["Sequential Chimeric Osteocutaneous DCIA-Perforator-SIEA Flap to Reconstruct an Osteocutaneous Defect in the Lower Extremity and the Importance of Preserving the Ascending Branch - A Case Report"]. / "Sequenzieller chimärer Beckenkamm-SIEA-Lappen zur Rekonstruktion eines osteokutanen Defektes des Unterschenkels und die Wichtigkeit zur Schonung des Ramus Ascendens ­ ein Fallbericht".

BACKGROUND: The deep circumflex iliac artery (DCIA) perforator flap is an established method to reconstruct osteocutaneous defects. However, the cutaneous perforators come with a great anatomic variability. To deal with this problem, we used a sequential chimeric osteocutaneous free flap for reconstruction. PATIENTS AND METHODS: A 58-year-old man presented with an open tibial fracture after an avalanche accident resulting in an extended osteocutaneous defect in the lower extremity. The injury required osteocutaneous free flap coverage. We reconstructed the defect with a sequential chimeric osteocutaneous DCIA-perforator-SIEA flap. RESULTS: The preservation of the ascending branch of the deep circumflex iliac vessels offered us the possibility to effectively cover an extended osteocutaneous defect in the lower extremity with a sequential chimeric osteocutaneous DCIA-perforator-SIEA flap. In our patient, the sequential chimeric osteocutaneous DCIA-perforator-SIEA flap healed without complications. A small hernia developed at the inguinal donor site area, but it healed without further complications after surgical treatment. The patient regained an adequate function and returned to daily life and physical exercise. CONCLUSION: While preparing the DCIA-perforator free flap, it is important to preserve the ascending branch of the deep circumflex iliac vessels and the vessels needed to harvest either a SIEA or SCIP flap.

Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. OBJECTIVES: The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. METHODS: All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. RESULTS: Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11). CONCLUSIONS: Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

[Breast implant removal and simultaneous aesthetic optimization : Possibilities, technical considerations and outcome analysis]. / Brustimplantatentfernung und simultane ästhetische Optimierung : Möglichkeiten, technische Überlegungen und Ergebnisanalyse.

BACKGROUND: Breast augmentation is currently the leading aesthetic surgical procedure worldwide. Thus, there is a high prevalence of women with breast implants demanding serious know-how and expertise concerning long-term complication management. Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. The authors of this article have also been confronted more and more with the unspecified complex of symptoms named breast implant disease (BID), also called breast implant illness (BII). The treatment of choice for BID is implant removal. OBJECTIVE: Analysis of problems and solutions regarding implant removal. Specific patient analysis according to patients' breast and body configuration. Technical considerations for surgery and preoperative planning. Evaluation of the authors' techniques. PATIENTS AND METHODS: Evaluation of all patients over a period of 3 years requesting implant removal after esthetic augmentation mammoplasty at the authors' department. All patients were treated according to their specific demands regarding breast shape after implant removal. They either received additional mastopexy, lipofilling or both or simple implant removal without further intervention. Demographic, implant-specific, perioperative and postoperative data have been evaluated for all patients. Additionally, all patients were asked to complete a questionnaire regarding satisfaction and outcome. RESULTS: We observed a trend for more satisfied patients with less invasive procedures (simple implant removal or simultaneous lipofilling vs. explantation and mastopexy ± lipofilling, 1.8 vs. 2.0 or 2.6, p = 0.198). Patients' average scoring was better if they suffered from an implant rupture (1.55 vs. 2.17, p = 0.053). Overall, a high patient satisfaction has been observed for all procedures. CONCLUSION: Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. Exactly these patients, consulting their doctor for those problems and questions seem to profit from implant removal. Simultaneous lipofilling and mastopexy of the breast are good options to nevertheless generate an esthetically pleasing result.

The Single-port Laparoscopic Omental Free Flap: Reconstruction of Dorsal Hand Defects with Negligible Donor-site Scar.

The reconstruction of complex dorsal hand injuries can be challenging. For coverage of dorsal hand defects, thin flap tissue is preferred. In addition, it is ideal to raise flaps with minimal donor-site morbidity and a discrete scar. In a 65-year-old obese man, we successfully reconstructed a soft-tissue defect measuring 7 × 5 cm at the dorsal hand with an omental free flap harvested through single-port laparoscopy. Our patient regained hand function and is satisfied with the aesthetic results. We propose the single-port laparoscopic omental free flap to be a suitable option for free flap dorsal hand reconstruction, especially in obese patients with small defects. The technique provides a thin free tissue with a concomitant negligible donor-site scar.

The Subcalcaneal Fat Pad: An Innovative Space for Passage of the Pedicle in Free Flap Reconstruction of Lateral Heel Defects.

Soft-tissue defects of the lateral heel remain a challenge for reconstructive surgeons. Although a reliable vascular supply for free flap anastomosis is available anteriorly from the anterior tibial vessels and medially from the posterior tibial vessels, the vascular anatomy of the lateral side lacks suitable donor vessels for free flap anastomoses. Although the pedicle can be passed either ventrally beneath the skin or dorsally between the Achilles tendon and calcaneus, these passages are hardly applicable for lateral heel defects. We identified the space between the plantar surface of the calcaneus and the plantar aponeurosis as an innovative approach for reconstruction. Therefore, we propose the subcalcaneal fat pad as an alternative and reliable route for the passage of the flap pedicle to the posterior tibial vessels in free flap reconstruction of soft-tissue defects in the lateral calcaneal region. Consequently, the vascular pedicle can be safely anastomosed to the posterior tibial vessels. This approach provides a new option for recipient vessels in free flap reconstruction.

Patient-Reported Outcome Analysis after Resident Performed Upper Blepharoplasty: A Suitable Procedure for Young Surgeons.

Upper blepharoplasty is one of the most frequently performed aesthetic surgeries worldwide. While it is considered a low risk procedure, patients have high expectations regarding the outcome of elective surgery of the face and the majority of residents usually have little exposure to cosmetic surgeries in the early years of their training. All eligible patients who had undergone bilateral upper blepharoplasty at the senior author's institution between January 2016 and August 2019 were invited to participate in an online questionnaire. Our study used a 27-item questionnaire to evaluate postoperative patient satisfaction and compared the patient reported outcome between operations conducted by surgeons with more than 3 years of experience and less than 3 years. In total, 102 patients returned the completed questionnaire and were included in our study after further screening. There was no significant difference in patient reported satisfaction concerning the aesthetic outcome (8.75 vs. 8.29, p=0.49), and complications (6.2 vs. 18.6%, p=0.63), related to the experience of the surgeons. Overall patient satisfaction was very high, while the rate of complications was low. Patient reported aesthetic outcomes after blepharoplasty demonstrated no significant difference comparing the experience of the surgeons.

Anterograde Injection of Alteplase Salvages Deep Inferior Epigastric Perforator Flap in Reconstructive Breast Surgery.

The DIEP flap is currently considered the gold standard for autologous reconstructive breast surgery. Postoperative flap failure due to microvascular postanastomotic thrombotic occlusion is a rare but severe complication. Alteplase, a thrombolytic agent typically used in the setting of an ischemic stroke, myocardial infarction, or pulmonary embolism, has also been injected into the microcirculation of flaps as a rescue procedure due to imminent flap loss. The purpose of this article is to provide an overview and detailed guidance for such a thrombolytic procedure due to suspected thrombotic microsurgical failure in free flap surgery. We report the case of a 43-year-old woman who underwent unilateral breast reconstruction with a DIEP flap at our department. Approximately 12 hours postoperatively, an arterial inflow problem was suspected and revision surgery was performed. Peripheral flap perfusion remained absent without an obvious cause and distal thrombosis was assumed to be present. Therefore, alteplase was gradually injected into the arterial pedicle in the anterograde direction just distal to the anastomosis while clamping the artery proximally. About 3 hours after selective flap thrombolysis, microcirculation of the flap was successfully restored without complications. Anterograde injection of alteplase can successfully salvage a free flap. To our knowledge, evidence for optimal dosing and delivery of alteplase for the treatment of thrombosed DIEP flaps has not been published to date. Our approach presents a therapeutic option that both maximizes alteplase concentration in the flap and minimizes the dosage required for flap salvage to significantly reduce systemic adverse effects.

Microsurgical Scalp Replantation: Lessons Learned and Technical Considerations.

Total scalp avulsion is defined as a severe soft-tissue injury which involves the hairy scalp and commonly occurs in women as a result of the entrapment of long hair in high-speed rotating industrial machinery. The first microvascular replantation of an avulsed scalp was described by Miller et al in 1976 when both superficial temporal arteries along with five veins were successfully reanastomosed. Our patient was managed with a vein graft measuring 8 cm in length for reanastomosis of the superficial temporal artery. Furthermore, after successful replantation, we used an expander for aesthetic refinement and achieved an excellent outcome. A scalp replantation should be performed in every possible case. Despite partial skin necrosis, hair growth in the remaining areas is possible. In cases of partial skin necrosis, it is possible to eliminate the hairless areas by implanting an expander and excising the hairless area. A pressure-related ulcer at the occiput is likely due to immobility of the head postoperatively and may be avoided by using a halo fixation device.

Anatomical Analysis of the Lateral Femoral Cutaneous Nerve and Its Passage beneath the Inguinal Ligament.

BACKGROUND: Meralgia paraesthetica is a mononeuropathy of the lateral femoral cutaneous nerve. According to the literature, the nerve travels beneath the inguinal ligament 1.3 to 5.1 cm medial to the anterior superior iliac spine. Compression at this site may cause pain and paresthesia. The aim of this study was to provide more accurate measurements to improve the diagnostic and surgical management of meralgia paraesthetica. METHODS: The lateral femoral cutaneous nerve was dissected bilaterally in 50 Thiel-embalmed human cadavers. Measurements were performed with a standard caliper at the superior and inferior margins of the inguinal ligament. The distance from the inner lamina of the anterior superior iliac spine to the medial margin of the lateral femoral cutaneous nerve was measured. Data were collected and statistical analysis was performed with R. RESULTS: Ninety-three lateral femoral cutaneous nerves of 50 cadavers were dissected. In 6 percent of cadavers, the lateral femoral cutaneous nerve could not be found. The mean distance from the inner lamina of the anterior superior iliac spine to the lateral femoral cutaneous nerve's medial border was 2.1 ± 1.3 cm (range, 0.2 to 6.4 cm; 95 percent CI, 1.8 to 2.4 cm) at the superior margin of the inguinal ligament and 1.9 ± 1.4 cm (range, 0.2 to 3.0 cm; 95 percent CI, 1.6 to 2.2 cm) at the inferior border of the inguinal ligament. CONCLUSION: This anatomical study shows that the majority of the lateral femoral cutaneous nerve passes beneath the inguinal ligament in a very narrow area of 0.6 cm.

[Decompression of the lateral femoral cutaneous nerve of the thigh : Treatment of meralgia paresthetica]. / Operative Dekompression des Nervus cutaneus femoris lateralis : Behandlung der Meralgia paraesthetica.

OBJECTIVE: Treatment of non-responding pain to conservative treatment located at the anterolateral thigh with surgical decompression of the lateral femoral cutaneous nerve of the thigh (LFCN). INDICATIONS: Compression syndrome of the LFCN; patients suffering from the following symptoms: pain (dysesthesia), numbness (paresthesia), hypersensibility to temperature (or temperature changes) along the course of the LFCN located at the anterolateral thigh. CONTRAINDICATIONS: A new or recrudescent hernia with additional pain or recent laparoscopic hernia repair as a supposed iatrogenically induced compression of the LFCN. SURGICAL TECHNIQUE: Dissection and release of the LFCN of connective tissue, scar tissue, bone rims, and retraction located along the passage underneath the inguinal ligament and distally. POSTOPERATIVE MANAGEMENT: Suture removal after 10-14 days, no sports for 2 weeks. Physiotherapy if necessary. Neurography 4 months after surgery (obligatory if symptoms are persistent). The patient should be followed up for about 24 months. RESULTS: Of the patients, 69% had a history of trauma or surgery, which were designated as the onset of pain. Of these patients, 78% had hip prostheses and 22% had previous falls. Postoperatively, a significant reduction of pain of 6.6 points on the numeric rating scale was observed. All other evaluated parameters also improved postoperatively. Patient satisfaction was high, with 86% reporting complete satisfaction, and 14% reporting partial satisfaction.

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases.

BACKGROUND: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. PATIENTS AND METHODS: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. RESULTS: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. CONCLUSION: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

Age and Overweight Are Not Contraindications for a Breast Reconstruction with a TMG-Flap-A Risk and Complication Analysis of a Retrospective Double Center Study Including 300 Patients.

INTRODUCTION: The transverse myocutaneous gracilis (TMG) flap has become a popular and reliable alternative for autologous breast reconstruction. Initially described as a valuable tissue source for women with low body-mass index, indications nowadays have widely expanded. The Western civilization demographic development with its aging population and the steady growing average BMI has led to increasing breast reconstructions with TMG flaps in overweight and aged individuals. PATIENTS AND METHODS: A total of 300 TMG free flaps for unilateral autologous breast reconstruction were evaluated in the form of a retrospective double center cohort study. Data extraction, study group formation and statistical analysis (One-way analysis of variance (ANOVA), Pearson's chi-squared statistical analysis and relative risk calculation) were done specifically to evaluate age and BMI as risk factors for postoperative complications and outcome. RESULTS: No significant differences in patients' age and BMI in the complication groups compared to the no-complication group could be found. No significant difference regarding the occurrence of complications could be found in any of the formed risk-groups. No significant increase of minor-, major- or overall complications, flap loss or revision surgeries were found in the elderly patient groups or for patients with overweight. CONCLUSION: Age and overweight do not significantly increase the risk for postoperative complications after breast reconstructions with free TMG flaps. The findings of this study support the fact that microsurgical breast reconstruction with a free TMG flap should not solely be reserved for younger patients and females with a lower BMI.

Management of Radial Nerve Lesions after Trauma or Iatrogenic Nerve Injury: Autologous Grafts and Neurolysis.

BACKGROUND: Proximal radial nerve lesions located between the brachial plexus and its division into the superficial and deep branches are rare but severe injuries. The majority of these lesions occur in association with humerus fractures, directly during trauma or later during osteosynthesis for fracture treatment. Diagnostics and surgical interventions are often delayed. The best type of surgical treatment and the outcome to be expected often is uncertain. METHODS: Twelve patients with proximal radial nerve lesions due to trauma or prior surgery were included in this study and underwent neurolysis (n = 6) and sural nerve graft interposition (n = 6). Retrospective analysis of the collected patient data was performed and the postoperative course was systematically evaluated. The Disabilities of the Arm, Shoulder, and Hand (DASH) and the LSUHS (Louisiana State University Health Sciences) scores were used to determine regeneration after surgery. Comparison between the patients' and calculated normative DASH scores was performed. RESULTS: All patients had a traumatically or iatrogenically induced proximal radial nerve lesion and underwent secondary treatments. The average time from radial nerve lesion occurrence to surgical intervention was approximately four months (1.5-10 months). Eight patients (66.67%) had a humeral fracture. During follow up, no statistically significant difference between the calculated normative and the patients' DASH scores was observed. The LSUHS scores were at least satisfactory. CONCLUSIONS: Neurolysis or sural nerve graft interposition performed within a specific period of time are the primary treatment options for radial nerve lesions. They should be performed depending on the lesion type. Regeneration to a satisfactory degree was observed in all patients, and the majority achieved full recovery of sensory and motor functions. This was the first study to highlight the efficiency of neurolysis and sural nerve graft interposition as secondary treatment interventions, especially for radial nerve lesions.

Bilateral Simultaneous Breast Reconstruction with DIEP- and TMG Flaps: Head to Head Comparison, Risk and Complication Analysis.

BACKGROUND: A two center retrospective cohort study of simultaneous bilateral breast reconstructions using double deep inferior epigastric perforator (DIEP) flaps and double transverse myocutaneous/upper gracilis (TMG) flaps was conducted. The aim of this study was to compare surgical procedures, complications, and overall outcome. PATIENTS AND METHODS: Two study groups, either receiving a simultaneous bilateral breast reconstruction, with double DIEP flaps (n = 152) in group 1, or double TMG flaps (n = 86) in group 2, were compared. A detailed risk and complication analysis was performed. Patient characteristics, operative time and the need for further operations were evaluated. RESULTS: Double DIEP patients had donor site complications in 23.7% and double TMG patients in 16.3% (p = 0.9075, RR 1.45). Flap loss rates of 3.5% (double TMG) and 2.6% (double DIEP) were recorded (p = 0.7071, RR 1.33). The need for postoperative lipofilling was significantly higher in double TMG patients (65.1% vs. 38.2 %, p = 0.0047, RR 1.71). CONCLUSION: Complication analysis favors the double DIEP procedure. Donor site morbidity was lower and less severe in the double TMG group. Later fat grafting was more frequently needed after double TMG reconstructions. Further studies, preferably of prospective nature, are needed to evaluate the benefit of bilateral simultaneous breast reconstructions.

Effects of Preoperative Extracorporeal Shockwave Therapy on Scar Formation-A Pilot Study on 24 Subjects Undergoing Abdominoplasty Surgery.

OBJECTIVES: Extracorporeal shockwave therapy (ESWT) has been demonstrated as a feasible noninvasive method to improve wound healing. This effect was demonstrated to result from increased perfusion and angiogenesis due to systemic growth factor expression. We, therefore, hypothesized that preoperative ESWT reduces scar formation after surgery. METHODS: A prospective, controlled pilot study on 24 patients undergoing abdominoplasty was conducted and the efficacy of preoperative unfocused, low energy EWST was evaluated. The right and left half of the operative area were randomly allocated to ESWT or placebo treatment in intrapatient control design. At 6 and 12 weeks after surgery, scar formation was evaluated by 19 different scar parameters included in the patient, observer scar assessment, and the Vancouver scar scale. RESULTS: The overall rating of the Vancouver and POSAS scale with Mann-Whitney (MW) analysis revealed a clear trend favoring ESWT. At week 6, 7 of 19 parameters clearly favored ESWT (MW > 0.53). At week 12, 8 of 19 parameters clearly favored ESWT. The largest differences were observed in thickness and overall impression (Vancouver scar scale). CONCLUSIONS: ESWT presumably reduces scar formation and postoperative symptoms after abdominoplasty surgery. Further studies are required to confirm ESWT efficacy with statistical significance. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Occult papillary thyroid cancer presenting as cystic metastasis of the lateral neck: A case report.

RATIONALE: Papillary thyroid cancer accounts for up to 85% of all cases of thyroid carcinoma. This disease entity is notorious for metastatic invasion of adjacent lymph nodes, including the cervical lymph nodes, potentially presenting as a growing lateral neck mass. However, these lesions tend to be recognized and diagnosed soon due to the palpable mass. PATIENT CONCERNS: This report describes a very rare case of a huge slow-growing neck metastasis based on a 6 mm papillary thyroid microcarcinoma. This patient presented with a painless, but continuously growing right lateral neck mass. Aside from that, no specific complaints were mentioned. DIAGNOSIS: The underlying cause of this patient's neck mass turned out to be an occult papillary thyroid microcarcinoma (Ø 6 mm) with metastatic invasion and subsequent cystic degeneration of cervical lymph nodes. Accurate diagnosis was made after surgical intervention through histopathological analysis. INTERVENTIONS: The patient underwent complete resection of the cervical mass in conjunction with total thyroidectomy and right cervical neck dissection, followed by adjuvant iodine- and chemotherapy. OUTCOME: Margin free surgical resection without any postoperative complications could be achieved. The patient received iodine supplementation and remained free of recurrence during regular clinical follow-ups for 2 years. The therapy was curative. LESSONS: This case report emphasizes the importance of a thorough diagnostic work-up including preoperative tissue sampling of any cervical neck mass, since a benign appearance on imaging does not exclude a malignant process.