Management of giant inferior triangle lumbar hernia (Petit's triangle hernia): A rare complication following delayed breast reconstruction with extended latissimus dorsi myocutaneous flap.

INTRODUCTION: Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors. PRESENTATION OF CASE: The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted. DISCUSSION: Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair. CONCLUSION: The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications.

Preliminary experience with a dynamic resorbable fixation device for craniosynostosis surgery.

The advent of resorbable osteosynthesis material has revolutionized craniomaxillofacial surgery. The need to provide rigid bony fixation in the surgical treatment of craniofacial deformities has inspired an ongoing evolution of surgical innovations and implants. Stability of the plates has been improved, but the duration of their stability remains an ongoing problem. In infant craniofacial fixation, it is important to provide initial stability, but after 4 to 6 weeks, this is no longer required as the brain is rapidly expanding. Surgery was performed on 10 patients with sagittal suture synostosis with conventional suture resection, remodeling, and fixation with resorbable miniplate (PolyMax-RAPID) struts held in position with modeled resorbable pockets affixed to the neurocranium with resorbable screws placed across the resected suture between June 2004 and September 2008. All the patients presented a satisfactory aesthetic result without complications after at least 1-year follow-up. We present a further innovative method of craniofacial fixation in infants using resorbable plates as floating struts providing stability and at the same time controlled dynamic expansion of the cranial vault guided by brain growth.

Correction of severe ptosis with a silicone implant suspensor: 22 years of experience.

BACKGROUND: Patients with severe ptosis caused by poor or absent function of the levator muscle but with good frontalis muscle excursion usually benefit from a frontalis sling procedure. This is currently carried out using organic or inorganic material to connect the upper eyelid to the frontalis muscle. METHODS: The aim of this study was to evaluate retrospectively 112 patients who underwent frontalis sling procedures between 1989 and 2011 using a preformed silicone implant suspensor to correct severe ptosis. RESULTS: The results obtained using this technique were good or fair in 95.54 percent of the cases and poor in 4.46 percent of the cases. The authors discuss the results of the study and the cases in which the procedure should be indicated and highlight the advantages of the method. CONCLUSION: The availability of this low-cost sterile device, together with the fact that it is ready to use, requires less invasive surgery, saves time, and is sufficiently versatile to allow adjustments to be made at any time, makes the silicone eyelid sling an attractive choice for correcting ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Functional detrusor myoplasty for bladder acontractility: long-term results.

PURPOSE: We present the long-term results of a multicenter investigation with latissimus dorsi detrusor myoplasty in patients with bladder acontractility caused by lower motor neuron lesion in whom there is no treatment alternative other than lifelong clean intermittent catheterization. MATERIALS AND METHODS: From 2001 to 2008, 24 patients (median age 39 years, range 13 to 63, 16 males, 8 females) requiring complete clean intermittent catheterization 4 to 7 times daily underwent latissimus dorsi detrusor myoplasty at 4 centers worldwide. Before the procedure patients were on clean intermittent catheterization for a median of 55 months (range 17 to 195). Median followup was 46 months (range 8 to 89) and was performed by urodynamics and measurement of post-void residual urine volume. Bladder contractility index was calculated. The t test was used for statistical analysis. RESULTS: Of the 24 patients 17 (71%) gained complete spontaneous voiding with a mean post-void residual urine volume of 25 ml (range 0 to 100). Mean bladder contractility index increased from 20.1 ± 7.6 to 176.2 ± 25.4 (p <0.001). In 3 patients (13%) the frequency of clean intermittent catheterization was reduced to 2 to 4 times daily with a mean post-void residual urine volume of 200 ml (range 150 to 250). Mean bladder contractility index was 12.0 ± 7.2 preoperatively and 68.7 ± 28.1 postoperatively (p = 0.12). Recurrent urinary tract infections (defined as the presence of clinical symptoms such as dysuria and fever, and microbiological evidence of germs) ceased in 21 of 23 patients (91%, mean preoperatively 8 per year). Four patients (17%) required clean intermittent catheterization with the same frequency as before the procedure (mean bladder contractility index preoperatively 22.5 ± 10.3 and postoperatively 26.0 ± 12.3, p = 0.83). No chronic pain at the donor site or vesicoureteral reflux was observed in any patient. CONCLUSIONS: The results of this multicenter analysis demonstrate that latissimus dorsi detrusor myoplasty is an effective alternative to clean intermittent catheterization in a select group of patients with neurogenic bladder acontractility.

Sensitivity and specificity of ICG angiography in free flap reexploration.

Microscope-integrated indocyanine green near-infrared videoangiography (ICGA) is a new imaging technique to assess vascular flow through diminutive vessels used in microvascular surgery. The purpose of this investigation was to evaluate the diagnostic accuracy of ICGA in detecting microvascular thrombosis in reexploration surgery. Patients undergoing emergent reexploration surgery after free tissue transfer were enrolled in this clinical study. After the patients had been returned to the operating room the pedicle vessels were exposed and a microangiography was performed. Independent of the result, the anastomoses were opened and surgically explored. Sensitivity and specificity was calculated, using the result of exploration surgery as a reference standard. Of 200 free flaps 20 (10%) underwent reexploration surgery. The most common surgical finding was microvascular thrombosis (55%). In one case vascular compromise was due to confusion of artery and vein with anastomosis of two veins. In 40% of patients an intact vascular pedicle was found. The sensitivity and specificity of ICGA to detect microvascular thrombosis was 100% and 86%, respectively. ICGA provides an excellent diagnostic accuracy for detecting microvascular thrombosis in reexploration surgery. Routine implementation of this technique may expedite a correct diagnosis and facilitate the surgical approach by preventing unnecessary surgical manipulation of intact anastomoses.

The intrinsic transit time of free microvascular flaps: clinical and prognostic implications.

BACKGROUND: Microscope-integrated indocyanine green near-infrared videoangiography (ICGA) is a new method for the intraoperative assessment of vascular flow through microvascular anastomoses. The intrinsic transit time (ITT) describes the time period from the dye appears at the arterial anastomosis (t(1)) till it reaches the suture line of the venous anastomosis (t(2)). As the transit time reflects blood flow velocity within the flap, prolonged ITT might correlate with low blood flow and a higher rate of postoperative thrombosis. We performed a clinical trial evaluating the association between intraoperative free flap transit time and early anastomotic complications in elective microsurgery. METHODS: One hundred consecutive patients undergoing elective microsurgical procedures underwent intraoperative ICG angiography (ICGA). In patients with anastomotic patency, angiograms were retrospectively reviewed and the intrinsic transit time was calculated. Postoperative outcome was registered and compared with the ITT. End points included early reexploration surgery and flap loss within the first 24 hours after surgery. RESULTS: Fourteen patients were excluded from the study due to technical anastomotic failure. The overall flap failure rate was 6% (5/86); the incidence of early re-exploration surgery was 10% (9/86). With a median of 31 seconds patients with an uneventful postoperative course showed significantly shorter ITTs than patients with flap loss or early postoperative reexploration (median: >120 seconds). An optimal cut-off value of ITT > 50 seconds was determined to be strongestly associated with a significantly increased risk of at least one positive end point. CONCLUSIONS: This study demonstrates a significant predictive value of the intrinsic flap transit time for the development of flap compromise and early re-exploration surgery.

The ideal split-thickness skin graft donor site dressing: rediscovery of polyurethane film.

The almost single disadvantage of polyurethane film dressings, an uncontrolled leakage, is probably as often described as its numerous advantages for split-thickness skin graft donor sites. We solved this problem by perforating the polyurethane film, which permits a controlled leakage into a secondary absorbent dressing. The study included 30 adult patients. Skin graft donor sites at the proximal thigh were dressed with the modified film dressing. Our results indicate that this dressing concept is associated with a reliable, rapid rate of epithelization. Both, controlled leakage and minimal pain caused particular comfort for patients and ward staff. Furthermore, this dressing was also suited for differently shaped and large donor sites. We conclude that the modification results in a more practicable, comfortable, and cost-effective film dressing, which requalifies the polyurethane film as an ideal dressing material for split-thickness skin graft donor sites.

Avaliação da perfusão do retalho de perfurante da artéria epigástrica inferior microcirúrgico aplicado em reconstrução mamária / Evaluation of the inferior epigastric artery perforator flap perfusion in breast reconstruction

Introdução: O retalho de perfurante da artéria epigástrica inferior (“DIEP”) tem se tornado popular, nos últimos anos, por utilizar o sistema epigástrico profundo como pedículo e preservar a musculatura abdominal, evitando seqüelas na área doadora. Objetivo: O objetivo do presente estudo foi avaliar as variações de fluxo sanguíneo cutâneo medido por meio do laser doppler no retalho DIEP, durante o período transoperatório de reconstruções mamárias. Método: Doze pacientes foram submetidas à reconstrução mamária com 14 retalhos DIEP. Por meio do laser doppler, foram medidas as perfusões cutâneas nas quatro zonas do retalho, nos momentos pré-operatório, incisado, pré-transferência e pós-transferência. Os valores em unidade de perfusão tecidual (“TPU”) foram transformados em porcentagens do valor de referência (pré-operatório) e foram analisados por meio do teste de Friedman. Resultados: O padrão do comportamento hemodinâmico encontrado foi aumento dos valores da perfusão cutânea no momento incisado, sem diferença estatística. Estes valores sofreram uma redução estatisticamente significante para níveis abaixo dos valores de referência, no momento pré-transferência e se mantiveram, no momento pós-transferência, nas zonas II e IV. Nas zonas I e III, os valores pós-transferência não foram diferentes dos valores de referência. Discussão: O padrão hemodinâmico obtido é semelhante ao do retalho transverso do músculo reto abdominal (“TRAM”) pediculado e microcirúrgico, no momento incisado. Após a dissecção do retalho, a perfusão é reduzida abaixo dos valores de referência, semelhante ao TRAM pediculado. As zonas I e III foram melhores perfundidas do que as zonas II e IV.

Clinical outcome of abdominal wall after DIEP flap harvesting and immediate application of abdominoplasty techniques.

BACKGROUND: Although breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is a well-known technique, few publications have reported the aesthetic outcome of the abdomen and the donor-site closure techniques utilized. The aim of this study was to analyze the feasibility of immediate clinical application of traditional abdominoplasty techniques after DIEP flap harvesting. METHODS: Forty-four patients underwent 48 DIEP flap breast reconstructions, with 32 immediate and four bilateral procedures. All patients underwent full abdominoplasties with some technique of musculoaponeurotic system plication. Information on age, weight, height, smoking status, comorbid medical conditions, complications, and revision surgery was collected. RESULTS: In all patients, the anterior rectus fascia was closed by a two-layer imbrication-type closure and the rectus diastasis was corrected by a median plicature. In 36 patients (81.8 percent), a contralateral rectus plicature was performed. In 21 patients (47.7 percent), plication of the external oblique aponeurosis was performed. All patients achieved an improved abdominal contour, and 41 (93.2 percent) were satisfied with their result. Ten patients (22.7 percent) had minor complications. CONCLUSIONS: Clinical application of abdominoplasty techniques is feasible immediately after DIEP harvesting and must address not only skin and subcutaneous tissue but also the muscular abdominal wall. All of the musculofascial plication techniques improved the definition of the waistline. Patient selection is crucial to achieve a satisfactory outcome. The main objective is that patients safely undergo dual procedures with no increased risk and with the added aesthetic benefits at the abdominal donor site.

Evaluation of cutaneous sensibility on infraorbital nerve area.

Normal facial sensibility on the area of the infraorbital nerve was determined in 24 healthy subjects. The measurement of two points discrimination distance and the evaluation of cutaneous pressure threshold were assessed on both sides on the zygomatic, paranasal, and superior labial skin. Cutaneous sensibility varied from region to region but was consistent from one normal individual to another. Cutaneous sensibility of the superior labial skin was more accurate than zygomatic and paranasal skin in all tests. Sex and dominant sides did not have significant influence on the results. The measurement of two point discrimination distance and the evaluation of cutaneous pressure threshold provided reliable and reproducible data that can be used as a standard to determine facial cutaneous sensibility.

Outcome analysis of breast-conservation surgery and immediate latissimus dorsi flap reconstruction in patients with T1 to T2 breast cancer.

BACKGROUND: The latissimus dorsi myocutaneous flap is frequently used for total breast reconstruction; however, few reports have been available regarding clinical outcome following conservative breast surgery. The aim of this study was to perform a retrospective review on 48 patients undergoing immediate latissimus dorsi myocutaneous flap surgery following conservative breast surgery between 1999 and 2004. METHODS: Information on age, body mass index, smoking history, comorbid medical conditions, and oncologic status was collected. Reconstructed breast and donor-site complications were evaluated. RESULTS: Mean follow-up was 16 months. In 56.2 percent of patients, tumors measured 2 cm or less (T1) and in 47.9 percent were located in the upper outer quadrants. Flap complications occurred in seven and donor-site complications occurred in 12 of 48 patients. Dorsal seroma (20.8 percent), dorsal dehiscence (6.2 percent), and partial flap loss (6.2 percent) were the most common complications. Surgical intervention with skin suture was necessary in two cases of dorsal wound dehiscence. Partial flap losses were limited and were treated by a conservative approach. A significant association (p = 0.035) was detected between dorsal seroma and obesity (body mass index or = 30 kg/m) and was associated with a 5.2-fold increase in the odds of developing this complication. No significant association between complications and age, smoking history, hypertension, diabetes, axillary lymph node dissection, or chemotherapy was found. CONCLUSIONS: On the basis of our observations, the latissimus dorsi myocutaneous flap is a consistent technique for reconstruction following conservative breast surgery. Donor-site complications are more often observed in those who are obese; they are higher risk patients.

The feasibility of sentinel lymph node detection in patients with previous transaxillary implant breast augmentation: preliminary results.

BACKGROUND: Transaxillary breast augmentation has gained popularity because of the good aesthetic results and scar placement in a less visible position. As breast-augmented patients age, an increasing number of breast cancer cases can be expected. Sentinel lymph node detection (SLND) is a well-established technique in breast cancer. To date, no information is available regarding the feasibility of SLND for patients with previous transaxillary implants. METHODS: A 28-year-old women with bilateral breast hypoplasia underwent a bilateral breast augmentation by the transaxillary approach. One week earlier, SLND was accomplished through two periareolar injections of 0.1 mCi 99m-technetium-labeled fitate and lymphoscintigraphy. A 3.5-cm-long axillary incision was performed, and the dissection continued through the subfascial plane to create the implant's pocket. A silicone gel implant (215 g round, low-profile, textured Silimed) was inserted. RESULTS: A satisfactory aesthetic result was obtained. Two postoperative lymphoscintigraphies were performed (15 days and 7 months after surgery) with satisfactory SLND. No complication was noted. CONCLUSION: The initial data show that SLND in the setting of prior breast implant augmentation through the transaxillary approach is feasible. Additional prospective studies and larger clinical series are necessary to analyze the accuracy of SLND for patients with previous breast implants.

Evaluation of cutaneous abdominal wall sensibility after abdominoplasty.

Changes in cutaneous sensibility are common after diverse plastic surgical procedures. Although prior studies examined aesthetic results, combined procedures, and new abdominoplasty techniques, few examined the effect of undermining on cutaneous sensibility. This study aimed to analyze and quantify cutaneous sensibility after classic abdominoplasty. Two groups of patients were studied: a control group of 10 patients without surgery and another group of 25 patients who had undergone classic abdominoplasty. The abdominal wall surface was divided into nine regions. Pain sensibility was evaluated by tests with needles, and thermal sensibility by test tubes containing hot and cold water. Superficial tactile sensibility was tested using the Pressure-Specified Sensory Device (PSSD), which is capable of determining the cutaneous pressure threshold. Statistical analysis was conducted using Student's 't-test'. The results showed a decrease in the three types of sensibility. Statistical analysis showed a significant difference (p < 0.05) between the groups for all regions tested. The centermost regions of the abdominal wall presented the highest index of analgesia and thermal anesthesia, as well as higher cutaneous pressure thresholds.

Epidemiologia e tratamento das úlceras de pressão: experiência de 77 casos / Epidemiological profile and treatment of pressure sores: experience with 77 cases

Ulceras de pressão são úlceras decorrentes de isquemia tecidual provocadas pela alteração do reflexo de dor em pacientes com lesão medular, pacientes debilitados, idosos ou cronicamente doentes. No Brasil, poucos estudos vem sendo realizados a respeito das úlcera de pressão e seu tratamento. O objetivo desse trabalho é avaliar a distribuição epidemiológica, o tratamento e complicaçòes das úlceras de pressão no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de 01 de fevereiro de 1997 a 01 de março de 1999 no Instituto de Ortopedia e Traumatologia. Um estudo prospectivo foi realizado neste período através de um protocolo que avaliava sexo, idade, fatores de risco, localização, dimensões, classificação das úlceras, tipo de tratamento, complicações pós-operatórias, tempo de internação e cronicidade da úlcera. O tratamento era avaliado através da taxa de sucesso e recorrência. O tempo de seguimento médio foi de 1 ano e 6 meses. (6 meses a 2 anos). Com 45 pacientes com 77 úlceras foram avaliados neste período. Em relação ao sexo , foi encontrada uma predomibância masculina 4:1. 32,47 por cento das úlceras tiveram sua localização em região sacral e 32,47 por cento trocantérica e 15,58 por cento isquiáticas. Na maioria jovem (média de 34,78 anos), com lesão medular (100 por cento dos pacientes), vítimas de lesões por arma de fogo (60 por cento dos pacientes), de caráter crônico (93,3 por cento) e lesão grau IV (67,53 por cento). As úlceras trocantéricas possuiam dimensões maiores (9,5 cm). 77,92 por cento das úlceras de pressão foram tratadas cirurgicamente, com predomínio dos retalhos miocutâneos (45 por cento) . Em relação a avaliação do tratamento temos: a taxa de sucesso do tratamento das úlcera de pressão foi de 80 por cento trocantérica, 84 por cento sacral e 66,6 por cento isquiática. A taxa de recorrência foi de 25 por cento. A taxa de complicação variou segundo a localização: úlcera trocantérica 84 por cento, 50 por cento isquiática e 64 por cento sacral.

Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: an anatomical and clinical analysis.

A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.

Importance of lateral row perforator vessels in deep inferior epigastric perforator flap harvesting.

Free flaps based on perforator vessels, and in particular the deep inferior epigastric perforator (DIEP) flap, are currently being applied in abdominal reconstruction. However, one of the main disadvantages is the operative complexity. Through anatomical study and clinical experience with the DIEP flap in breast reconstruction, the intramuscular path of the perforator vessels was comparatively studied, to establish the main anatomical parameters that favor procedure planning. Thirty DIEP flaps from 15 fresh cadavers were used. The number, location, and intramuscular course of the perforator vessels were determined. In addition, an initial clinical study was performed in 31 patients using 35 DIEP flaps in breast reconstruction. The number, location, and the intramuscular course of the perforators were assessed. In the cadaver study, 191 perforator vessels were detected (6.4 vessels per flap). Thirty-four percent were located in the lateral row, and the rectilinear course was observed in 79.2 percent of these vessels. In the medial row, only 18.2 percent of the perforator vessels presented this configuration (p = 0.001). Thirty-one patients underwent DIEP flap breast reconstruction, with 26 immediate and four bilateral reconstructions. In 22 of 35 flaps (62.9 percent), two perforators were used. In 25 flaps (71.4 percent), the lateral row perforators with a rectilinear course were observed. Mean operative time was 7 hours and 37 minutes. Two total flap losses and two partial necroses were observed. The majority of the lateral row perforators presented a rectilinear intramuscular course, which was shorter than that of the medial row perforators. This anatomical characteristic favors dissection with reduced operative time and vascular lesion morbidity, resulting in an important anatomical parameter for DIEP flap harvesting.

Aesthetic refinements in breast augmentation with deep inferior epigastric perforator flap: a case report.

The principle of free flaps based on perforator vessels and the development of deep inferior epigastric perforator flap (DIEP) is currently used in reconstructive microsurgery. Clinical experience and research have shown that perforator flaps provide numerous advantages over the conventional myocutaneous flaps and combine muscle preservation and sequel minimization at the donor site. Clinical use of autogenous tissue or perforator flaps in aesthetic breast surgery or augmentation mammaplasty is not a common practice. The authors indicate the use of the DIEP flap to correct severe hypomastia after bilateral breast augmentation with silicon implants, followed by infection and implant extrusion. Using the DIEP flap is a new option for patients who have had complications from breast augmentation with implants or severe hypomastia and have excess tissue in the lower abdomen. Additional studies and clinical research are necessary to evaluate the real benefits as compared to silicone implants, such as operative time, the recovery period and financial implications.

Consideraçöes no tratamento do traumatismo da ponta digital / Considerations of finger injuries treatments

Os autores fazem uma revisao bibliográfica no que se refere a lesoes traumáticas de ponta de dedo e do leito ungueal, a fim de oferecer uma orientaçao mais eficaz sobre procedimentos a serem observados para estes casos nos serviços de urgência. Os autores reportam um levantamento das práticas adotadas nos últimos dez anos, o que possibilita uma atualizaçao dos métodos e técnicas para o tratamento deste tipo de patologia.