soft tissue defects after major upper arm replantations.

High-resolution ultrasound of the supraclavicular brachial plexus--can it improve therapeutic decisions in patients with plexus trauma?

Patients with major traumatic brachial plexus lesions benefit from early surgery, but they are seldom isolated by today's diagnostic workup. Subjects with ambiguous findings after such workups usually undergo a trial of conservative treatment and those without improvement delayed surgery. Our study focuses on this problem. Hence, the purpose of this study was to evaluate the impact of high-resolution ultrasound (HR-US) on patient recruitment for non-delayed surgery. Twelve patients after blunt shoulder trauma and standardized HR-US assessment who underwent plexus surgery were included in this prospective observational study. Thereby, a total of 168 plexus elements were evaluated. All findings were compared to electrophysiological data if available and tested statistically against the gold-standard, i.e., surgical validation. Major plexus lesions were correctly detected by HR-US in nine patients (20 plexus elements). In two patients (five plexus elements), the lesion was underestimated by HR-US in relation to the gold standard (surgical inspection). Our analysis showed a high positive (1.0) and an acceptable negative predictive value (0.92) for the grading of traumatic plexus lesions with HR-US. Based on HR-US findings alone, 9 of 11 patients with objective major lesions would have undergone early surgery. In conclusion, HR-US proved a valuable tool for the triage of patients with traumatic lesions into surgical and non-surgical candidates.

The superficial inferior epigastric artery (SIEA) flap: indications for breast reconstruction.

The lower abdominal skin and fat have become a standard for breast reconstruction because the abdominal tissue can mimic the breast to a high degree. With today's increasing focus on safety and routine of microsurgical interventions, more attention must be paid to donor-site morbidity. The superficial inferior epigastric artery (SIEA) free flap is the least invasive microsurgical procedure for breast reconstruction because this operative technique does not require harvesting of the rectus muscle or the abdominal fascia. A total of 11 breast reconstructions were performed with this technique and had an average follow-up of 23 months. The anatomy, operative technique, and various indications for the SIEA flaps are demonstrated.

Sciatic nerve enlargement in the Klippel-Trenaunay-Weber syndrome.

The case of a 35-year-old woman with Klippel-Trenaunay-Weber syndrome (KTWS) showing clinical symptoms of a peroneal nerve lesion is presented. An immense nerve enlargement along most of the sciatic, peroneal and tibial nerve was found to be due to a lipoma arising from the epi- and perineurium. Treatment consisted of extensive microsurgical neurolysis and excision of the tumor resulting in decompression of the affected nerves. Although rare, a perineural lipoma should be kept in mind in patients with KTWS showing neurological abnormalities.

Peroneal nerve lesion after sural nerve graft harvest: an unusual complication--case report.

After harvesting of the sural nerve, the patient developed a partial palsy of the common peroneal nerve due to a lesion of the peroneal nerve and a neuroma of the sural nerve stump. Motor function recovered after performing neurolysis of the common peroneal nerve and mobilization of the neuroma. The sural nerve, in this case originating from the common peroneal nerve, was harvested using a nerve stripper and four small skin incisions. Direct lesion by the forced use of the nerve-stripping instrument followed by the formation of a neuroma close to the peroneal nerve are the suspected reasons for motor dysfunction. Although many authors report using a nerve stripper as a safe, less invasive method to gain nerve material for transplantation, we recommend lengthening the skin incision so as to be aware of anatomical variations and to refrain from pulling the nerve distally to avoid the described complications.

Aesthetic refinements in reconstructive microsurgery of the lower leg.

Even if a surgical procedure is performed for reconstructive and functional reasons, a plastic surgeon must be responsible for the visible result of the work and for the social reintegration of the patient; therefore, the aesthetic appearance of a microsurgically reconstructed lower leg must be considered. Based on the experience of 124 free-tissue transfers to the lower leg performed in 112 patients between January 1994 and March 2001 (110 [88.7 percent] were transferred successfully), three cases are presented. Considerations concerning flap selection and technical refinements in designing and tailoring microvascular flaps to improve the quality of reconstruction, also according to the aesthetic appearance, are discussed.

Schwannoma of the brachial plexus: cross-sectional imaging diagnosis using CT, sonography, and MR imaging.

Primary brachial plexus tumors are rare, usually benign, and in general have a good prognosis after surgical excision. We present a case of a schwannoma in which sonography enabled the correct diagnosis of a probably benign brachial plexus tumor. Key to the diagnosis was the demonstration of a smooth-bordered, longish, and well-defined nodule along a brachial plexus nerve root. Cross-sectional imaging modalities that provide a high degree of soft tissue contrast and spatial resolution, such as sonography and MR imaging, were suitable methods to establish the correct preoperative diagnosis. Findings at CT, sonography, MR imaging, and surgery are discussed.

Modified free paraumbilical perforator flap: the next logical step in breast reconstruction.

The free paraumbilical perforator flap that was developed with only the perforator penetrating the rectus abdominis muscle seems nearly ideal from the donor-site perspective, because it reduces morbidity virtually to that of an abdominoplasty. However, it requires "supermicrosurgery" skills for suturing of vessels with diameters of 0.7 mm or less, making the procedure technically demanding and risky. Another significant disadvantage of that technique is that the flap has very short vascular pedicles. To overcome the disadvantages of the free paraumbilical perforator flap, a minor modification in flap harvesting that improves the vessel size and length is described. Results for a total of 15 patients who underwent breast reconstruction with modified free paraumbilical perforator flaps are presented, and the advantages and disadvantages of this flap are discussed.