A new protocol for improving immediate monitoring of skin-island free flap with near-infrared spectroscopy and ultrasound.

BACKGROUND: Postoperative monitoring is essential for detecting early complications and improving the salvage rate of free flaps. We propose a new protocol for free flap monitoring based on the combination of near-infrared spectroscopy (NIRS) and ultrasound. METHODS: All free flaps with a skin paddle were included and divided into two groups according to the immediate postoperative monitoring method used: ultrasound examination (control group) or those monitored using our protocol (study group). The number of surgical revisions, intraoperative findings, immediate flap failure, sensitivity, and specificity were compared between the two groups. RESULTS: A total of 221 free flaps performed in 209 patients were included. The NIRS automatically detected vascular compromise in 21.8% of cases. A complication was confirmed in half of these cases by ultrasound examination, and surgical reintervention was indicated (10.9%), even in the absence of clinical changes in the skin paddle. In all the surgical revisions, the complication was confirmed, and there was no flap necrosis in the non-revised cases. The salvage rate for revised flaps and the flap survival rate were higher in the study group (salvage rate: 25% vs 72.7%; survival rate: 92.5% vs 97%). A sensitivity of 100% and a specificity of 100% were found for the combination of both monitoring methods. CONCLUSION: The proposed protocol is a non-invasive and reliable method for early identification of postoperative complications of free flaps that allows higher rates of salvage rate and reduces the need for specific staff with continuous on-site presence for flap monitoring.

Primary Melanoma of the Breast Parenchyma: An Oncoplastic Approach.

Primary melanoma of the breast parenchyma (PMPB) is a rare and aggressive disease, with only a few cases reported in the literature. We present the case of a 50-year old woman who underwent mastectomy and immediate breast reconstruction using a free DIEP flap following recurrence after breast conserving surgery. This report highlights the importance of an oncoplastic approach for this diagnosis and the benefit of immediate autologous breast reconstruction.

Prevention of perioperative limb neuropathies in abdominal free flap breast reconstruction.

BACKGROUND AND AIMS: Perioperative peripheral neuropathies are a significant cause of post-operative morbidity in patients undergoing prolonged procedures. The aims of this study were to determine the incidence and possible causes of peripheral neuropathy in patients undergoing abdominal free flap breast reconstruction and to develop methods of ameliorating this problem. METHODS: A 4-year retrospective study of patients undergoing abdominal free flap breast reconstruction by a single surgeon and anaesthetist was undertaken to determine the incidence and potential causes of perioperative neuropathy. A new positioning protocol was introduced to minimise the stretch on the brachial plexus and to protect peripheral nerves from compression forces. In addition, regular intraoperative physiotherapy was introduced. A prospective study was then conducted on patients managed by the same team to evaluate the effect of this change in practice on the subsequent incidence of peripheral neuropathies. RESULTS: Over the 4-year retrospective period, 93 consecutive patients underwent abdominal free flap breast reconstruction, six of whom (6.5%) developed a peripheral neuropathy. Following the introduction of the new positioning protocol, prospective data collected on 65 consecutive patients showed no further occurrences of perioperative neuropathy (p = 0.04). There were no significant differences in the characteristics between the two cohorts. CONCLUSION: Perioperative peripheral neuropathy in abdominal free flap breast reconstruction is a preventable problem. This paper presents a peripheral neuropathy prevention protocol for managing these patients.

Treatment of rhinophyma with the Versajet Hydrosurgery System.

Rhinophyma is thought to represent the most severe expression of acne rosacea for which surgery is the mainstay of treatment. The use of Versajet Hydrosurgery System has not been previously described for the treatment of this condition. We present six patients with moderate to severe rhinophyma ranging from 41 to 77 years of age who were treated successfully with this technique.

Comparison of commonly used mesher types in burns surgery revisited.

Meshed skin grafts are commonly used in the treatment of burns. Machines for meshing skin are expensive and therefore choosing the correct machine is important. We describe the two available groups of meshers, those that use carriers and those that do not, with advantages and disadvantages of each group. A cost comparison of the use of each type of mesher has been formulated. This information should aid the purchasers in making a more informed choice.

Triamcinolone reduces seroma re-accumulation in the extended latissimus dorsi donor site.

BACKGROUND: The incidence of donor site seroma after autologous latissimus dorsi (ALD) breast reconstruction is in the order of 70%. In the majority of cases the seroma recurs following an initial aspiration. We designed a double-blind randomised controlled trial to test the hypothesis that an intracavity injection of the anti-inflammatory corticosteroid triamcinolone would inhibit seroma re-accumulation. METHODS: We recruited 52 ALD breast reconstructions in 49 patients, of whom 41 involved immediate reconstruction and 11 delayed reconstruction. Patients exhibiting seromas at their first postoperative visit were randomised to receive either intracavity triamcinolone 80 mg (Group A, n=29) or saline (Group B, n=23), following seroma aspiration. We recorded the incidence of wound complications, total time (days) and number/volume of subsequent aspirations to dryness. RESULTS: Triamcinolone significantly reduced the need for any further aspiration (A=16/29, B=22/23), total number of aspirations (A: median=1, interquartile range=0-1; B: median=4, interquartile range=2-5; P<0.0001), total volume aspirated (A: median=30 ml, interquartile range=0-80; B: median=325 ml, interquartile range=199-550; P<0.0001), and total time to dryness (A: median=12 days, interquartile range 7-17; B: median=37 days, interquartile range 20-49; P<0.0001). The incidence of adjuvant chemotherapy (A=16/29, B=9/23) and radiotherapy (A=16/29, B=10/23) was similar, and there was no effect upon donor site complications (Group A=4/29, Group B=2/23, P=0.725). The mean follow-up time for patients in the steroid group was 264 days compared to 254 days for those in the placebo group. Steroid injections were well tolerated, and there were no infective complications. CONCLUSION: Following initial aspiration, intracavity injection of triamcinolone significantly reduced seroma re-accumulation after ALD breast reconstruction.