A Forgotten Entity following Breast Implant Contracture: Does Baker Need a Change?

Although capsular contracture represents one of the most important complications after breast augmentation, local inflammation and fibrosis can lead, in very rare cases, to capsular calcification, an often-forgotten radiological sign of capsular contracture. In this article, the authors present a clinical case of breast implant calcification in an 81-year-old patient. Although this complication has been rarely described, the literature was reviewed to clarify the role of the local microenvironment in capsular contracture and calcification. At present, capsular contracture patients are classified using the conventional Baker score and the histological Wilflingseder classification. As it was not possible to consider capsular calcification when classifying our patient using the traditional scores, the authors propose an updated version of the current scale.

Occult Pathologic Findings in Reduction Mammaplasty in 5781 Patients-An International Multicenter Study.

Breast cancer is among the most commonly diagnosed cancers in the world, affecting one in eight women in their lifetimes. The disease places a substantial burden on healthcare systems in developed countries and often requires surgical correction. In spite of this, much of the breast cancer pathophysiology remains unknown, allowing for the cancer to develop to later stages prior to detection. Many women undergo reduction mammaplasties (RM) to adjust breast size, with over 500,000 operations being performed annually. Tissue samples from such procedures have drawn interest recently, with studies attempting to garner a better understanding of breast cancer's development. A number of samples have revealed nascent cancer developments that were previously undetected and unexpected. Investigating these so-called "occult" findings of cancer in otherwise healthy patients may provide further insight regarding risk factors and countermeasures. Here, we detail occult findings of cancer in reduction mammaplasty samples provided from a cohort of over 5000 patients from 16 different institutions in Europe. Although the majority of our resected breast tissue specimens were benign, our findings indicate that there is a continued need for histopathological examination. As a result, our study suggests that preoperative imaging should be routinely performed in patients scheduled for RM, especially those with risk factors of breast cancer, to identify and enable a primary oncologic approach.

Spalthauttransplantation zur Defektdeckung am Ohr: eine statistische Analyse.

HINTERGRUND UND ZIELE: Die Rekonstruktion nach Entfernung ausgedehnter maligner Hauttumoren am Ohr ist eine Herausforderung. Verschiedene Methoden der Defektdeckung wurden beschrieben. Lappenplastiken, längere Anästhesiezeiten, geringe Compliance und Antikoagulation stellen bei den oft älteren Patienten zusätzliche Risiken dar. Eine rasch, effizient und unkompliziert durchführbare Methode der Defektdeckung ist daher wünschenswert. Ziel der Studie war die Beurteilung des ästhetischen Resultats, des Heilungsprozesses, der Komplikations- und Rezidivrate nach Transplantation ungenetzter Spalthaut (SPHT) zur Defektdeckung nach knorpelerhaltender Resektion maligner Tumoren am Ohr. PATIENTEN UND METHODIK: 32 Patienten wurden nach Entfernung von Hauttumoren am Ohr einer Defektdeckung mittels SPHT unterzogen. ERGEBNISSE: Die durchschnittliche Defektgröße betrug 8,0 cm2 . Eine vollständige Einheilung des Transplantates erfolgte in allen Fällen innerhalb von zwei Wochen. Wesentliche Komplikationen traten nicht auf. Das ästhetische Resultat wurde sowohl von den Patienten als auch von einem Dermatochirurgen und zwei plastischen Chirurgen als gut bewertet. SCHLUSSFOLGERUNGEN: Die SPHT am Ohr ist eine zuverlässige Methode zur Deckung ausgedehnter Hautdefekte. Selbst bei großen Tumoren des äußeren Ohres ist der Ohrknorpel nicht immer infiltriert. Eine knorpelschonende Tumorresektion mit anschließender Defektdeckung mittels SPHT ist eine ausgezeichnete und rasch durchführbare Technik mit hoher Patientenzufriedenheit.

Split-thickness skin grafting for reconstruction of auricular skin defects: a statistical analysis.

BACKGROUND AND OBJECTIVES: Surgical reconstruction following the removal of large malignant auricular lesions is challenging. While many options for defect closure have been described, in the elderly population usually affected flap surgery, long anesthesia times, patient compliance, and anticoagulant therapy pose additional risks. An alternative quick, simple, and effective method of defect closure is therefore highly desirable. The objective of the present study was to assess the aesthetic outcome, healing process, complications, and recurrence rates associated with unmeshed split-thickness skin grafts (STSGs) used for covering large auricular skin defects following cartilage-sparing skin cancer removal. PATIENTS AND METHODS: Under local tumescent anesthesia, 32 patients received STSGs for defect closure following the removal of malignant cutaneous neoplasms of the ear. RESULTS: The average defect size was 8.0 cm². In all cases, complete healing of the recipient site occurred within two weeks. There were no major complications. The aesthetic outcome was rated highly by patients as well as by the dermatosurgeon involved and two independent plastic surgeons. CONCLUSIONS: STSGs are a valid option for closing large auricular skin defects. Even large cutaneous tumors of the external ear do not necessarily infiltrate the cartilage. Thus, cartilage-sparing tumor resection with subsequent defect closure using a STSG is an excellent and quick method associated with high patient satisfaction.

The current preferred female lip ratio.

BACKGROUND: Perception of beauty is influenced by the individual's demographic background and characteristics. However, objective measurements and ratios remain the foundation for aesthetic evaluations. This study aimed to elucidate if there exists a universally applicable ideal upper to lower lip ratio. METHODS: An interactive online survey was designed. Modifiable ranges of lip ratios were achieved via digital alteration, enabling participants to change the ratio of a single female model's lips. The questionnaire was translated into multiple languages and sent to more than 9000 plastic surgeons and the general public worldwide. Demographic data were collected and analysis of variance was used to investigate respective lip ratio preferences. RESULTS: A total of 1011 responses from 35 different countries (response rate of 14%) was gathered. The majority of survey takers (60%) chose the 1.0:1.0 lip ratio as most attractive. No differences were found in respect to lip ratio preference and the self-reported ethnicity. However, interesting preferences prevailed when analyzing the subgroups regarding lower lip size. CONCLUSION: Age, gender, country of residence, and profession significantly impact individual upper to lower lip ratio preferences. However, a 1.0:1.0 lip ratio can apparently be considered most pleasing in females.

Regeneration patterns influence hindlimb automutilation after sciatic nerve repair using stem cells in rats.

INTRODUCTION: Hindlimb autophagy is common after rat sciatic total axotomy and is considered as a sign of neuropathic pain. We applied adult stem cells in a fibrin conduit in a total sciatic axotomy model to improve nerve regeneration, investigating whether a correlation could be detected between stem cells effects on regeneration and limb autophagy. MATERIAL AND METHODS: After sciatic nerve section, a 1-cm sciatic gap was crossed using fibrin conduits. Experimental groups included empty fibrin conduits, fibrin conduits seeded with primary Schwann cells, and fibrin conduits seeded with Schwann cell-like differentiated mesenchymal or adipose-derived stem cells (dMSCs and dASCs). Controls were represented by autografts and by sham rats (tot n=34). At 16 weeks post-implantation, regeneration pattern was analysed on histological sections and related to eventual autophagy. Hindlimbs were evaluated and scored according to autophagy Wall's scale and X-Rays radiological evaluation. RESULTS: All regenerative cell lines significantly improved myelination at the mid conduit level, compared to the empty tubes. However, dMSC could not significantly improve myelination at the distal stump, showing a more chaotic regeneration compared to both other cells groups and controls. Autophagy was correlated to this regeneration patterns, with higher autophagy scores in the empty and dMSC group. CONCLUSION: Hindlimb autophagy can be used as index of neuropathic pain due to nerve lesion or on-going immature regeneration. dMSC group was characterized by a less targeted regeneration comparing to dASC and primary Schwann cells, which confirmed their effectiveness in regeneration and potential in future clinical applications.

Knee Donor Site Morbidity Following Harvest of Medial Femoral Trochlea Osteochondral Flaps for Carpal Reconstruction.

PURPOSE: This study examines donor site morbidity associated with the medial femoral trochlea (MFT) when used as a donor site for vascularized osteochondral flaps for reconstruction of challenging carpal defects such as proximal pole scaphoid nonunion and advanced Kienböck disease. METHODS: The retrospective study population included all patients who had undergone MFT flap harvest for scaphoid or lunate reconstruction. Chart review, patient questionnaires, and validated knee function assessment tools were used: International Knee Documentation Committee Subjective Knee Form scores ranged from 0 (maximal disability) to 100 (no disability). Western Ontario and McMaster Universities osteoarthritis index scores ranged from 0% (no disability) to 100% (maximal disability). Magnetic resonance imaging and radiographs were obtained on the donor knee on the majority of patients. RESULTS: Questionnaire response rate was 79% (45 of 57 patients). Average patient age was 35 ± 11 years (range, 19-70 years). Average postoperative follow-up was 27 ± 17 months (range, 9-108 months). The indication for MFT flap reconstruction was scaphoid nonunion in 30 patients and Kienböck disease in 15 patients. All 45 patients had a stable knee on examination. Magnetic resonance and radiographic imaging obtained on 35 patients exhibited no pathological changes. Average duration of postoperative pain was 56 ± 59 days (range, 0-360 days); average duration until patients reported the knee returning to normal was 90 ± 60 days (range, 14-360 days). Forty-three of 44 patients would have the same surgery again if needed; overall satisfaction with the surgery was rated as 5 ± 1 (range, 2-5) on a scale from 0 (no satisfaction) to 5 (maximal satisfaction). Average International Knee Documentation Committee score was 96 ± 9 (range, 56.3-100) and the average Western Ontario and McMaster Universities score was 6% ± 16% (range, 0%-68%). CONCLUSIONS: Medial femoral trochlea osteochondral flap harvest results in minimal donor site morbidity in the majority of patients. Symptoms are time limited. Intermediate-term follow-up demonstrates excellent results in subjective outcome measures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical Applications of the Transverse Musculocutaneous Gracilis Flap for Secondary Breast Reconstruction after Simple Mastectomy.

BACKGROUND: In secondary autologous breast reconstruction, the current standard is a flap derived from the lower abdomen or the back. If these donor sites are not available because of lack of tissue, prior operations, or simply the patient's desire to avoid these donor sites, the authors use the transverse musculocutaneous gracilis flap if feasible. METHODS: The authors retrospectively evaluated only patients where secondary autologous breast reconstruction was performed with a transverse musculocutaneous gracilis flap because of the prior mentioned reasons. Indications, limitations, advantages, and technique are discussed by sharing the authors' experience in 23 patients using 26 transverse musculocutaneous gracilis flaps. RESULTS: No flap loss could be observed in this series. In four patients, minimal lateral skin necrosis could easily be managed by débridement and primary wound closure. In 12 cases, subsequent lipofilling was performed for a better breast shape. On average, patient satisfaction was high. CONCLUSIONS: Secondary reconstruction after simple mastectomy using the transverse musculocutaneous gracilis flap requires a little more experience than after skin-sparing mastectomy but, especially combined with later lipofilling, can lead to an optimally shaped breast in selected patients with substantial skin laxity and fat distribution at the inner thigh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Aesthetic Breast Augmentation Mastopexy Followed by Post-surgical Pyoderma Gangrenosum (PSPG): Clinic, Treatment, and Review of the Literature.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic ulcerative skin disease, often developing after a trauma or surgical wounds. In the literature there are several reports of post-surgical PG (PSPG) of the breast. The authors of this article experienced an impressive case of PSPG after an aesthetic breast augmentation mastopexy. PSPG is a rare but severe complication in this elective aesthetic surgical procedure. METHOD: A systematic review of the literature was performed, focusing on PSPG after aesthetic breast surgery (augmentation mammoplasty/mastopexy). The online databases Pubmed, Medline, and Cochrane were used and additionally a Google© search was conducted. We compared the data obtained from a systematic literature review to an index case of PSPG after esthetic augmentation mammoplasty. RESULTS: The literature search identified seven articles describing eight cases of PSPG after aesthetic breast surgery. In four of these cases augmentation mammoplasty had been carried out, in two cases mastopexy and in two cases augmentation mammoplasty and mastopexy (augmentation mastopexy). The patient we treated and describe in this paper underwent an augmentation mastopexy outside our clinic. Eight patients suffered from local disease, at the site of surgical wounds, one patient had disseminated disease. Leukocytosis was present in five cases (out of nine). Eight patients had received corticosteroid treatment, one patient refused such treatment. The duration of corticosteroid treatment was on average for 41 days (range 21-60 days). In all cases, the areola had been spared. Complete healing of PSPG was observed on average after 5 months (range 1.5 months-1 year). DISCUSSION: PSPG of the breast after aesthetic breast surgery is rare, but every plastic surgeon should consider this possibility, especially if skin disease develops post-surgery, mimicking wound infection that does not respond to broad-spectrum antibiotic treatment. CONCLUSION: Although the literature does not recommend this step, implant removal is recommended by the authors because bacterial wound infection normally cannot be ruled out definitely in the early stages of disease. Additional surgical intervention should be limited to the absolute necessary and performed only under adequate systemic immunosuppressive therapy.

Propionibacterium avidum infection following breast reduction: high morbidity from a low-virulence pathogen.

Propionibacterium avidum is a common inhabitant of sebaceous glands, traditionally considered to be of low virulence and generally found on implanted foreign material. We report a rare case of P. avidum breast abscess, causing severe morbidity following breast reduction surgery. A 36-year-old woman presented with a non-painful wound discharge 3 weeks postoperatively, and was treated conservatively. She was readmitted 7 weeks postoperatively with a red and tender breast. A purulent discharging abscess was drained under ultrasound guidance. A 2-week intravenous course of amoxicillin-clavulanic acid, followed by oral replacement for a month resulted effective. Serial ultrasound imaging was useful in treatment decision-making. The infective potential of P. avidum may be underappreciated. Proximity of sutures to the axilla, tobacco smoking and the potential for resorbable sutures to host bacteria may predispose to infection, and should raise the clinician's awareness.

Redefining the vascular anatomy of the peroneus brevis muscle flap.

The peroneus brevis flap can be used as either proximally or distally based flap for coverage of small to medium-sized defects in the lower leg. The purpose of this study was to clarify the vascular anatomy of the peroneus brevis muscle. An anatomical dissection was performed on 17 fixed adult cadaver lower legs. Altogether, 87 segmental branches (mean 5.1 ± 1.6 per leg) either from the fibular or anterior tibial artery to the muscle were identified. Sixty-two were branches from the fibular artery (mean 3.4 ± 1.1 per fibular artery), whereas 25 (mean 1.4 ± 0.9 per anterior tibial artery) originated from the anterior tibial artery. The distance between the most distal vascular branch and the malleolar tip averaged 4.3 ± 0.6 cm. An axial vascular bundle to the muscle could be identified in all cadavers; in one leg two axial supplying vessels were found. Their average length was 5.5 ± 2.4 cm and the average arterial diameter was 1.1 ± 0.5 mm, the average venous diameter was 1.54 ± 0.7 mm. The constant blood supply to the peroneus brevis muscle by segmental branches from the fibular and tibial artery make this muscle a viable option for proximally or distally pedicled flap transfer. The location of the most proximal and distal branches to the muscle and conclusively the pivot points for flap transfer could be determined. Furthermore, a constant proximal axial vascular pedicle to the muscle may enlarge the clinical applications. Perfusion studies should be conducted to confirm these findings.

Reconstruction with vascularized medial femoral condyle flaps in hindfoot and ankle defects: a report of two cases.

In this article, we report using free vascularized medial femoral condyle (MFC) flaps for reconstruction of bone defects and nonunion of the hindfoot and ankle in two patients. One patient had an open calcaneal fracture and hindfoot bone defect with impaired gait due to Achilles tendon functional loss. The second patient had nonunion with a chondral defect of the talus after a fall. Following uneventful recoveries, good objective and subjective results were achieved in terms of pain reduction and improved gait in both patients. No further operative intervention was needed during a 3-year follow-up period. The versatility of the corticoperiosteal graft from the MFC makes it an important reconstructive tool for addressing several major surgical problems of bony nonunion in the extremities, including posttraumatic reconstruction of hindfoot and ankle disorders.

Defect closure in the paranasal region: an enduring challenge.

BACKGROUND: The paranasal region constitutes a demanding issue for the reconstructive surgeon. Its complex anatomy, with concavity in close contact with convexity, and a high density of functional and aesthetically important facial components demands specific concern. Due to such complexity, numerous procedures for the reconstruction of paranasal defects have been published, including skin grafts and flaps in random pattern or axial style from the glabella, upper lid, nasal root, or cheek. OBJECTIVES: In this review, we recall classical reconstructive procedures and compare them with innovative procedures that could possibly gain importance in the following years. METHODS: We contrast the pros and cons concerning donor site morbidity, surgical elaborateness, and functional and aesthetic outcome, and substantiate our findings with photographic results from our own patient material. RESULTS AND CONCLUSION: The reconstruction of paranasal defects remains a challenge; nevertheless, the growing toolbox of reconstructive instruments facilitates a perfect reconstructive result.

The distally based peroneus brevis muscle flap-clinical series and review of the literature.

The distally pedicled peroneus brevis muscle flap is rarely used for defect coverage in the distal lower leg. The purpose of this article was to present our clinical series and provide a review of the literature to analyze the overall complication rates and safety of this flap. In our clinical series of 10 patients undergoing reconstruction with the flap, one necrosis of the distal half of the flap and one necrosis of a skin graft occurred. Our review of the literature identified 192 patients undergoing reconstruction with distally pedicled peroneus brevis flaps. The overall complication rate was 41.6%. Typical indications, complications, advantages and disadvantages to alternatives are discussed. The distally pedicled peroneus brevis flap is an interesting option for soft tissue coverage in the distal lower leg. The donor site can always be closed primarily, the anatomy is constant and complication rates are comparable to alternatives in this region like the distally based sural fasciocutaneous flap.

Paravertebral compartment syndrome after training causing severe back pain in an amateur rugby player: report of a rare case and review of the literature.

BACKGROUND: Acute compartment syndrome (CS) of the paravertebral muscles without external trauma is rarely reported in literature. Not all of clinical symptoms for CS are applicable to the paravertebral region. CASE PRESENTATION: A 30-year-old amateur rugby player was suffering from increasing back pain following exertional training specially targeting back muscles. He presented with hardly treatable pain of the lumbar spine, dysaesthesia of the left paravertebral lumbar region as well as elevated muscle enzymes. Magnetic resonance imaging (MRI) showed an edema of the paravertebral muscles. Compartment pressure measurement revealed increased values of 47 mmHg on the left side. Seventy-two hours after onset of back pain a fasciotomy of the superficial thoracolumbar fascia was performed. Immediately postoperatively the clinical condition improved and enzyme levels significantly decreased. The patient started with light training exercises 3 weeks after the operation. CONCLUSIONS: We present a rare case of an exercise-induced compartment syndrome of the paravertebral muscles and set it in the context of existing literature comparing various treatment options and outcomes. Where there is evidence of paravertebral compartment syndrome we recommend immediate fasciotomy to prevent rhabdomyolysis and further consequential diseases.

Second-degree burn within a tattoo after intense-pulsed-light epilation.

The use of high energy light sources [laser, intense pulsed light (IPL)] is booming in aesthetic surgery. A trend, especially concerning usage of photoepilation in cosmetic institutes, is detectable. Photoepilation works through selective photothermolysis, by heating the chromophore melanin within the hair follicles. We present a case impressionably demonstrating that high-energy light demands profound knowledge of its mechanism of action, and can cause severe harm in absence of basic knowledge. Photoepilation is a balancing act between maximal therapeutic effect and minimal side effect risk. Nevertheless, complications have to be clearly distinguished from professional errors. The latter are rising especially with IPL devices, mainly because its use depicts a legal grey area in most of the countries and is not bound to physicians' supervision. Due to its worse risk-benefit profile as compared with that of laser therapy, we advise against the use of IPL devices and claim for stricter regulation of its use, similar to laser devices.