RESUMO
These guidelines have been produced with the involvement of the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons. Recommendations have been derived after a review of published data regarding the use of acellular dermal matrix (ADM), biological and synthetic mesh in breast reconstruction. The guidelines represent a consensus opinion on the optimal management of patients having biological or synthetic mesh assisted breast reconstruction informed by peer-review publications. The Guidelines should be used to inform clinical decision making. Ultimately, members of the MDT remain responsible for the treatment of patients under their care.
Assuntos
Implantes de Mama , Neoplasias da Mama/cirurgia , Mamoplastia/instrumentação , Telas Cirúrgicas , Estética , Feminino , HumanosRESUMO
BACKGROUND: Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion. METHODS: All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed. RESULTS: Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05). CONCLUSIONS: Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Hiperemia/etiologia , Mamoplastia/efeitos adversos , Retalho Perfurante , Complicações Pós-Operatórias/etiologia , Adulto , Neoplasias da Mama/cirurgia , Estudos de Coortes , Artérias Epigástricas , Feminino , Humanos , Mastectomia , Pessoa de Meia-Idade , Valor Preditivo dos TestesAssuntos
Artérias/anatomia & histologia , Artérias/diagnóstico por imagem , Retalho Perfurante/irrigação sanguínea , Abdome/anatomia & histologia , Abdome/diagnóstico por imagem , Angiografia , Humanos , Mamoplastia , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X , Ultrassonografia DopplerRESUMO
As peripheral nerves bend and stretch, internal elements need to move in relation to each other. However, the way in which intraneural components interact is poorly understood. Previous work identified a distinct core and sheath in the rat sciatic nerve and provides a useful model with which to investigate this interaction. Here we have focused on identifying the mechanical and anatomical characteristics of the interface between core and sheath. Nerve samples, 15 and 20 mm long, of rat sciatic nerves were harvested and placed in a purpose-built jig, and a tensile testing machine was used to pull core from sheath. Mechanical tests of specimens in which core had been previously pulled from sheath by 25% of its initial length achieved a mean pull-out force approximately six times smaller than that achieved using intact controls. These results are consistent with the proposal that core-sheath interactions involve physical connections rather than a viscous fluid interface. Anatomical features of this interface were characterised using transmission electron microscopy. It appeared that sheath was derived from epineurium and most of the perineurium, whilst core consisted of endoneurium and a small proportion of the perineurium: the plane of cleavage appeared to involve the innermost perineurial cell layer.